My Opinions

An Introduction

As managed care continues to make substantial changes in the field of behavioral healthcare, it is important to understand what you are paying for with your health care monies. There is a great degree of difference between professionals degrees in this field, and those differences may affect the effectiveness and quality of your psychotherapy work.

In nearly every state in the U.S., therapists must be licensed to practice (e.g., receive a fee for services) under specific, protected titles. For instance, the terms “psychologist” and “psychiatrist” are protected legal terms in every state and, when referring to providing clinical services, can only be used by properly licensed professionals. Ideally, such licensure helps to ensure that the professional has passed a minimum set of qualifications via a written examination and that if a problem arises with their provision of professional services, the authorities of that state have some recourse. In the real world, however, bad therapists obtain licensure all the time and the redress procedures for filing a complaint against a therapist nearly always favor the therapist. Nevertheless, when shopping for a therapist, make sure the professional is licensed whenever possible. I wrote for Mental Help Net.)

And yes, you should shop and compare therapists, just like you would in making any important life decision. You will spend a fair amount of your hard-earned money to pay for the therapist’s services (whether it’s done out of pocket or via your insurance/HMO premiums). You deserve to know basic information about the professional you are about to trust your innermost feelings and thoughts to, including their professional background, their educational background, how many years they’ve been practicing, and how much experience they’ve had in helping people with problems similar to your own. The more experience they’ve had and the longer they’ve been in practice are usually two of the best indicators to look for in finding a suitable clinician. A professional, regardless of their educational background, who has had 20 years of therapy experience and has worked with dozens of individuals presenting with problems similar to your own is much more likely to be of help to you than someone with 2 years of experience and you’re the first person they’ve seen with your particular mental health concern. (It makes sense, doesn’t it? The research backs up this view.)

Keep in mind that if you find your first choice in a therapist isn’t working out, give the therapist a pink slip and ask for a referral to one of his or her colleagues. Remember, the therapist works for you. If you don’t feel like you’re clicking after a few sessions, or the therapist isn’t listening to your concerns or providing you with enough feedback in your sessions, let them know. Don’t be afraid to change therapists if your concerns aren’t adequately addressed to your satisfaction.

There are a number of degrees which I didn’t cover in my original writings, but which are included in the other people’s comments section. These degrees/clinicians include licensed professional counselors, marriage and family counselors, and psychiatric nurses, to name a few.

Psychologist (Ph.D)

Doctorate of Philosophy (Research degree)

General description: Doctoral degree in either clinical or counseling psychology

This is the traditional degree of practicing, academic, and research psychologists. Training includes courses in psychological assessment, theories and practice of different types of psychotherapy, research and statistics, as well as diagnosis and ethics. A dissertation is required which must be defended. The emphasis of this degree is on research and theory, much more so than any other degree discussed here. A pre-internship experience (called a practicum) is usually an integral part of the program. Some programs require multiple practicums. The average length of a Ph.D program is 6 to 7 years. Ph.D psychologists most often pursue careers in academia or practice.

The differences between a Ph.D psychologist who graduated from a clinical program as opposed to a counseling program are minimal. Clinical programs, which are more widespread, tend to focus more on serious mental illness (e.g., depression, schizophrenia, anxiety, etc.), its assessment and treatment. Counseling programs tend to focus more on change-of-life issues (e.g., divorce, relationship problems, academic problems, etc.) and assessment of those problems. However, this is a broad generalization and the actual experiences of the clinician will vary according to the program they graduated from.

As an interesting side note, psychologists are now trying to gain prescription privileges. Given their lack of medical training and education, where is the wisdom in such a misguided attempt to gain ground on psychiatrists?

Psychologist (Psy.D)

Doctorate of Psychology (Professional degree)

General description: Doctoral degree in clinical psychology.

