A question about Psych RXP laws? Collaboration agreements?

[Tom4705]

So I know that in the 7 states where psych rxp laws exist, one must have their doctorate in psychology, get a masters degree in psychopharmacology with a certain amount of clinical hours with oversight under their belt and pass the PEP exam. But after all of this, there is a mandatory collaboration agreement with a PCP/doctor that goes on forever? So if a psychologist prescribes to 15 different patients, they have to have 15 perpetual collaboration agreements? Am I understand this right??? How is that practical in this niche?


Is there no state where after it's all said and done, a qualified prescribing psychologist could prescribe independently without being bound by a collaboration agreement?

Please if you are against psychologists prescribing on principle please refrain from that debate on this thread I'm looking for objective information regarding this issue.

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[AcronymAllergy]

I could be wrong, but looking at Louisiana's law, I believe they allow for a certificate of advance practice that no longer requires ongoing collaboration. The psychologist just has to basically keep the PCP updated on the treatment plan and progress, which can be done by sending along the patient's intake and follow-up notes.

 

[Tom4705]

I could be wrong, but looking at Louisiana's law, I believe they allow for a certificate of advance practice that no longer requires ongoing collaboration. The psychologist just has to basically keep the PCP updated on the treatment plan and progress, which can be done by sending along the patient's intake and follow-up notes.

Does the PCP have to approve before any prescriptions are made? How does a psychologist for all practical purposes keep up with so many different PCPs while still being able to effectively manage their practice? What's the financial compensation for prescribing psychologists? I'm curious as to how their day to day looks like.


And the other 6 states mandate ongoing collaboration?

 

[AcronymAllergy]

Does the PCP have to approve before any prescriptions are made? How does a psychologist for all practical purposes keep up with so many different PCPs while still being able to effectively manage their practice? What's the financial compensation for prescribing psychologists? I'm curious as to how their day to day looks like.


And the other 6 states mandate ongoing collaboration?

Can't say I know the answer to any of those questions; my response was just based on a quick read of LA's RxP law. But looking at that law, I don't think (in LA) the PCP has to approve medication changes once the psychologist has an advance practice certificate.

As for other states that may require ongoing consultation, I imagine the psychologist develops a routine that involves scheduling time to make those calls at some point in their day. No clue on financial compensation, but I suspect you could look up the CMS reimbursement rates for the prescribing psychology CPT codes to get a rough idea.

 

[Tom4705]

Can't say I know the answer to any of those questions; my response was just based on a quick read of LA's RxP law. But looking at that law, I don't think (in LA) the PCP has to approve medication changes once the psychologist has an advance practice certificate.

As for other states that may require ongoing consultation, I imagine the psychologist develops a routine that involves scheduling time to make those calls at some point in their day. No clue on financial compensation, but I suspect you could look up the CMS reimbursement rates for the prescribing psychology CPT codes to get a rough idea.

Any ideas on where to find that info? I'm a lowly undergrad, still learning

 

[AcronymAllergy]

Any ideas on where to find that info? I'm a lowly undergrad, still learning

The best place is going to be the primary sources (i.e., the individual state laws). There may be a compilation of it somewhere, like on APA's website relating to RxP, but I'm not sure.

Although other folks on here, particularly those living in RxP states, may know more than me.

 

[psych.meout]

Any ideas on where to find that info? I'm a lowly undergrad, still learning

If you're an undergrad and so interested in prescribing, why not go into psychiatry instead?

 

[PsyDr]

All states require a collaborating physician. The term collaborating may mean slightly different things.


In NM and ID, the treating physician must approve the prescription before it is sent by the psychologist. Additionally, the prescribing psychologist must be supervised by a physician, for 2 years, under the term "conditional prescribing psychologist". Supervision is similar to traditional supervision of practica students. After that time in supervision, the psychologist may apply for full prescribing authority. If granted, the psychologist no longer has to be supervised by a physician. However, all patients must still be under the care of a physician.

In LA, the patient must be under the care of a physician. The psychologist evaluates the patient, and ask the physician “Is it okay if I prescribe XYZ?”. Then the physician says “Sure.”. Then, the psychologist can prescribe. All of this must be documented in writing. After 2 years, the psychologist can apply for “advanced practice”. If granted, the psychologist can immediately prescribe, but must send the chart note to the referring physician within 48hrs. Note that the patient must be under the care of a physician at all times.

In IA, prescribing psychologists must be supervised by a physician AND the referring physician must agree with the prescription.

In IL, the psychologist must have an ongoing collaborative relationship with a physician. The requirements in this state are more extensive, and restrict the patients that can be seen.

No idea about CO or UT. While their laws have been passed, I do not think their rules have been published. But UT's laws say they can’t prescribe any controlled substances (e.g., stimulants, benzos ). That seems on brand for UT.

 

[AcronymAllergy]

So short answer: if you haven't yet started your professional training and you want the clearest path to having prescribing privileges in your treatment tool box, medical school is the way to go. Another option is psych graduate school (if that's your primary goal/desire) followed at some point by completing an NP program (or in the reverse order).

 

[GT_Neuro]

Wow! Why bother putting all the time, effort, and $$ pursuing RX privileges, at least per the demands of the current guidelines. Who needs the hassle and bother.

