Despise for “midlevels” on this forum

[depthpsych]

Long-time reader of these forums.

When it comes to so-called “midlevels” (e.g., LCSWs/LPCs or whatever state-specific iteration of these terminal masters degrees) I am wondering if people here can separate out what is good for clinical psychologists from a financial-, prestige-, and so-on perspective, from what is good for society from a realistic, clinical, healthcare perspective?

Take a random state, like Washington State, for example: There are almost 8 million people in WA State and maybe two doctoral-level clinical psychology Ph.D. programs in the whole state, pumping out, what, maybe 6-7 people a year each, many of whom presumably move out of state, go into academia, into some administrative position, into integrated primary care/health psych, into a specialized field such as pediatric neuropsychology or something, and so on and so forth: Who provides therapy to the regular people of WA State with mental disorders? People with social anxiety disorder, PTSD, MDD, and other folks with disorders that have high prevalence rates?

It’s “midlevels” and Psy.D. folks, right?
(People from Psy.D. programs seem to get just as much flak as people with “midlevel” degrees on this forum, so they’re considered similar in this post).

Second, a different point on the same topic: Can anyone share with me any peer-reviewed, published randomized comparative trials comparing Ph.D. psychologists to Psy.D. psychologists, and trials comparing the former to various “midlevels,” too, showing differential efficacy by provider type when it comes to outpatient therapy (for any disorder)?

Third, I work with a lot of “midlevels” and some are great and know about comparable effect sizes for the unified protocol for the transdiagnostic treatment of emotional disorders relative to other disorder-specific treatments, for example, and try to use applicable ESTs. Characterizing all “midlevels” as scientifically illiterate hacks who do EMDR and play in sandboxes all day is a gross generalization, obviously. It upsets me.

Lastly, has anyone looked at the client and therapist “Treatments that Work”-type workbooks in a while? There is a lot of skill in their application, of course, but we are not talking about engineering rockets to return to the earth unscathed here. I think if a reasonably intelligent and motivated clinician wants to learn an EST for a particular disorder and spends time and energy reading the client/therapist manuals and so on, then they are probably in good shape for treating folks with it. If anything, the manualized “cookbook”-type studied and disseminated treatments maybe even played a role in elevating “midlevels” to a similar status when it comes to outpatient therapy because they are so accessible, though I rarely see that movement bashed on here—and that’s fine: I think it’s probably a net good to have more people across counseling and social work programs learning about and applying ESTs with some fidelity, because there are not enough clinical psychologists with Ph.D.s to meet the need.

I have a Ph.D. in clinical psychology from an R-1. “Midlevel” creep is probably bad for my career, my earning potential, and so on, and in that sense it does suck; but, I have to acknowledge the movement makes good sense when considering other factors and it was probably inevitable when it comes to meeting the demand for outpatient therapy and is a net positive for most Americans seeking mental health services for garden-variety mental disorders.

Can’t both sides be true to an extent? What am I missing?

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[WisNeuro]

Long-time reader of these forums.

When it comes to so-called “midlevels” (e.g., LCSWs/LPCs or whatever state-specific iteration of these terminal masters degrees) I am wondering if people here can separate out what is good for clinical psychologists from a financial-, prestige-, and so-on perspective, from what is good for society from a realistic, clinical, healthcare perspective?

Take a random state, like Washington State, for example: There are almost 8 million people in WA State and maybe two doctoral-level clinical psychology Ph.D. programs in the whole state, pumping out, what, maybe 6-7 people a year each, many of whom presumably move out of state, go into academia, into some administrative position, into integrated primary care/health psych, into a specialized field such as pediatric neuropsychology or something, and so on and so forth: Who provides therapy to the regular people of WA State with mental disorders? People with social anxiety disorder, PTSD, MDD, and other folks with disorders that have high prevalence rates?

It’s “midlevels” and Psy.D. folks, right?
(People from Psy.D. programs seem to get just as much flak as people with “midlevel” degrees on this forum, so they’re considered similar in this post).

Second, a different point on the same topic: Can anyone share with me any peer-reviewed, published randomized comparative trials comparing Ph.D. psychologists to Psy.D. psychologists, and trials comparing the former to various “midlevels,” too, showing differential efficacy by provider type when it comes to outpatient therapy (for any disorder)?

Third, I work with a lot of “midlevels” and some are great and know about comparable effect sizes for the unified protocol for the transdiagnostic treatment of emotional disorders relative to other disorder-specific treatments, for example, and try to use applicable ESTs. Characterizing all “midlevels” as scientifically illiterate hacks who do EMDR and play in sandboxes all day is a gross generalization, obviously. It upsets me.