This is a newer (circa. 1968) degree offered to those individuals interested exclusively in the practice of psychology. Its focus tends to be more clinically-oriented than the traditional Ph.D, offering more pre-internship experience and practical coursework, in lieu of courses on research and statistics (although most Psy.D programs also require a dissertation). Some programs require up to three practicum experiences before internship. These practicums typically are 15-25 hours per week, for an entire year. Therefore, some graduate students in these programs will graduate with over 1,500 – 2,500 pre-internship clinical hours, and gain another 1,000 – 2,000 hours while on internship. This amount of direct clinical training experience is equaled by no other profession today (nor do any come close). These clinical experiences cover all aspects of treatment, modalities, and settings in mental health, from community mental health centers and day treatment programs, to geriatric and university counseling centers.

If the Psy.D program doesn’t require a dissertation (which generally includes the authoring of original research), it will have a requirement for a research paper with less of an emphasis on creating original research. The research paper can be a literature review or some other similar type of contribution to the field.

The average length of a Psy.D program is 5 to 6 years. Most Psy.D psychologists pursue careers in practice, although some also enter into research and academia. As with the above doctoral degree, psychologists aren’t eligible to become licensed in a state (a legal distinction, not an educational one) until at least one year after receiving their degree. Licensure typically involves a certain amount of additional supervised clinical hours, and receiving a certain minimum score on a national and state psychology licensing examination.

Counselor/Therapist (M.A., M.S.)

Master of Arts/Master of Science

General description: Master’s degree in clinical or counseling psychology

For many graduate programs, this is a prerequisite before admittance. Most programs are two years in length and end in the defense of a thesis. Many programs offer terminal degrees, which allows individuals to not go on and pursue a doctoral degree, but go out into the world with the Master’s degree alone. Master’s level therapists are usually trained in psychotherapy techniques, but have little or no courses in psychological assessment, theory, and research. Most Master’s students either go on for their doctorate or become general psychotherapists.

Social Worker (M.S.W., Ph.D)

Master of Social Work/Doctorate of Philosophy

General description: Master’s or doctoral degree in social work

Social work programs range in length from two to three years, and include some practical experience (through either practica or internships). Like the M.S. degree above, social work students are trained in psychotherapy and social work techniques and background, with an emphasis in most programs toward integrating people within community resources. Most social work students go on into careers as social workers and general psychotherapists. Family therapists and EAP counselors are also often M.S.W.’s (or L.C.S.W.’s – Licensed Counselor of Social Work, a legal distinction not made in the degree, but requiring the therapist to undergo examination for licensing in that particular state).

There is also a distinction between a (licensed) clinical social worker and a general social worker. To become a clinical social worker, I’m told many graduates of the social work degree then go on to a two- to four-year institution to get more specialized training in a particular type of therapy or milieu. It should be noted, though, that this training is not required by most states for a person with a degree in social work to do psychotherapy.

The terms used to describe social workers vary from state to state, and may include such titles as: Licensed Counselor of Social Work, Counselor of Social Work, psychotherapist, therapist, etc.

Psychiatrist (M.D.)

Medical degree

General description: Medical degree with a specialty in psychiatry

Psychiatrists start out as regular doctors, traditionally with four years of medical school after college. During this time, physicians interested in specializing in psychiatry will typically take clinical electives in topics relating to psychiatry and a clinical rotation in psychiatry.

Psychiatrists then go on to complete a residency in psychiatry. A psychiatric residency typically involves three to four years of additional clinical training, generally in a hospital setting. Experience in medication management, inpatient and outpatient treatment modalities, and crisis evaluations is usually gained during the physician’s residency. Psychiatric residents will typically have didactic training in the form of seminars on common mental health topics, such as psychotherapy, professional ethics, psychological assessment, etc. The quality and content of these seminars varies widely from residency to residency. Outside of their residency experiences, psychiatrists typically have no formal educational background in psychological assessment, research, or in the practice or theory of psychotherapy. Psychiatric residencies generally do not prepare psychiatrists for work in research or understanding the complex statistics used in most research today.

Psychiatrists gain licensure when they graduate from medical school; there is no separate license for the specific practice of psychiatry. However, some psychiatrists will choose to apply for board certification in psychiatry to demonstrate they have received specific, additional training and education. Other psychiatrists still choose to go into a psychoanalytic institute after residency and get more formal training in the practices of psychiatry through a psychoanalytic or psychodynamic orientation, but this is strictly a personal choice. Psychiatrists are the only mental health professionals who can prescribe medication and nowadays, this is the majority of what psychiatrists spend their time doing for the treatment of most mental disorders. Psychiatrists sometimes still practice some type of psychotherapy, especially if they’re in a private practice.