 

[psych.meout]

Wow! Why bother putting all the time, effort, and $$ pursuing RX privileges, at least per the demands of the current guidelines. Who needs the hassle and bother.

That's why it doesn't make sense to do it if you aren't even in grad school yet, like OP.

 

[PsyDr]

Wow! Why bother putting all the time, effort, and $$ pursuing RX privileges, at least per the demands of the current guidelines. Who needs the hassle and bother.

That’s like saying neuropsychology post docs don’t make sense because neurologists make more money and have greater scope of practice.


1) If someone primarily wants to be a psychologist, who practices in the prescribing subspecialty: it makes sense.

2) if someone wants to be a prescriber who happens to be a psychologist: it makes no sense.

 

[texanpsychdoc]

So no, not all states require this agreement. Louisiana for example does not. New Mexico I believe recently got rid of theirs. Colorado does, Illinois for sure does (they just love to be completely different than others and fussy).

I'm in my second year of the post-doc M.S.CP program with FDU and live in Texas.

 

[Tom4705]

I could be wrong, but looking at Louisiana's law, I believe they allow for a certificate of advance practice that no longer requires ongoing collaboration. The psychologist just has to basically keep the PCP updated on the treatment plan and progress, which can be done by sending along the patient's intake and follow-up notes.

Does the PCP have to approve it? Because it seems very impractical to have say, 10 patients and have to wait for all of those PCPs to approve your treatment plan while still being an effective prescriber. If they don't have to approve and it's merely just sending them updates without their input, that's different. Is there any source for this loosening of restriction?

 

[Tom4705]

Wow! Why bother putting all the time, effort, and $$ pursuing RX privileges, at least per the demands of the current guidelines. Who needs the hassle and bother.

I sadly agree.

 

[Tom4705]

So no, not all states require this agreement. Louisiana for example does not. New Mexico I believe recently got rid of theirs. Colorado does, Illinois for sure does (they just love to be completely different than others and fussy).

I'm in my second year of the post-doc M.S.CP program with FDU and live in Texas.

Texas is planning on having Psych RXP laws passed? Or are you planning on moving to a state where it's legal once you finish your training?

 

[Tom4705]

If you're an undergrad and so interested in prescribing, why not go into psychiatry instead?

I understand this is an extremely unpopular opinion in these parts but I have yet to see any evidence that the additional training Psychiatrists get in the first 4 years of medical school leads to significantly better outcomes in competence for psychopharmacology on a consistent basis. Or put another way, I haven't seen any evidence of the widespread disasters on the part of Psych NPs and/or Prescribing psychologists that Psychiatrists have been shouting from the rooftops for decades would happen. In fact, I've seen some evidence to quite the contrary. There was a study that came out of Harvard that tested 66 prescribers. A mixture of Psychiatrists, general physicians, psychiatric nurse practitioners, general nurse practitioners, prescribing psychologists, and general psychologists (meaning psychologists without postdoctoral training in psychopharmacology). Psychiatrists performed the best, followed by Prescribing Psychologists, then Psychiatric Nurse Practitioners. According to the study, there was no statistical difference between these 3 groups. General physicians and general nurse practitioners performed worse than these 3 groups, and general psychologists performed worse than them. The study was published as part of a students PHD dissertation on Prescription privileges for psychologists. Happy to post it for anyone interested.

And considering most who prescribe psychotropic meds from the get go are general MDs and General NPs, not psychiatrists, I don't really see any outcry for their supposed lack of relevant knowledge.

If med school/psychiatry was the only way to prescribe, id do it. But its not, and I feel as though too large a portion of the first four years are overkill in terms of volume and not useful for the practice of psychopharmacology.

If I'm not already sentenced to crucifixion yet on this forum for saying this, I believe that in a world that made sense and was more efficient, psychiatry would be it's own thing like dental school is.

I want to do a mixture of both psychotherapy and prescribing in the long run. The overkill and irrelevance of the first four years of medical school combined with the fact that modern psychiatry gets next to no training in psychotherapy of any type in their programs makes it the least palatable option of the 3 major choices in my view. Psych RXP I've considered and in concept makes sense (hence the initial question) but it limits me to a handful of states in which I can practice, most of which I don't want to live in, and in half of those it seems as though the Psych RXP laws are almost intentionally designed to repulse those interested. In Utah you can only prescribe SSRIs. In almost all states you need to have a collaborative relationship with every patients PCP, which, should I want to run my own practice, would be logistically almost impossible, and since you have to have a PCP agree and sign off on any medication change, it sounds like a nightmare for propespective patients as many do not always stick with their first psychotropic drug prescribed. Sometimes it takes multiple attempts to find the right one, as I'm sure many of you know better than I. If the collaboration was temporary, even if the timeframe was years, but eventually was no longer needed, I'd still possibly consider it. And this is of course to say that I'm not a huge fan of research, which you have to eat breath and sleep in a Psychology doctorate even if you want a career in clinical practice. Although sadly I'd be missing out on training in assessments, that was something that greatly interested me too, but I think i have a greater interest in psychopharmacology.