Lastly, has anyone looked at the client and therapist “Treatments that Work”-type workbooks in a while? There is a lot of skill in their application, of course, but we are not talking about engineering rockets to return to the earth unscathed here. I think if a reasonably intelligent and motivated clinician wants to learn an EST for a particular disorder and spends time and energy reading the client/therapist manuals and so on, then they are probably in good shape for treating folks with it. If anything, the manualized “cookbook”-type studied and disseminated treatments maybe even played a role in elevating “midlevels” to a similar status when it comes to outpatient therapy because they are so accessible, though I rarely see that movement bashed on here—and that’s fine: I think it’s probably a net good to have more people across counseling and social work programs learning about and applying ESTs with some fidelity, because there are not enough clinical psychologists with Ph.D.s to meet the need.

I have a Ph.D. in clinical psychology from an R-1. “Midlevel” creep is probably bad for my career, my earning potential, and so on, and in that sense it does suck; but, I have to acknowledge the movement makes good sense when considering other factors and it was probably inevitable when it comes to meeting the demand for outpatient therapy and is a net positive for most Americans seeking mental health services for garden-variety mental disorders.

Can’t both sides be true to an extent? What am I missing?

Just as a point of reference, people here don't really have a blanket "all PsyDs are bad" attitude, just the diploma mills. The legitimate PsyDs are routinely recommended, moreso if they are funded.

 

[SomeGreatNotion]

Long-time reader of these forums.

When it comes to so-called “midlevels” (e.g., LCSWs/LPCs or whatever state-specific iteration of these terminal masters degrees) I am wondering if people here can separate out what is good for clinical psychologists from a financial-, prestige-, and so-on perspective, from what is good for society from a realistic, clinical, healthcare perspective?

Take a random state, like Washington State, for example: There are almost 8 million people in WA State and maybe two doctoral-level clinical psychology Ph.D. programs in the whole state, pumping out, what, maybe 6-7 people a year each, many of whom presumably move out of state, go into academia, into some administrative position, into integrated primary care/health psych, into a specialized field such as pediatric neuropsychology or something, and so on and so forth: Who provides therapy to the regular people of WA State with mental disorders? People with social anxiety disorder, PTSD, MDD, and other folks with disorders that have high prevalence rates?

It’s “midlevels” and Psy.D. folks, right?
(People from Psy.D. programs seem to get just as much flak as people with “midlevel” degrees on this forum, so they’re considered similar in this post).

Second, a different point on the same topic: Can anyone share with me any peer-reviewed, published randomized comparative trials comparing Ph.D. psychologists to Psy.D. psychologists, and trials comparing the former to various “midlevels,” too, showing differential efficacy by provider type when it comes to outpatient therapy (for any disorder)?

Third, I work with a lot of “midlevels” and some are great and know about comparable effect sizes for the unified protocol for the transdiagnostic treatment of emotional disorders relative to other disorder-specific treatments, for example, and try to use applicable ESTs. Characterizing all “midlevels” as scientifically illiterate hacks who do EMDR and play in sandboxes all day is a gross generalization, obviously. It upsets me.

Lastly, has anyone looked at the client and therapist “Treatments that Work”-type workbooks in a while? There is a lot of skill in their application, of course, but we are not talking about engineering rockets to return to the earth unscathed here. I think if a reasonably intelligent and motivated clinician wants to learn an EST for a particular disorder and spends time and energy reading the client/therapist manuals and so on, then they are probably in good shape for treating folks with it. If anything, the manualized “cookbook”-type studied and disseminated treatments maybe even played a role in elevating “midlevels” to a similar status when it comes to outpatient therapy because they are so accessible, though I rarely see that movement bashed on here—and that’s fine: I think it’s probably a net good to have more people across counseling and social work programs learning about and applying ESTs with some fidelity, because there are not enough clinical psychologists with Ph.D.s to meet the need.

I have a Ph.D. in clinical psychology from an R-1. “Midlevel” creep is probably bad for my career, my earning potential, and so on, and in that sense it does suck; but, I have to acknowledge the movement makes good sense when considering other factors and it was probably inevitable when it comes to meeting the demand for outpatient therapy and is a net positive for most Americans seeking mental health services for garden-variety mental disorders.

Can’t both sides be true to an extent? What am I missing?

It's not that you're missing anything but rather this forum functions as a way for providers to vent (as the VA thread title suggests). Is some of it gross generalization or unfair scapegoating? Probably...but it also reflects real experiences that providers encounter. I would also suggest to view these forums as less a reflection of some objective truth and more like community-building of like-minded (sometimes) providers. Unfortunately community-building typically involves ingrouping/outgrouping as unfair as that may be.