Other People’s Comments

From: Paul Regan

…[I[n your advice on choosing a therapist, you state that Ph.D psychologists are inherently better trained than CCSW’s. Come on, you know that the intensity and quality of clinical training in graduate programs varies substantially within disciplines, probably more than it does between the mental health disciplines.

Also, in all of your writings, you fail to recognize Licensed Professional Counselors. If you don’t know who we are, we have;

M. S. degrees (60 credit hours) a national professional exam (National Counselor Exam) supervision requirements of 2000 face to face client contact in conjunction with 200 face to face with a clinical supervisor. All of which must be post-graduate.

These requirements are identical to those of CCSW’s (LCSW’s).

In the future, please include LPC’s in your writings about qualified mental health practitioners.

Thanks, Paul

From: Cooper

Here in California, licensed Marriage, Family, and Child Counselors (MFCCs) and prelicensed trainees and interns are considered by the state as psychotherapists along with doctoral-level therapists in many legal considerations. The Master’s Degree program they must complete and the 3,000-hour supervised internship and licensing procedures are specified by the California Code of Regulations and the state Business and Professions Code, and include coursework and supervised practice in assessment and diagnosis, theory and practice, law and ethics, human sexuality, child abuse, human development, and counseling of individuals, couples, families, and children. Some programs require a professional paper or thesis, and some require, or give the option for, passing a comprehensive exam similar to the state licensing exam with written and oral components. Beginning next year, the licensing Board will also require continuing education credits for license renewal.

I have worked in inpatient psychiatric care for several years, and have had many patients tell me they had much better counseling success with their MFCCs than with doctoral-level psychologists and psychiatrists, or that they finally experienced major improvements in their lifestyles when they experienced therapy with an MFCC as an adjunct to psychiatric consultation. MFCCs are trained to deal with relationships, whether they are in the workplace, in society, or in the intimate atmosphere of the home. Problems with these relationships, past or present, are at the root of most pathology.

We are admittedly at the bottom of the mental-health food chain, but we are a growing, competent force to be reckoned with.

From: Michael Kasdaglis

Thank you for your effort in providing useful information on Mental Health Issues. I would like to bring to your attention the following issues regarding Social Work, and Mental Health services and education.

The Masters in Social Work is ap. 65 to 75 credits. Depending on the School one can chose a clinical track, which will mandate about two-thirds of the graduate work to be done in Psychopathology, Abnormal Psychology, Diagnostics, Psychopharmacology, Theories of Psychology, Systems Analysis, Child Psychology, Family Therapy theories, Developmental Psychology, History of Psychology, Process, etc. Additionally, there is a requisite that all graduates have undergone a minimum of one year -almost full time- in a mental health setting, and under clinical supervision, and following a P/T placement during their first year. Following graduation, one may chose to undergo a 3-year supervision under a licensed practitioner in order to qualify to become licensed. In addition to the licensure, one may decide to be tested on knowledge and practice in order to be admitted to the Academy of Clinical Social Workers (ACSW). Beyond the ACSW and following 10 years of direct practice with an additional post-graduate degree in a related field, one may qualify to test for the DCSW (Diplomate in Clinical Social Work). Such individuals are listed in The National Clinical Register of the NASW. With all due respect -and perhaps standards have changed in the last 10 or so years, I cannot see how a masters in Psych, or even a Phd is superior, or more suited for the diagnosis and treatment of mental disorders. Perhaps in Psychometrics; Yes… But !! As a clinical supervisor for a number of Universities, I am amazed when I interview new-comers to the field -fresh graduates from MS and Phd programs. Upon questioning them and following a review of their courses, I am confused. At a maximum they have had three courses in areas relevant to mental health. Please review any University’s program of study and you will also be amazed. Their courses are now known as : The Empowerment Model, Domestic Violence, Feminism, African Studies, The gay Movement, Short or Brief Focus Therapy, cultural diversity, hispanic studies, Aids awareness -very useful in sensitizing professionals, but maybe over and above basic Psychopathology…. When I asked them about Haley, Jacobson, Mahler, Kernberg, Bleurer, Piaget, Minuchin, Kohut, etc., they look at me as if though I fell from space. What is particularly distressing is the new breed of MFTs (Marriage and Family Therapists)… When I went for my MFT at Downstate College of Medicine, the requirement was a minimum of a masters in a Mental Health related filed, and a certification, or license… Now a BS degree is sufficient -not even the GRE. I have found no MFT graduate knows who Salvadore Minuchin, Jay Haley, Nathan Ackerman, Bowen, Karl Whiteiker, Polazoli, etc., is…. Like programmed robots they all respond the same way “We studied systems theory..” “.. we are eclectic…” The end result is that Mental Health has been mugged by convenience at the corner of Managed Care Blvd and Political Correctness… Psychiatry has been reduced to three diagnoses : Adults are either depressed, or addicted.. Children only have ADD/ADHD. Prozac and Ritalin coupled with assisting people in shedding guilt and shame, are the prime models of therapy … towards a shameless, guilt free society, where self-caring has been replaced with self-catering and self- indulgence. And in the meanwhile the mentally ill suffer, personality disorders are rampant, and the children fall into drugs and conduct disorders while parents are told “It isn’t your fault, he/she has ADD; how about some Ritalin?” Finally, treatment is “Brief Therapy” or “Solution Focus.” Every therapist begins treatment with the same question : “And what would it look like if the problem went away ?” Imagine asking my schizophrenic patients that question… or the borderline.. or the malignant narcissist..