What that leaves me with, and what I'm probably going to end up doing in the end, is become a Psych NP, working under a Dr or working for a clinic/hospital/another private practice for 5-7 years to gain experience and get additional training concurrently in Psychotherapy, in NYC where I currently live there are high quality psychoanalytic institutes that train you in both psychodynamic therapy and psychoanalysis proper. That's something I'm considering, but of course there's other options for psychotherapy. And then eventually start my own private practice part time, and eventually transition fully. This seems like the most logical path for my goals.


If anyone disagrees with me or thinks I'm insane or dangerous or whatever, I'm open to being wrong, but if you could explain how I'm wrong with real world examples that aren't mere theoreticals 99.99998% of the time I'd love to hear it. Alternatively, any additional advice that I might be missing would be greatly appreciated

 

[AcronymAllergy]

I understand this is an extremely unpopular opinion in these parts but I have yet to see any evidence that the additional training Psychiatrists get in the first 4 years of medical school leads to significantly better outcomes in competence for psychopharmacology on a consistent basis. Or put another way, I haven't seen any evidence of the widespread disasters on the part of Psych NPs and/or Prescribing psychologists that Psychiatrists have been shouting from the rooftops for decades would happen. In fact, I've seen some evidence to quite the contrary. There was a study that came out of Harvard that tested 66 prescribers. A mixture of Psychiatrists, general physicians, psychiatric nurse practitioners, general nurse practitioners, prescribing psychologists, and general psychologists (meaning psychologists without postdoctoral training in psychopharmacology). Psychiatrists performed the best, followed by Prescribing Psychologists, then Psychiatric Nurse Practitioners. According to the study, there was no statistical difference between these 3 groups. General physicians and general nurse practitioners performed worse than these 3 groups, and general psychologists performed worse than them. The study was published as part of a students PHD dissertation on Prescription privileges for psychologists. Happy to post it for anyone interested.

And considering most who prescribe psychotropic meds from the get go are general MDs and General NPs, not psychiatrists, I don't really see any outcry for their supposed lack of relevant knowledge.

If med school/psychiatry was the only way to prescribe, id do it. But its not, and I feel as though too large a portion of the first four years are overkill in terms of volume and not useful for the practice of psychopharmacology.

If I'm not already sentenced to crucifixion yet on this forum for saying this, I believe that in a world that made sense and was more efficient, psychiatry would be it's own thing like dental school is.

I want to do a mixture of both psychotherapy and prescribing in the long run. The overkill and irrelevance of the first four years of medical school combined with the fact that modern psychiatry gets next to no training in psychotherapy of any type in their programs makes it the least palatable option of the 3 major choices in my view. Psych RXP I've considered and in concept makes sense (hence the initial question) but it limits me to a handful of states in which I can practice, most of which I don't want to live in, and in half of those it seems as though the Psych RXP laws are almost intentionally designed to repulse those interested. In Utah you can only prescribe SSRIs. In almost all states you need to have a collaborative relationship with every patients PCP, which, should I want to run my own practice, would be logistically almost impossible, and since you have to have a PCP agree and sign off on any medication change, it sounds like a nightmare for propespective patients as many do not always stick with their first psychotropic drug prescribed. Sometimes it takes multiple attempts to find the right one, as I'm sure many of you know better than I. If the collaboration was temporary, even if the timeframe was years, but eventually was no longer needed, I'd still possibly consider it. And this is of course to say that I'm not a huge fan of research, which you have to eat breath and sleep in a Psychology doctorate even if you want a career in clinical practice. Although sadly I'd be missing out on training in assessments, that was something that greatly interested me too, but I think i have a greater interest in psychopharmacology.

What that leaves me with, and what I'm probably going to end up doing in the end, is become a Psych NP, working under a Dr or working for a clinic/hospital/another private practice for 5-7 years to gain experience and get additional training concurrently in Psychotherapy, in NYC where I currently live there are high quality psychoanalytic institutes that train you in both psychodynamic therapy and psychoanalysis proper. That's something I'm considering, but of course there's other options for psychotherapy. And then eventually start my own private practice part time, and eventually transition fully. This seems like the most logical path for my goals.


If anyone disagrees with me or thinks I'm insane or dangerous or whatever, I'm open to being wrong, but if you could explain how I'm wrong with real world examples that aren't mere theoreticals 99.99998% of the time I'd love to hear it. Alternatively, any additional advice that I might be missing would be greatly appreciated

I don't think you'll get much argument in the psychology forum here about the safety of RxP. But what jumps out to me about your plan is the 5-7 years of additional experience/training you plan to pursue after the NP. When considering the time spent in the NP program itself, and that you have an interest in psychopharmacology (and limited interest in research), psychiatry seems to make the most sense from the outside looking in. You mention that psychiatry provides "next to no training in psychotherapy." I suppose it depends on how you define "next to no," but my understanding is that psychiatry residencies are required, at least in name, to provide training in psychotherapy. I suspect there are some that do a much more thorough job of that than others, and regardless, you'll still get more psychotherapy training than you would via an NP program. I also imagine some of that may be influenced by your own interest. My own personal bias and experience would rank psychotherapy training and exposure (e.g., breadth, depth) obtained while in-program, in a highly generalized sense, as follows: psychology (from a reputable program) > psychiatry > MSW/LMHC > NP. I don't think I personally know any NPs who actually provide psychotherapy and who aren't also psychologists or masters-level therapists.