 

[Dazen]

Personal opinion as a clinical PhD student of what I’ve gathered as common lines of reasoning that I also generally agree with related to your post:

1. Midlevels and doctoral providers have pretty similar earning potential and opportunity when it comes to outpatient therapy, give that success here is frequently based on marketing/networking. If someone’s primary goal is to provide outpatient therapy, a masters degree is a very reasonable option. Also, a good deal of research shows that therapeutic alliance primarily matters for less severe presenting concerns.

2. Similar to 1, the primary areas of differentiation between midlevel and doctoral level providers are in assessment and specialty areas (e.g., forensic, neuro). These are the primary reasons to pursue a doctoral degree if you’re interested in a clinical career (obviously if you’re research focused, the doctorate makes sense). Although there are people who get the doctorate to have more intensive training in therapy, it’s less clear if there’s a financial benefit for this path.

3. Anyone practicing or promoting pseudoscientific techniques hurts the profession. This can happen at any level of training, but is more likely to be supported by midlevels because they have less rigorous scientific training. That doesn’t mean any individual person with a masters doesn’t understand ESTs or is inherently less capable at learning. They’ve just on average had less exposure to the concepts and research methodology and therefore shouldn’t be expected to know as much.

4. The doctoral degree isn’t the solution to the current mental health crisis. As was mentioned, there are only so many students who can be trained through a research mentor model yearly and that won’t keep up with demand for services and the path takes far longer. Having more well-trained masters-level providers will fill this gap much more efficiently from a public health perspective.

Obviously none of this is rocket science, but I wanted to summarize what I’ve taken away from being mostly a lurker on these forums over the years, since it seems pretty different from the OP’s experience. I often recommend the masters route to people who have no stated interest in research or assessment because the PhD seems like overkill for them. I’m also personally protective of the PhD remaining a research degree and not getting rid of the mentor model, because there is also a continued need for psychology research. I’m also biased as someone who’s primarily researched focused though.

Feel free to push back on this because I’m definitely still learning about the profession beyond school. I just find these conversations really interesting.

 

[bcliff]

Can’t both sides be true to an extent? What am I missing?

Pulled the following text from the thread discussing pros and cons of considering removal of the predoctoral internship - I feel like the bolded sentence reflects the frustration of many providers. You'll notice that midlevels are not mentioned at all:

Conservative Public: "Therapy is just talking to someone about yourself and feeling validated, it doesn't actually help or fix anything, just keeps therapists with a job."
(Some) Psychologists: "No that's not it at all. Actual therapy is based in empiricism and years of education, training, and experience."
(Other) Psychologists: "I can treat everything with EMDR, reiki, and supportive listening. Your feelings are always valid and i will never challenge you. I went to the international school of professional psychology by the way and we were taught everything there."

We've done this to ourselves. There's more bad therapists than good ones. What other fields can we say that about? (i know there's probably some but I have a hard time thinking of one in healthcare....maybe chiropractic.).

I think in daily practice, most of us are openminded and results-oriented. I refer patients I see for neuropsychological evaluation to a wide range of providers, including social workers and counselors, particularly if I've had a positive interaction with them and/or have been impressed by their work, documentation, etc. - To your point, OP, often I'm referring to midlevels because those are either the only providers in the area or the only providers in the area who except my patient's insurance.

 

[Sanman]

A few things are being conflated here and need to be addressed. I will only speak for myself though. So, things I hate:

1. Poor financial decisions and undue financial burden - It is bad for the individual and can lead to unethical decisions. You are more likely to just take people's money when under severe financial pressure. This is not a PhD vs PsyD issue. Funded PsyD programs exist.

2. Poor clinical treatment - this hurts the public and the field as a whole because bad treatment gives us a bad reputation.

3. Lowering of educational standards - again poor training leads to clinicians that practice poorly.

4. Laziness - see point 3

5. Decreasing clinical reimbursements and lack of renumeration for specialist training - this drives the dumbing down of training and outcomes.

Notice, there is no specific degree or level of education required. Don't drown yourself in debt, learn how to do good work, do good work. That's it.

As for putting aside my personal and financial bias, I am. Financially, I want as many mid-levels and PsyDs as possible pumped out with poor educations and tons of debt. Being mid career and having minimal debt, it is easy to go out, bankroll a practice, and pay these folks a 50/50 split. They won't know any better and tons of student loans means they will be subservient little employees who need regular cash flow to make their payments and I can squeeze for more productivity. Easy road to getting rich. I started my career in companies like this, I know how to copy that playbook. Doesn't mean it is good for the younger clinicians or the public. I can name several companies paying clinicians $80k to see 12 patients/day. Sound good to you?

