Monday, May 04, 2009

Psychologists who don't like psychologists

Or who don't think psychologists are innately and inherently superior to social workers. A few weeks back, this popped up on the ABCT listserv:

Our department is putting together a presentation for 3rd party payors and others that, among other things, attests to the cost-effectiveness of treatment and evaluations provided by psychologists. I would appreciate any suggestions for articles or other resources that attests to this. In particular, our leadership is interested in research showing decreased use of expensive medical procedures when behavioral issues are effectively addressed earlier rather than later. Nina Dresden, PhD

An entirely reasonable request. But not this response:

I would be interested in hearing if we can create positive PR as to why licensed psychologists can provide more effective treatment than other mental health care providers. It seems that many thrid-party payers are trying to load their panels with master's level practitioners and seem to be actively trying to make it exceedingly difficult for psychologists to provide care to their subscribers. Paris Hilton, PhD

"Create positive PR"? In other words, they can't convincingly argue that doctoral-level therapists are actually any better than master's-level, so they want to drum up some spin to confuse the clients. I wanted to respond, but I've already been kind of visible on the listserv, so I sat back and waited.

Not for long:

As a non-psychologist on the listserve, I am interested that you are talking about creating PR to show that psychologists provide more effective treatment than other mental health providers instead of looking for evidence that psychologists provide more effective treatment. As a masters-level social worker who has made every effort to base my clinical practice on proven techniques, I would be interested but surprised to hear that the discipline itself is a major factor in clinical effectiveness. Steve Austin, LCSW

Other psychologists started weighing in:

Last time I looked at the literature I think there was very little support for the notion that being a psychologist necessarily makes someone a better clinician. I agree with Steve that we have to follow the data here and I would be very disappointed to see ABCT follow in APA footsteps in terms of becoming an organization that cares more about guild protection than science.

I also think it is important to remember that although ABCT's membership is heavily weighted towards doctoral-level psychologists, we are a multidisciplinary organization. And if our goal really is to advance evidence-based practice, we are far more likely to succeed if we welcome masters-level practitioners and ask them to be our allies. Sophie Caldwell, PhD

Another psychologist leapt in to defend Dr. Paris.

Just to play devil's advocate and take a chance on political incorrectness, is "guild protection" necessarily a bad thing? The reality is we are dealing with professional issues as well as scientific ones, and it pays not to confuse the two. Look, masters-level people in my state can get licensed as social workers, professional counselors, psychiatric nurses, etc., if they meet those 'guild' qualifications... and nobody's stopping them from doing cognitive behavior therapy if they want. And each of those 'guilds' have their own organization and clubs that are largely exclusive. In fact, any individual off the street can call him or herself a counselor, psychotherapist, coach, or 'wisdom guy', read a couple of books by David Barlow or Edna Foa, charge money for administering cognitive behavior therapy, and nobody can stop them.

In other words, a licensed social worker with actual training in CBT is no better than a "life coach."

But the problem comes when the community wants to know if a particular professional is qualified to administer what it presumes to be 'evidenced [sic.] based practice', so it sets up certain criteria for each license or certification. The criteria may not always be perfect, but the alternative is to let anybody practice. Why shouldn't similar concerns be manifested in professional organizations such as ABCT? Hell, I find it questionable that the state can hire bachelor level graduates and call them social workers.

I find it questionable that my certificate in evidence-based practice, part of a statewide project in developing, studying, and implementing effective therapies, is discounted by this dingbat. Although I agree that bachelor-level social workers aren't as qualified as master's-level.

Another 'guild' issue, independent of 'evidence based practice', is that institutions and insurance companies are generally run by M.B.A.'s, not clinicians, and are looking for the cheapest alternatives independent of professional qualifications. Without some sort of 'guild' representation, we are at a real disadvantage. David Dingbat, PhD

And the truth comes out. Because we're paid less, we're less qualified. Another social worker responded to him (much more politely than I would have, so it's good that I held back):

I have been a practicising clinical social worker for a number of years. I'm sure that all of us in clinical practice have our "war stories" where we witnessed bad clinical decisions and were frustrated with inadequate care for our patients. I also have directedly witnessed "guild" sorts of hierarchial behaviors.

I've had my social work interns pushed aside by psychiatric residents who told them they had to make way because the resident should enter a room first, or a social work intern told to leave an office because the psychology intern had priority over her. Michigan, where I live and practice, has finally after many years of pressure, now made social workers licensed in the state. We now are required to obtain continuing education to retain our licenses (thank God). This goes a long way to enhancing our professional credentials.

Some of the public still see us as assistance payment workers, or as not having the same skills as psychologists. Just this week, a new patient of mine has asked to see a psychologist, because "they know more." The advantage of being part of a multidisciplinary professional organization is that we can begin to break down some of those archaic beliefs.

What I like about our new license requirements is that it forces clinicians to continue developing their knowlege and skills. I posted a recent email where I complained that some training of social work master's students is presented by professors who do not have cognitive therapy credentials. I recently presented 2 workshops on cognitive therapy for pain management to social workers seeking to gain CEs. None of them had much knowledge about CBT. They were all interested and intrigued and wanted to know more. I find that hopeful.

We are all in this together. Please don't be bitter about your experiences. I hope that the ABCT can be a welcoming organization to those of us who have the interest, the knowledge, the skills, and the commitment to provide quality evidence based treatment for our patients. We can all learn from each other and grow personally and professionally from that experience. Sandy Ellison, LCSW

And another psychologist weighed in:

The key issue to me is who is administering evidence based treatments, how to maximize the number of providers doing that, and what does the science say about the capabilities of different levels of professionals to administer said treatments. Psychologists' guild protection, as far as I can tell, has done NOTHING to advance evidence based practice. APA -- our dominant guild protection body -- will approve all sorts of claptrap for continuing education and has taken NO meaningful stance on advancing evidence-based practice. Instead, they spend hundreds of thousands of dollars lobbying against masters-level therapists -- who the research says CAN effectively administer evidence based treatment with appropriate training -- and pushing prescription privileges for psychologists with inadequate levels of training requirements. I.e., encouraging psychologists to offer sub-standard care.

So in this instance is guild protection a bad thing? I would argue yes, because the values of the people handling guild protection do not remotely align with the advancement of evidence based practice. ABCT embracing masters level practitioners who are committed to evidence based practice, however, moves us further along in increasing the dissemination of evidence based treatments. I think we are missing the boat if we view this as a political correctness issue.

What more can I say? Sorry if this post isn't so interesting to most readers, but my pride in my profession was very hard-won. It was difficult to give up the dream of being a psychologist and recasting myself as a social worker. For a long time I didn't take pride in my title.

Now I do -- because I'm providing all kinds of treatment at all kinds of levels, clinical as well as sociological, talk therapy as well as direct services. I help people feel better; I help people, period. And there are more than a few psychologists who believe in what I do as much as I do.

I don't think any of them are at The Bad Place. But those psychologists are crazy.
Copyright (c) "Ayelet Survivor"

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