There are plenty of RxPs who make the requirements work. I know of a few myself who have very successful private practices consisting of just themselves and possibly another psychologist or two. As was said above, RxP as a career path makes sense for psychologists who are already practicing and want to branch out in that regard, and in general for folks who want to be psychologists but also have the ability to prescribe. In your case, it doesn't necessarily sound like you want to be a psychologist. So I would agree that RxP is a roundabout way of getting where you want to be.

 

[texanpsychdoc]

Texas is planning on having Psych RXP laws passed? Or are you planning on moving to a state where it's legal once you finish your training?

I've been on the RxP board here in Texas and we are submitting our proposal this December to be on to docket for 2025. I am not planning to move at all. I'm a Texan, I'm home. We have several psychologists on our board who prescribe, but do so either in NM or LA. I know one commutes to LA to do so and the other does it via tele-health.

 

[texanpsychdoc]

I understand this is an extremely unpopular opinion in these parts but I have yet to see any evidence that the additional training Psychiatrists get in the first 4 years of medical school leads to significantly better outcomes in competence for psychopharmacology on a consistent basis. Or put another way, I haven't seen any evidence of the widespread disasters on the part of Psych NPs and/or Prescribing psychologists that Psychiatrists have been shouting from the rooftops for decades would happen. In fact, I've seen some evidence to quite the contrary. There was a study that came out of Harvard that tested 66 prescribers. A mixture of Psychiatrists, general physicians, psychiatric nurse practitioners, general nurse practitioners, prescribing psychologists, and general psychologists (meaning psychologists without postdoctoral training in psychopharmacology). Psychiatrists performed the best, followed by Prescribing Psychologists, then Psychiatric Nurse Practitioners. According to the study, there was no statistical difference between these 3 groups. General physicians and general nurse practitioners performed worse than these 3 groups, and general psychologists performed worse than them. The study was published as part of a students PHD dissertation on Prescription privileges for psychologists. Happy to post it for anyone interested.

And considering most who prescribe psychotropic meds from the get go are general MDs and General NPs, not psychiatrists, I don't really see any outcry for their supposed lack of relevant knowledge.

If med school/psychiatry was the only way to prescribe, id do it. But its not, and I feel as though too large a portion of the first four years are overkill in terms of volume and not useful for the practice of psychopharmacology.

If I'm not already sentenced to crucifixion yet on this forum for saying this, I believe that in a world that made sense and was more efficient, psychiatry would be it's own thing like dental school is.

I want to do a mixture of both psychotherapy and prescribing in the long run. The overkill and irrelevance of the first four years of medical school combined with the fact that modern psychiatry gets next to no training in psychotherapy of any type in their programs makes it the least palatable option of the 3 major choices in my view. Psych RXP I've considered and in concept makes sense (hence the initial question) but it limits me to a handful of states in which I can practice, most of which I don't want to live in, and in half of those it seems as though the Psych RXP laws are almost intentionally designed to repulse those interested. In Utah you can only prescribe SSRIs. In almost all states you need to have a collaborative relationship with every patients PCP, which, should I want to run my own practice, would be logistically almost impossible, and since you have to have a PCP agree and sign off on any medication change, it sounds like a nightmare for propespective patients as many do not always stick with their first psychotropic drug prescribed. Sometimes it takes multiple attempts to find the right one, as I'm sure many of you know better than I. If the collaboration was temporary, even if the timeframe was years, but eventually was no longer needed, I'd still possibly consider it. And this is of course to say that I'm not a huge fan of research, which you have to eat breath and sleep in a Psychology doctorate even if you want a career in clinical practice. Although sadly I'd be missing out on training in assessments, that was something that greatly interested me too, but I think i have a greater interest in psychopharmacology.

What that leaves me with, and what I'm probably going to end up doing in the end, is become a Psych NP, working under a Dr or working for a clinic/hospital/another private practice for 5-7 years to gain experience and get additional training concurrently in Psychotherapy, in NYC where I currently live there are high quality psychoanalytic institutes that train you in both psychodynamic therapy and psychoanalysis proper. That's something I'm considering, but of course there's other options for psychotherapy. And then eventually start my own private practice part time, and eventually transition fully. This seems like the most logical path for my goals.


If anyone disagrees with me or thinks I'm insane or dangerous or whatever, I'm open to being wrong, but if you could explain how I'm wrong with real world examples that aren't mere theoreticals 99.99998% of the time I'd love to hear it. Alternatively, any additional advice that I might be missing would be greatly appreciated

I would mention that it was within the last few years that a New Mexico RxP psychologist got in big trouble due to malpractice in prescribing. So....now we know of at least one case.

 

[texanpsychdoc]

I don't think you'll get much argument in the psychology forum here about the safety of RxP. But what jumps out to me about your plan is the 5-7 years of additional experience/training you plan to pursue after the NP. When considering the time spent in the NP program itself, and that you have an interest in psychopharmacology (and limited interest in research), psychiatry seems to make the most sense from the outside looking in. You mention that psychiatry provides "next to no training in psychotherapy." I suppose it depends on how you define "next to no," but my understanding is that psychiatry residencies are required, at least in name, to provide training in psychotherapy. I suspect there are some that do a much more thorough job of that than others, and regardless, you'll still get more psychotherapy training than you would via an NP program. I also imagine some of that may be influenced by your own interest. My own personal bias and experience would rank psychotherapy training and exposure (e.g., breadth, depth) obtained while in-program, in a highly generalized sense, as follows: psychology (from a reputable program) > psychiatry > MSW/LMHC > NP. I don't think I personally know any NPs who actually provide psychotherapy and who aren't also psychologists or masters-level therapists.