 

[PikminOC]

Access to care will always be an issue. So why not pump out people after a bachelor's or a high school degree who are "reasonably intelligent and motivated clinician wants to learn an EST for a particular disorder and spends time and energy reading the client/therapist manuals and so on, then they are probably in good shape for treating folks with it. "

Where's the line? Where should it be drawn? Should there be a line?

 

[WisNeuro]

Speaking of the "just read and implement the treatment manual" mentality, that's exactly part of the problem with some midlevels and more poorly trained doctoral therapists. The manual is setting a very loose scaffolding, if you don't have the solid foundation of understanding of theory and practice with the underlying modality (CBT, psychodynamic, etc) you are doing a great disservice to the patient. Add to that the aforementioned inability for most to properly evaluate research, and that's how we get Brainspotting, EMDR, somatic work, etc. If that upsets people, I really don't care. We should be more upset at poor patient care and pseudoscience abounding than mean words.

 

[depthpsych]

Access to care will always be an issue. So why not pump out people after a bachelor's or a high school degree who are "reasonably intelligent and motivated clinician wants to learn an EST for a particular disorder and spends time and energy reading the client/therapist manuals and so on, then they are probably in good shape for treating folks with it. "

Where's the line? Where should it be drawn? Should there be a line?

The operative word was “clinician”—in the US implying a college degree, two additional years for a graduate degree, and 2,000+ hours (give or take based on state-by-state variations in licensure requirements) of post-graduate supervised clinical experience.

It’s a good question about the line and where it should best be drawn. We do probably underestimate the effectiveness of paraprofessionals.

 

[PsyDr]

Well, you’re missing the part where your opinions only require your feelings as evidence but others’ opinions demand more stringent evidence.

 

[depthpsych]

Well, you’re missing the part where your opinions only require your feelings as evidence but others’ opinions demand more stringent evidence.

Can you be more specific about what part you’re referring to?

The part where I asked for any empirical evidence to suggest that clinical psychologists with Ph.D.’s outperform other mental health providers when it comes to outpatient therapy and nobody responded with any research findings?

(By contrast, there is a body of research findings on the comparative effectiveness of paraprofessional versus professional helpers.)

 

[PikminOC]

Can you be more specific about what part you’re referring to?

The part where I asked for any empirical evidence to suggest that clinical psychologists with Ph.D.’s outperform other mental health providers when it comes to outpatient therapy and nobody responded with any research findings?

(By contrast, there is a body of research findings on the comparative effectiveness of paraprofessional versus professional helpers.)

Pls post your citations

 

[PikminOC]

What about "reasonably intelligent and motivated PERSON" to be more inclusive?

 

[PsyDr]

Can you be more specific about what part you’re referring to?

.....

Sure

Second, a different point on the same topic: Can anyone share with me any peer-reviewed, published randomized comparative trials comparing Ph.D. psychologists to Psy.D. psychologists, and trials comparing the former to various “midlevels,” too, showing differential efficacy by provider type when it comes to outpatient therapy (for any disorder)?

Third, I work with a lot of “midlevels” and some are great and know about comparable effect sizes for the unified protocol for the transdiagnostic treatment of emotional disorders relative to other disorder-specific treatments, for example, and try to use applicable ESTs. Characterizing all “midlevels” as scientifically illiterate hacks who do EMDR and play in sandboxes all day is a gross generalization, obviously. It upsets me.

.....

Can’t both sides be true to an extent? What am I missing?

Your third point is based upon your own emotions, and experience. That appears to be sufficient proof to you, for that specific point. If you change the subject of the argument, but maintain the structure, it falls apart. What is the difference between your experience and someone else's? Whose is more valid?

This is preceded by your second point: a demand for the highest level of empirical evidence to refute a point that is supported by a much lower level of evidence.

It's like saying, "I read one published article that vaccines cause autism. I need RCT evidence to disprove that to me. Plus, my nephew got the autism after inoculation, and I just know that caused that." It's a dishonest argument structure.

 

[cara susanna]

I wouldn't say that all midlevels are bad! I've been very open that I know some who are excellent clinicians, who stick very closely to evidence-based practice. I DO think that midlevels are susceptible to non-evidence based therapy approaches because they just don't get the scientific training that we do. It isn't a bad thing, but it is a limitation to their training and one that I'm not sure they're always aware of. Granted, my opinion is probably being heavily influenced by what I've seen in r/psychotherapy on Reddit, meaning comments from posters whose flair identifies them as midlevel therapists.