I would like to state that I am aware my letter may be construed as the work of a radical or a fundamentalist.. Not by any means.. It is, however, the product of utter frustration with our Professional Leaders, Managed Care Companies, and Institutions of Learning that are at present prostituting the Mental Health profession in return for their economic growth.

Thank you for your Page.

Michael Kasdaglis, DCSW, LCSW, CMFT, LMFT, CFLM,…

Clinical Director

Family Crisis Intervention, Florida

From: Bonnie S. Dank

One of the major omissions from this link on your listings is the new group of psychiatric nurses. Titles range from Clinical Specialist-Psychiatric, Advanced Practice Psychiatric Nurse, Psychiatric Nurse Specialist, and most recently, Psychiatric nurse Practitioner. What all of these nurses have in common is at least a Master’s degree and a national certification attained by at least 400 hours of patient contact (in therapy, individual or group; or in other clinical settings) as well as considerable hours of supervision. In addition, they must pass a national certification exam administered by the American Nurses Credentialing Center. Psychiatric Nurse Practitioners have additional certification as Adult or Primary Care Nurse Practitioners which requires additional certification requirements and an additional exam.

These advanced practice nurses are trained in family, individual and group psychotherapy. In addition, some may choose to do clinical training in Consultation-Liaison Psychiatric nursing, child psychiatric nursing, home health care, teaching, or research.

In addition, most programs offer courses in physical assessment and psychopharmacology. In fact, some 35+ states allow advanced practice nurses to prescribe medications, with or without the supervision of a physician. This only makes sense as all nurses have a background of undergraduate training in medical, surgical, obstetrics/gynecology, and pediatric nursing as well as courses in human pathology (illness) and pharmacology.

Nurses bring much that has been part of nursing historically to their role as therapists. This includes an emphasis on wellness and prevention as well as the traditional role of patient advocate.

In the current political and economic settings, Advanced Practice Psychiatric Nurses are a natural to provide primary mental health intervention to both acutely and chronically ill psychiatric patients as part of a team or in private practice.

Thanks for letting me put my two cents in!

Bonnie S. Dank, B.S.N., R.N.,C., M.P.H. (and soon to be a Graduate Psychiatric Nurse Practitioner)

From: Ted Mick

Found your letter interesting regarding the different mental health professionals. Please be informed that there are four federally recognized professionals in this field, three of whom you listed (psychiatrists, psychologists, social workers); the fourth, (or first, as I have a bias, also!) are nurses who are prepared in the mental health specialty at the Master’s level for advanced practice, who then spend an additional 100 hours of supervision in order to qualify for the national certification exam which can lead to independent practice, if desired. Yes, all four have a different focus — which is fortunate for everyone who needs a qualified and competent “therapist” – and for us as professionals, also. Fortunately, if we work together, we can provide comprehensive care for those who require our services.