There are plenty of RxPs who make the requirements work. I know of a few myself who have very successful private practices consisting of just themselves and possibly another psychologist or two. As was said above, RxP as a career path makes sense for psychologists who are already practicing and want to branch out in that regard, and in general for folks who want to be psychologists but also have the ability to prescribe. In your case, it doesn't necessarily sound like you want to be a psychologist. So I would agree that RxP is a roundabout way of getting where you want to be.

Having taught in multiple psychiatry residency programs, they get "exposure," reluctantly so I should add. Even LPCs and LCSWs get much better training in therapy than psychiatry residents. They basically got exposed to CBT and get a watered down and condensed version of it, often qualified as an elective rather than a requirement.

 

[Dr_Bee]

I don't think you'll get much argument in the psychology forum here about the safety of RxP. But what jumps out to me about your plan is the 5-7 years of additional experience/training you plan to pursue after the NP. When considering the time spent in the NP program itself, and that you have an interest in psychopharmacology (and limited interest in research), psychiatry seems to make the most sense from the outside looking in. You mention that psychiatry provides "next to no training in psychotherapy." I suppose it depends on how you define "next to no," but my understanding is that psychiatry residencies are required, at least in name, to provide training in psychotherapy. I suspect there are some that do a much more thorough job of that than others, and regardless, you'll still get more psychotherapy training than you would via an NP program. I also imagine some of that may be influenced by your own interest. My own personal bias and experience would rank psychotherapy training and exposure (e.g., breadth, depth) obtained while in-program, in a highly generalized sense, as follows: psychology (from a reputable program) > psychiatry > MSW/LMHC > NP. I don't think I personally know any NPs who actually provide psychotherapy and who aren't also psychologists or masters-level therapists.

There are plenty of RxPs who make the requirements work. I know of a few myself who have very successful private practices consisting of just themselves and possibly another psychologist or two. As was said above, RxP as a career path makes sense for psychologists who are already practicing and want to branch out in that regard, and in general for folks who want to be psychologists but also have the ability to prescribe. In your case, it doesn't necessarily sound like you want to be a psychologist. So I would agree that RxP is a roundabout way of getting where you want to be.

In my current role at the VA, I work closely with and help train psychiatry residents and hold an assistant professorship with the affiliated residency program. Some psychiatry residency programs are more focused on therapy than others, but even those that tout extensive training provide significantly less training than a masters program (LCSW/LMHC). In the program I am affiliated with 3rd year residents maintain a panel of roughly 4-6 outpatients and that concludes their psychotherapy training. Most residents receive no therapy training prior to or after 3rd year and as much as I love working with the residents in my current role, the vast majority are woefully undertrained and lacking in basic counseling skills. So I would rank psychology (from a reputable program) > MSW/LMHC > psychiatry >NP. Now that said, psychiatrists can pursue additional training after residency to increase counseling competence, but what they receive in residency is lackluster at best.

 

[clausewitz2]

And considering most who prescribe psychotropic meds from the get go are general MDs and General NPs, not psychiatrists, I don't really see any outcry for their supposed lack of relevant knowledge.

Come over to the Psychiatry forum, we complain about the kind of nonsense we see from PCPs and NPs all the time.

 

[clausewitz2]

Having taught in multiple psychiatry residency programs, they get "exposure," reluctantly so I should add. Even LPCs and LCSWs get much better training in therapy than psychiatry residents. They basically got exposed to CBT and get a watered down and condensed version of it, often qualified as an elective rather than a requirement.

I am not going to argue that the therapy training in most psychiatry residency programs is adequate by any means, but this is untrue. Training of some kind in at least three therapeutic modalities is necessary for a residency program to be accredited. It is not an elective. Most programs do this by some combination of CBT, a psychodynamic approach of some kind, and then some other third type. IPT is a popular choice.

 

[WisNeuro]

Come over to the Psychiatry forum, we complain about the kind of nonsense we see from PCPs and NPs all the time.

In my capacity working with midlevels as a colleague and as a patient, I avoid them as much as possible based on past experiences in both settings.

 

[texanpsychdoc]

I am not going to argue that the therapy training in most psychiatry residency programs is adequate by any means, but this is untrue. Training of some kind in at least three therapeutic modalities is necessary for a residency program to be accredited. It is not an elective. Most programs do this by some combination of CBT, a psychodynamic approach of some kind, and then some other third type. IPT is a popular choice.

Just speaking about my experiences being a professor in those programs and teaching them I suppose. To each their own

 

[AcronymAllergy]

In my current role at the VA, I work closely with and help train psychiatry residents and hold an assistant professorship with the affiliated residency program. Some psychiatry residency programs are more focused on therapy than others, but even those that tout extensive training provide significantly less training than a masters program (LCSW/LMHC). In the program I am affiliated with 3rd year residents maintain a panel of roughly 4-6 outpatients and that concludes their psychotherapy training. Most residents receive no therapy training prior to or after 3rd year and as much as I love working with the residents in my current role, the vast majority are woefully undertrained and lacking in basic counseling skills. So I would rank psychology (from a reputable program) > MSW/LMHC > psychiatry >NP. Now that said, psychiatrists can pursue additional training after residency to increase counseling competence, but what they receive in residency is lackluster at best.