 

[PsyDr]

Point of Order:

You guys realize ALL psychologists are midlevels, right? Ever wonder why Medicare requires us to get a referral before we can provide services?

 

[WisNeuro]

Point of Order:

You guys realize ALL psychologists are midlevels, right? Ever wonder why Medicare requires us to get a referral before we can provide services?

In that sense, I'd agree. Personally, I'm going by level of education. Master's level being "midway" between an iundergraduate degree and a doctoral degree.

 

[depthpsych]

Sure




Your third point is based upon your own emotions, and experience. That appears to be sufficient proof to you, for that specific point. If you change the subject of the argument, but maintain the structure, it falls apart. What is the difference between your experience and someone else's? Whose is more valid?

This is preceded by your second point: a demand for the highest level of empirical evidence to refute a point that is supported by a much lower level of evidence.

It's like saying, "I read one published article that vaccines cause autism. I need RCT evidence to disprove that to me. Plus, my nephew got the autism after inoculation, and I just know that caused that." It's a dishonest argument structure.

Thanks for your response and some fair points. It was a spur-of-the moment, emotion-driven, rant in many ways and I was trying to do too much with it.

I also realize I was making a gross generalization (i.e., that all SDN members in this forum view all midlevels as pseudoscientific hacks) in an effort to combat a gross generalization (i.e., that all midlevels are pseudoscientific hacks).

Still, I think some general sentiments hold up or at least worthy of consideration.

For example, someone up there posted that midlevels weren’t mentioned in a claim from another thread about how:
A) “there’s more bad therapists than good ones”
But, if we acknowledge that:
B) most therapists are midlevels now
Then:
C) most midlevels are bad therapists

It seems an implicit view held by some posters.

I do recognize, as someone else noted, that oftentimes when somebody just wants to do therapy and is asking for advice they are often encouraged to do a terminal masters degree in this forum, and I agree with that advice as it’s probably the best route for most barring a passion for research, teaching, and so on. However, some frequent-flyer posters seem to have a rather unsavory view about such routes and the competencies of the folks who have completed them, so that disconnect confuses me: Why recommend a route if one believes the route produces incompetent providers on the whole?

On that note, I would be interested in the “much lower level of evidence” that suggests that doctoral-level folks with Ph.D.’s outperform midlevels when it comes to outpatient if the highest standard is not available (which you’re right, it is not, as it was a rhetorical question and I guess in that sense dishonest).

 

[WisNeuro]

Thanks for your response and some fair points. It was a spur-of-the moment, emotion-driven, rant in many ways and I was trying to do too much with it.

I also realize I was making a gross generalization (i.e., that all SDN members in this forum view all midlevels as pseudoscientific hacks) in an effort to combat a gross generalization (i.e., that all midlevels are pseudoscientific hacks).

Still, I think some general sentiments hold up or at least worthy of consideration.

For example, someone up there posted that midlevels weren’t mentioned in a claim from another thread about how:
A) “there’s more bad therapists than good ones”
But, if we acknowledge that:
B) most therapists are midlevels now
Then:
C) most midlevels are bad therapists

It seems an implicit view held by some posters.

I do recognize, as someone else noted, that oftentimes when somebody just wants to do therapy and is asking for advice they are often encouraged to do a terminal masters degree in this forum, and I agree with that advice as it’s probably the best route for most barring a passion for research, teaching, and so on. However, some frequent-flyer posters seem to have a rather unsavory view about such routes and the competencies of the folks who have completed them, so that disconnect confuses me: Why recommend a route if one believes the route produces incompetent providers on the whole?

On that note, I would be interested in the “much lower level of evidence” that suggests that doctoral-level folks with Ph.D.’s outperform midlevels when it comes to outpatient if the highest standard is not available (which you’re right, it is not, as it was a rhetorical question and I guess in that sense dishonest).

Because if it's between a diploma mill and a masters degree, the competence and training is the same, but one is just a much better ROI. When people are locked into a certain path (I don't want to move and I don't want to do an ounce of research), the pragmatic path is pretty easy to see.

 

[Sanman]

Because if it's between a diploma mill and a masters degree, the competence and training is the same, but one is just a much better ROI. When people are locked into a certain path (I don't want to move and I don't want to do an ounce of research), the pragmatic path is pretty easy to see.

I will also add that until recently SW has had the upper hand in access to Medicare billing, acceptance by the VA system, etc. That they may not provide the best psychotherapy training is secondary to having the best advocacy. Counseling has significant problems with folks properly gaining post-doc hours and getting licensed in many states. Better poorly trained licensed provider than not licensed at all? At least from the perspective of the one paying all the money.