Thank you. It is always fun to inform others, especially professionals, of the “silent majority” in the health care field; professionals who are in great demand for the 21st Century!

Katherine Mick, MEd, MSN, ARNP,CS Newton, KS

From Frank R. Yeatman

I am responding to your brief description of “Counselor/Therapists” with M.A or M.S. degrees in clinical/counseling psychology. As the Chair of the Council of Applied Masters Programs in Psychology (CAMPP), I’d like to expand the description of terminal master’s programs in psychology.

CAMPP’s purpose is to foster the advancement of master’s training and education in applied psychology in all its aspects. Member programs of CAMPP meet the General Standards of Education and Training established at the First National CAMPP Conference (1990) and ratified at the Second National Conference (1994). The standards describe characteristics of well-designed and high quality programs that prepare master’s graduates for employment requiring applications of the principles of psychology.

General Standards of Education and Training Applied master’s degree programs in psychology should meet the following minimum standards: I. The program should be identifiable as a psychology program. This is to be defined primarily in terms of the disciplinary affiliations of those that teach in and administer the program. II. The program must have a mission statement that guides the structure and content of the curriculum. The mission statement should reflect a commitment to the CAMPP model of practitioners who bring scholarship and reflection to their work, and an understanding of diversity in clientele, methodology and application. III. The program and its curriculum should have a coherent organization and structure that reflects its mission statement. IV. The program should be the equivalent of two academic years of full time study. This would normally include 40-50 semester hours, or the equivalent, of program requirements. V. The program must include evidence of competence in the following areas: A. A base of general/theoretical psychology to include the following: 1.) Biological bases of behavior to the degree that it is appropriate for the subdiscipline; 2.) Acquired or learned bases of behavior; 3.) Social/cultural/systemic bases of behavior; 4.) Individual or unique bases of behavior. B. Understanding of methodology used to investigate questions and acquire knowledge in the discipline. This could include study in research design and/or methodology, statistics or critical thinking and scientific inquiry. At a minimum, there should be one course in research methods and/or statistics as applied to psychological questions. C. Applied Psychology 1.) Coursework in the theory, history, and applications of psychological principles and theories appropriate to the subdiscipline; 2.) Significant supervised experience appropriate to the subdiscipline; 3.) Ethical and professional standards; 4.) Sensitivity to social and cultural diversity, resulting in appropriate assessment and intervention strategies and other professional behaviors; 5.) Teaching of assessment relevant to goals of the training program (e.g., interviewing techniques, program evaluation). VI. Entrance requirements for the applied master s program in psychology should reflect the responsibility that the program has to the public. Efforts should be made to ensure that students have the intellectual and personal capabilities required to perform as competent professionals in the subdiscipline.VII. Students will demonstrate competence and professional behavior consistent with each program’s mission statement and goals prior to completion of the program. VIII. The program will have a sufficient number of appropriately trained faculty to accommodate the labor-intensive nature of teaching the skills of applied psychology. As can be seen from the General Standards, graduates from CAMPP member programs are trained in psychotherapy techniques, psychological assessment, theory, and research. For a list of CAMPP members, visit the website listed above, or write to: Frank R. Yeatman, Department of Psychology, Avila College, 11901 Wornall Road, Kansas City, MO 64145-1698. For a complete list of educational institutions offering master’s degrees in psychology (including both CAMPP and non-CAMPP schools, consult William Buskist and Amy Mixon’s recent book, the Allyn and Bacon Guide to Master’s Programs in Psychology and Counseling Psychology (1998; ISBN# 0-205-27436-6).

JMG responds: Two things… One, the Website is terribly out of date, which does not exactly inspire confidence in this organization. Two, many (most?) programs which offer Master’s degrees in psychology or counseling are not a member of this organization. Given that the organization is only 13 years old, there are hundreds of thousands of practitioners out there with Master’s degrees which could not have gone through such a program.

Distinctions Between Therapist Degrees