Are you referencing post-degree training for LCSW/LMHC, or during the actual degree program? I know multiple masters-level providers who received a good amount of psychotherapy training after completing the degree, but who had essentially no practical experience with it, and very limited classroom exposure, during their masters program.

 

[Dr_Bee]

Are you referencing post-degree training for LCSW/LMHC, or during the actual degree program? I know multiple masters-level providers who received a good amount of psychotherapy training after completing the degree, but who had essentially no practical experience with it, and very limited classroom exposure, during their masters program.

I can't speak for LCSWs, but I know for most masters of counseling degree programs they have to complete multiple practica (usually at least two semesters) and meet certain hour requirements before they graduate (this is likely similar to what many psychiatry residencies provide). They (LMHCs) would then be required to completed ~ two years post-graduate supervision (which I believe is similar for LCSW). Granted, I'm sure post-graduate/pre-licensure supervision is wildly variable, but it's two years more supervision than what psychiatry residents receive.

 

[Therapist4Chnge]

In my capacity working with midlevels as a colleague and as a patient, I avoid them as much as possible based on past experiences in both settings.

In my experience, it is very provider dependent. As the years go by, I have more appreciation for solid psychiatrists bc they are hard to find, but I also know some NPs that are scary w an Rx pad. Same for some other speciality areas.

If someone knows before choosing a training program they want to work in psych and prescribe, I encourage them to pursue Psychiatry. It’s not that there aren’t quality midlevels, but I’d rather someone have a shot at the most pharma training and then supplement afterwards for therapy than any other combination.

 

[tr]

The overkill and irrelevance of the first four years of medical school

Sorry just smh at this coming from someone who hasn't been through it.

In Utah you can only prescribe SSRIs.

This sounds pretty smart actually. SSRIs are relatively low risk and useful for lots of things. This is a much more intelligent way to go about providing broader access to care while maintaining safety, vs dumping an unfunded mandate on PCPs to take on the liability for another prescriber.

But for real, you want to prescribe lithium without knowing how to read an EKG?
Lamotrigine without ever having done a dermatology rotation?
Antipsychotics without understanding glucose metabolism and the endocrine system?
This is a case of not knowing what you don't know.

If anyone disagrees with me or thinks I'm insane or dangerous or whatever, I'm open to being wrong, but if you could explain how I'm wrong with real world examples that aren't mere theoreticals 99.99998% of the time I'd love to hear it. Alternatively, any additional advice that I might be missing would be greatly appreciated

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

Varies by patient and presentation of course, but I think the standard emerged because old-school psychoanalysis set an outrageously high opening bid. Amazed we have come down as much as we have from 1-2 hours 3x/week. I often feel like my therapy sessions are maybe 15-20 minutes of actual...

forums.studentdoctor.net

 

[medium rare]

As someone who has done this for the past 15+ years (clinical psychologist who prescribes as a psych NP), the most direct and consistent way to do this is to train as a psychologist first and then pursue PMHNP training - unless you know you want to go into psychiatry. I did my dissertation on RxP and thoroughly investigated all options when I was deciding to train as a prescriber after practicing as a clinical psychologist for several years. The clear best option was PMHNP training. Yes, NP training has its deficiencies but as someone who is already a licensed psychologist, those deficits are negligible.

I’m supportive of RxP for psychologists but the entire movement has been ridiculously slow and disparate. You cannot necessarily move from one RxP state to another just via the required RxP training because the requirements are so varied. Additionally, the required oversight - even if it’s only to get the PCP to approve the Rx represents a huge barrier to efficient practice.

I write dozens of Rx’s in a typical day. If I had to get approval of each PCP for each Rx, that would take days or even weeks. Not to mention that the majority of PCPs know little about mood stabilizers, antipsychotics, treatment-resistant depression strategies, pharmacologic management of OCD, and generally avoid anything to do with a psychostimulant, etc. Sounds simple in theory, much different in practice. And that’s not saying anything about those patients who have no PCP for whatever reason.

RxP for psychologists may evolve to be more commonplace and uniform in the decades to come, but for now it is quite piecemeal and largely ineffective.

 

[Tom4705]

I've been on the RxP board here in Texas and we are submitting our proposal this December to be on to docket for 2025. I am not planning to move at all. I'm a Texan, I'm home. We have several psychologists on our board who prescribe, but do so either in NM or LA. I know one commutes to LA to do so and the other does it via tele-health.

Good luck, I hope the legislation passes. How restrictive do you expect it to be?

 

[Tom4705]

I would mention that it was within the last few years that a New Mexico RxP psychologist got in big trouble due to malpractice in prescribing. So....now we know of at least one case.

What happened? Do you have a link to the story?

 

[Tom4705]

Come over to the Psychiatry forum, we complain about the kind of nonsense we see from PCPs and NPs all the time.

Then I don't see how one could make the case it's the first four years of medical school that makes someone a safe prescriber. If Psych NPs and Prescribing Psychologists do better than PCPs and standard NPs, it would indicate to me it's the direct training in psychopharmacology.