 

[depthpsych]

Pls post your citations

Sure thing, though full disclosure it’s not my main area, and I suspect there are methodological issues and so on, but this research area exists and a cursory review of the findings seem to suggest that the notion of paraprofessional helpers being effective—perhaps in some limited contexts with specific patient populations—is seemingly less outrageous than many psychologists would suspect who tend to shy away from questioning and empirically examining untested assumptions in the field.

I listed a subset of publications:

Hattie, J. A., Sharpley, C. F., & Rogers, H. J. (1984). Comparative effectiveness of professional and paraprofessional helpers. Psychological Bulletin, 95(3), 534–541. https://doi.org/10.1037/0033-2909.95.3.534

Montgomery EC, Kunik ME, Wilson N, Stanley MA, Weiss B. Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms? Bulletin of the Menninger Clinic 2010; 74(1): 45-62. [PubMed]

Bright, J. I., Baker, K. D., & Neimeyer, R. A. (1999). Professional and paraprofessional group treatments for depression: A comparison of cognitive-behavioral and mutual support interventions. Journal of Consulting and Clinical Psychology, 67(4), 491–501. https://doi.org/10.1037/0022-006X.67.4.491

Christensen, A., & Jacobson, N. S. (1994). Who (or What) Can Do Psychotherapy: The Status and Challenge of Nonprofessional Therapies. Psychological Science, 5(1), 8–14. https://doi.org/10.1111/j.1467-9280.1994.tb00606.x

 

[PikminOC]

Sure thing, though full disclosure it’s not my main area, and I suspect there are methodological issues and so on, but this research area exists and a cursory review of the findings seem to suggest that the notion of paraprofessional helpers being effective—perhaps in some limited contexts with specific patient populations—is seemingly less outrageous than many psychologists would suspect who tend to shy away from questioning and empirically examining untested assumptions in the field.

I listed a subset of publications:

Hattie, J. A., Sharpley, C. F., & Rogers, H. J. (1984). Comparative effectiveness of professional and paraprofessional helpers. Psychological Bulletin, 95(3), 534–541. https://doi.org/10.1037/0033-2909.95.3.534

Montgomery EC, Kunik ME, Wilson N, Stanley MA, Weiss B. Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms? Bulletin of the Menninger Clinic 2010; 74(1): 45-62. [PubMed]

Bright, J. I., Baker, K. D., & Neimeyer, R. A. (1999). Professional and paraprofessional group treatments for depression: A comparison of cognitive-behavioral and mutual support interventions. Journal of Consulting and Clinical Psychology, 67(4), 491–501. https://doi.org/10.1037/0022-006X.67.4.491

Christensen, A., & Jacobson, N. S. (1994). Who (or What) Can Do Psychotherapy: The Status and Challenge of Nonprofessional Therapies. Psychological Science, 5(1), 8–14. https://doi.org/10.1111/j.1467-9280.1994.tb00606.x

Those a very old papers. Nowadays the training for midlevels has been reduced to online schools. Not sure that can be compared.

And when it comes in midlevels in my field, when the nursing associates do the studies their effectiveness is labeled and equal, but then the physicians do the studies the results are that they are not.

Once again, even in my field, where do you draw the line? A two year community college course to learn the meds? Less or more and why?

 

[WisNeuro]

Age of studies is not necessarily an issue. When these studies talk about paraprofessionals, some of these aren't even midlevels. But, they are also dealing with mild reported symptoms in group format in one of the studies. It also had a problem with groups being unequal at baseline, no randomization, insufficient follow-up and no ITT analyses. another one had a pretty low n, 98 participants divided between 14 providers.

Age isn't really the issue here, but poor methodology most definitely is. It's worthy of empirical consideration, but these studies are weak evidence, at best.

 

[PikminOC]

Age of studies is not necessarily an issue. When these studies talk about paraprofessionals, some of these aren't even midlevels. But, they are also dealing with mild reported symptoms in group format in one of the studies. It also had a problem with groups being unequal at baseline, no randomization, insufficient follow-up and no ITT analyses. another one had a pretty low n, 98 participants divided between 14 providers.

Age isn't really the issue here, but poor methodology most definitely is. It's worthy of empirical consideration, but these studies are weak evidence, at best.

It can be both. Not mutually exclusive. I have been surprised by the race to the bottom with current training.

 

[WisNeuro]

It can be both. Not mutually exclusive. I have been surprised by the race to the bottom with current training.