 

[Tom4705]

As someone who has done this for the past 15+ years (clinical psychologist who prescribes as a psych NP), the most direct and consistent way to do this is to train as a psychologist first and then pursue PMHNP training - unless you know you want to go into psychiatry. I did my dissertation on RxP and thoroughly investigated all options when I was deciding to train as a prescriber after practicing as a clinical psychologist for several years. The clear best option was PMHNP training. Yes, NP training has its deficiencies but as someone who is already a licensed psychologist, those deficits are negligible.

I’m supportive of RxP for psychologists but the entire movement has been ridiculously slow and disparate. You cannot necessarily move from one RxP state to another just via the required RxP training because the requirements are so varied. Additionally, the required oversight - even if it’s only to get the PCP to approve the Rx represents a huge barrier to efficient practice.

I write dozens of Rx’s in a typical day. If I had to get approval of each PCP for each Rx, that would take days or even weeks. Not to mention that the majority of PCPs know little about mood stabilizers, antipsychotics, treatment-resistant depression strategies, pharmacologic management of OCD, and generally avoid anything to do with a psychostimulant, etc. Sounds simple in theory, much different in practice. And that’s not saying anything about those patients who have no PCP for whatever reason.

RxP for psychologists may evolve to be more commonplace and uniform in the decades to come, but for now it is quite piecemeal and largely ineffective.

I'm so glad you commented on this post, your insight is always incredibly helpful and unique in that you wear two hats, so to speak. I appreciate you.


From everything ive read and seen I agree with you 100% that psych rxp is impractical and a logistical nightmare. You'd know that better than anyone here, considering you did your dissertation on RXP. (Which by the way I would LOVE to read).


How do you feel that your degree in clinical psychology makes the supposed NP deficits negligible as opposed to if you just had the Psych NP training alone? Also do you mean holistically or just from the pharmacological point of view?


Also, given that you work in a PP, are you in a state that allows NP to operate independently? If not, has physician oversight affected your ability to prescribe in any way?



Also, on the psychotherapy side of things, what modality do you use? Is it CBT? Psychodynamic?

 

[tr]

Then I don't see how one could make the case it's the first four years of medical school that makes someone a safe prescriber. If Psych NPs and Prescribing Psychologists do better than PCPs and standard NPs, it would indicate to me it's the direct training in psychopharmacology.

It's both. The background in physiology and pathology is prerequisite for understanding the psychopharmacology.

If you were already a licensed psychologist who wanted to be able to provide low risk medications to your existing patients without having to route them back through the medical system, RxP would make total sense.

For an undergraduate with an apparent specific interest in complex psychopharmacology, the appropriate path is medical school.

Honestly before I went to med school I thought physicians were just dumb pill dispensers too. It's not like that. The complexity of the human body is unimaginable.

 

[tr]

Just speaking about my experiences being a professor in those programs and teaching them I suppose. To each their own

Also teaching faculty here. Have taught med students, residents, and psychology PhDs. (My PhD is in basic neuroscience.) No contest that a psychology doctorate blows psych residency out of the water for psychotherapy training.

But for someone with a specific interest, it's totally possible to emerge from psychiatry residency as a competent therapist. For those who are not interested, it's also easy to do the bare minimum and emerge with only a very basic and minimal understanding of psychotherapeutic principles.

As with most things, engagement is key. The training is there for those who want it.

 

[clausewitz2]

Then I don't see how one could make the case it's the first four years of medical school that makes someone a safe prescriber. If Psych NPs and Prescribing Psychologists do better than PCPs and standard NPs, it would indicate to me it's the direct training in psychopharmacology.

It's not the four years of med school as much as the years of residency. I agree we have not done a good job of producing outcome studies clearly showing a population-level difference between outcomes with MDs v. NPs. That does not mean we do not see train wrecks with certain characteristics more typically from NPs v. MDs. And yes, there are terrible psychiatrists out there as well who are happy to be the candyman and some NPs are pretty solid.

It is the case however that if you are knowledgeable in these areas and talk to many PMHNPs it emerges quickly that they are deep in "unknown unknowns" territory with many issues but quite confident that they know what they are doing.

I have less problem with psychologists being trained to prescribe medications, y'all are much less likely to assume "well I read this textbook and two papers about a topic, I know pretty much all there is to ever know."

 

[aim-agm]

Honestly before I went to med school I thought physicians were just dumb pill dispensers too. It's not like that. The complexity of the human body is unimaginable.

Another benefit of medical school is that it allows for a pivot if, in the midst of it, you discover a love for a different area of medicine than you expected. You can even switch during residency.

 

[aim-agm]

It is the case however that if you are knowledgeable in these areas and talk to many PMHNPs it emerges quickly that they are deep in "unknown unknowns" territory with many issues but quite confident that they know what they are doing.

I have less problem with psychologists being trained to prescribe medications, y'all are much less likely to assume "well I read this textbook and two papers about a topic, I know pretty much all there is to ever know."

A thought that has occurred to me is that one of the most important skills psychiatric treatment is that of diagnosis. You can go very far with a few relatively simple medications, but you can't even get started without a good approach to diagnosis. Psychologists and Psychiatrists are the two professions best trained to diagnose mental illnesses, albeit with different areas of relative strength.