It can be, if it's relevant. But, all too often I see people rejecting studies based on age, when the data and methodology are sound and age of the data has nothing to do with the conclusions. In and of itself, age of the study is not a valid criticism.

 

[PikminOC]

It can be, if it's relevant. But, all too often I see people rejecting studies based on age, when the data and methodology are sound and age of the data has nothing to do with the conclusions. In and of itself, age of the study is not a valid criticism.

I think it is when the training is very different now compared to them. If the training was the same it wouldn't be a valid criticism in my eyes

 

[Sanman]

Age of studies is not necessarily an issue. When these studies talk about paraprofessionals, some of these aren't even midlevels. But, they are also dealing with mild reported symptoms in group format in one of the studies. It also had a problem with groups being unequal at baseline, no randomization, insufficient follow-up and no ITT analyses. another one had a pretty low n, 98 participants divided between 14 providers.

Age isn't really the issue here, but poor methodology most definitely is. It's worthy of empirical consideration, but these studies are weak evidence, at best.

Lets also add that in most of the paraprofessional studies, the clients were properly diagnosed by a professional and paraprofessionals utilized methods taught and supervised by professionals. That is not how the real world works. No one said a bachelors level paraprofessional cannot be adequately taught how to conduct manualized CBT. Now, lets see the studies on accuracy of diagnosis and ethical violations between groups.

 

[WisNeuro]

I think it is when the training is very different now compared to them. If the training was the same it wouldn't be a valid criticism in my eyes

Sure, but that's actually besides the point in these articles. These articles are essentially saying that minimally trained lay people can deliver a manualized format that leads to similar outcomes. When this happened is largely irrelevant to that particular question, the age of the study really doesn't matter as it has no bearing on that particular scope. And, to your point, as midlevels would have more training than a layperson, your age of study criticism is even more irrelevant.

These studies have significant methodological limitations, but the time of study isn't one of them. We can focus on those without getting lost in the weeds on irrelevant things.

 

[WisNeuro]

Lets also add that in most of the paraprofessional studies, the clients were properly diagnosed by a professional and paraprofessionals utilized methods taught and supervised by professionals. That is not how the real world works. No one said a bachelors level paraprofessional cannot be adequately taught how to conduct manualized CBT. Now, lets see the studies on accuracy of diagnosis and ethical violations between groups.

Definitely an issue. Additionally, at least in some of the studies, the problem using very mild symptoms of something like depression. Pretty much any "intervention" will lead to positive change, at least in the short-term.

 

[PikminOC]

Lets also add that in most of the paraprofessional studies, the clients were properly diagnosed by a professional and paraprofessionals utilized methods taught and supervised by professionals. That is not how the real world works. No one said a bachelors level paraprofessional cannot be adequately taught how to conduct manualized CBT. Now, lets see the studies on accuracy of diagnosis and ethical violations between groups.

Irl I don't see any therapist doing manual cbt

 

[Sanman]

Irl I don't see any therapist doing manual cbt

I have done and continue to do it some circumstances.

 

[PikminOC]

Definitely an issue. Additionally, at least in some of the studies, the problem using very mild symptoms of something like depression. Pretty much any "intervention" will lead to positive change, at least in the short-term.

Exactly which is why in medication trials the meds have to separate from placebo which includes those improvements you refer to

 

[PikminOC]

I have done and continue to do it some circumstances.

Correct I am telling you what I see, not what you do

 

[Sanman]

Correct I am telling you what I see, not what you do

I am saying it is out there. Manualized/protocol therapies are quite common in systems like the VA assuming there is adequate staffing. In the private practice world, it is often very different (at least in the U.S.). This is because of the way we reimburse therapists. Supportive talk therapy with no prep is reimbursed the same as manualized therapies that require more prep work. Guess what happens when you reimburse more work and less work at the same rate? Unlike physicians, we don't get to bill on patient/case complexity.

 

[PikminOC]

I am saying it is out there. Manualized/protocol therapies are quite common in systems like the VA assuming there is adequate staffing. In the private practice world, it is often very different (at least in the U.S.). This is because of the way we reimburse therapists. Supportive talk therapy with no prep is reimbursed the same as manualized therapies that require more prep work. Guess what happens when you reimburse more work and less work at the same rate? Unlike physicians, we don't get to bill on patieent/case complexity.

Yes I'm in the real world. Not in the VA system

 

[WisNeuro]

Manualized treatments still get plenty of play outside of the VA.

 

[PikminOC]

Manualized treatments still get plenty of play outside of the VA.

I'm talking about my experience

 

[Sanman]

Manualized treatments still get plenty of play outside of the VA.