 

[Therapist4Chnge]

Differential diagnosis is where I have seen some larger gaps in training for NPs & PAs. I did my Rx training (B&M program) at the same time as a friend who did her NP (B&M program), and 75% of her questions to me were around differential diagnosis. Most of my questions for her were around pathophysiology/general medical conditions and how they can impact Rx decision-making.

I completed my training years ago and it was very beneficial for my clinical & research careers bc it enhanced my knowledge, but prescribing day-to-day required jumping through added hoops (& relocating to an Rx state). I make more doing IMEs & legal consulting, so I chose that instead. I could always go back and Rx, but I probably won’t.

 

[texanpsychdoc]

Also teaching faculty here. Have taught med students, residents, and psychology PhDs. (My PhD is in basic neuroscience.) No contest that a psychology doctorate blows psych residency out of the water for psychotherapy training.

But for someone with a specific interest, it's totally possible to emerge from psychiatry residency as a competent therapist. For those who are not interested, it's also easy to do the bare minimum and emerge with only a very basic and minimal understanding of psychotherapeutic principles.

As with most things, engagement is key. The training is there for those who want it.

I remember most of my students would come to me at the end of the term bragging about their new cushy PP job they got (typically in California) that was paying them an insane amount of money. They had zero interest in therapy. Residency didn't emphasize therapy. Typically if those who wanted more of a therapy training, they would seek a fellowship for a year. Which still is not comparison to what a psychologist goes through beginning day one in a Ph.D. or Psy.D. program.

 

[texanpsychdoc]

What happened? Do you have a link to the story?

It was brought up in our board meeting here in Texas. Sadly I do not have an article to point to. Wish I did.

 

[texanpsychdoc]

Good luck, I hope the legislation passes. How restrictive do you expect it to be?

The committee I've been on and the lobby group we have been working with is crafting our proposal to be where there is ZERO physician collaboration required. Our chair would just as well not have it done at all rather than be like Illinois or Colorado (who do require a collaboration or oversight agreement).

 

[Tom4705]

The committee I've been on and the lobby group we have been working with is crafting our proposal to be where there is ZERO physician collaboration required. Our chair would just as well not have it done at all rather than be like Illinois or Colorado (who do require a collaboration or oversight agreement).

That's amazing. I pray it works out! It seems like the only state that doesn't require a collaborative agreement that amounts to a supervising role on the part of a PCP/physician in the long run is Louisiana, at least once you get the "advanced practice" rxp role. Considering that Texas is right there, it would make sense it'd have a decent chance of passing. When is the proposal going to go forward? Is there any way I can keep updated with it?

 

[Tom4705]

Differential diagnosis is where I have seen some larger gaps in training for NPs & PAs. I did my Rx training (B&M program) at the same time as a friend who did her NP (B&M program), and 75% of her questions to me were around differential diagnosis. Most of my questions for her were around pathophysiology/general medical conditions and how they can impact Rx decision-making.

I completed my training years ago and it was very beneficial for my clinical & research careers bc it enhanced my knowledge, but prescribing day-to-day required jumping through added hoops (& relocating to an Rx state). I make more doing IMEs & legal consulting, so I chose that instead. I could always go back and Rx, but I probably won’t.

How much are you making now doing what you do if you don't mind me asking?

 

[Therapist4Chnge]

I work less than full-time, some weeks I work <20hr other weeks it’s 25-30hr. That includes non-billable time, and coordinating with my admin, counselor, and billing company. Working less than full-time I W-2 what I need and keep the rest in my business, but suffice to say I’m comfortable.

My clinical work is mostly chronic pain (often CRPS), mTBI/TBI, PTSD, and adjustment following injury. I provide assessment and consultation, and my counselor provides the follow-up counseling. I decline probably 20% of my clinical referrals and 30% of my legal referrals bc taking a bad case can be costly in time and aggravation.

My hourly rates for clinical & legal are on the high-end, but that helps weed out referrals. Basically, if I can’t bill at least $250-$300/hr, it’s not a good use of my time, and I bill multiples of that for legal and consulting work. As a result, I don’t take commercial insurance, Medicare, or Medicaid bc I lose money on all of them. I’d rather take half days and meet with lawyers, golf, and/or travel with my free time. I also provide pro-bono services and can waive charges for clinical cases, as needed. I also volunteer consulting time for non-profits that align with my beliefs. Add in that time and I “work” 25hr in a week, but largely doing things when I want.

I know I’m an outlier, but it also took years of cultivating the right kind of referrals and building a solid reputation through my work. I’ve never advertised or paid for marketing, but I do network and spend some of my social time/evenings at work events/dinners. I’m about 50/50 in plaintiff and defense work, which is why I have to be picky about my cases.

 

[texanpsychdoc]

That's amazing. I pray it works out! It seems like the only state that doesn't require a collaborative agreement that amounts to a supervising role on the part of a PCP/physician in the long run is Louisiana, at least once you get the "advanced practice" rxp role. Considering that Texas is right there, it would make sense it'd have a decent chance of passing. When is the proposal going to go forward? Is there any way I can keep updated with it?

We will be submitting it in December so it's in time for 2025 legislative cycle. You can try to keep tabs via Google. Once something is made public, you should be able to find it on Google and then just keep checking in on the proposed bill.