Especially if it is an EMDR manual.

 

[WisNeuro]

I'm talking about my experience

Same. I've never had a problem finding these treatments for patient referrals anywhere I've worked.

 

[WisNeuro]

Especially if it is an EMDR manual.

Don't get me started...

 

[Sanman]

Don't get me started...

Symptoms of a broken system. In much of Europe, only time limited EBPs such as CBT are offered on the government dime.

 

[WisNeuro]

Symptoms of a broken system. In much of Europe, only time limited EBPs such as CBT are offered on the government dime.

For most circumstances, probably how it should be.

 

[PikminOC]

Symptoms of a broken system. In much of Europe, only time limited EBPs such as CBT are offered on the government dime.

Government dime = taxpayer funded

 

[Sanman]

Government dime = taxpayer funded

So is Medicare/Medicaid and they pretty much allow anything based on their written guidelines.

 

[PsyDr]

On that note, I would be interested in the “much lower level of evidence” that suggests that doctoral-level folks with Ph.D.’s outperform midlevels when it comes to outpatient if the highest standard is not available (which you’re right, it is not, as it was a rhetorical question and I guess in that sense dishonest).

1) I never made any of those assertions.

2) I, too, am interested in things. And I For example, I would be interested to get the contact information of a private, FAA approved , instructor for Airships. Which set of interests demands action?

3) You are expressing opinions (e.g., your appraisal of some observed masters' levels). Why can't others have differing opinions?

 

[PikminOC]

1) I never made any of those assertions.

2) I, too, am interested in things. And I For example, I would be interested to get the contact information of a private, FAA approved , instructor for Airships. Which set of interests demands action?

3) You are expressing opinions (e.g., your appraisal of some observed masters' levels). Why can't others have differing opinions?

We can all.have different opinions. At least I hope so.

 

[depthpsych]

This is preceded by your second point: a demand for the highest level of empirical evidence to refute a point that is supported by a much lower level of evidence.

Maybe I misunderstood you: I thought you were suggesting that, although we don’t have gold-standard evidence from RCTs that clinical psychologists with Ph.D.’s outperform midlevels when it comes to therapy, that there is a “lower level of evidence” to refute the notion that they are equivalent. I was interested in that evidence, because I’ve never seen it to my knowledge.

You don’t have to respond, of course, can be interested in other things, and thankfully we are all entitled to our own opinions.

 

[Sanman]

Maybe I misunderstood you: I thought you were suggesting that, although we don’t have gold-standard evidence from RCTs that clinical psychologists with Ph.D.’s outperform midlevels when it comes to therapy, that there is a “lower level of evidence” to refute the notion that they are equivalent. I was interested in that evidence, because I’ve never seen it to my knowledge.

You don’t have to respond, of course, can be interested in other things, and thankfully we are all entitled to our own opinions.

No, he was saying that you are presenting your feelings in the OP with no facts and simultaneously asking others to back up their opinions with facts because you disagree with them. If you want to argue research, pick some literature and we can discuss the limitations. If you want to argue anecdotal opinions, well we all have them and your opinion is unlikely to change anyone else's opinion.

 

[PsyDr]

Maybe I misunderstood you: I thought you were suggesting that, although we don’t have gold-standard evidence from RCTs that clinical psychologists with Ph.D.’s outperform midlevels when it comes to therapy, that there is a “lower level of evidence” to refute the notion that they are equivalent. I was interested in that evidence, because I’ve never seen it to my knowledge.

You don’t have to respond, of course, can be interested in other things, and thankfully we are all entitled to our own opinions.

A. You're mixing opinions and empirically supported positions.


i. If the matter is of opinion, then yours is no better than anyone else's.

ii. If the matter is of an empirical nature, then you have offered a position and your required level of evidence. Since it is your assertion, then the onus is on you.

 

[depthpsych]

The null hypothesis is that there is no difference between the two provider types.

The alternative hypothesis is that there is a difference between the two types, favoring fully-funded doctoral-level practitioners over midlevels (an assertion postulated or alluded to on this forum by posters in various threads that preceded and inspired my OP). It seems like a semantics game.

If there are no good data to reject the null hypothesis then that’s fine: Absence of evidence is not evidence of absence and so on. Maybe it is quite unfair and unreasonable to start a thread asking for empirical evidence and I can see Sanman’s point about that sort of posting being discouraged or annoying and problematic.

(I’ll just hangout until condescending comments are made in another thread about midlevels and their effectiveness as a whole relative to clinical psychologists, then I’ll pop back on, the onus will be on them—since it will be their assertion—and we can continue this same conversation then I guess.)