Chapter 3: Current Controversies in Clinical Psychology PDF

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Chapter 3: Current Controversies in Clinical Psychology Prescription Privileges -Remember one key difference between psychiatrists and clinical psychologists -The ability to prescribe medication -The American Psychological Association (APA) has published numerous articles promoting prescription privileges for clinical psychologists -APA says that yes Clinical Psychologists should be able to prescribe psychotropic medications -psychopharmacology -Several states granted prescription privileges to trained psychologists in early 2000s -Louisiana, Illinois, New Mexico, Iowa -What are the arguments for and against? Argument for Prescription Privileges -Shortage of psychiatrists -Underserved populations may benefit -Clinical psychologists are more expert than primary care physicians -~80% of prescriptions written for psychotropic medications come from primary care physicians (not psychiatrists) -they do not get any extra training in how to treat mental illnesses -so, does it make sense to have them prescribe psychotropic medication? -Other non-physician professionals already have prescription privileges (do not have the same medical training, but CAN prescribe medication) -E.g., dentists, podiatrists, optometrists, and advanced practice nurses -why not extend this to clinical psychologists as well? -Convenience for clients -many clients are treated with both psychotherapy and psychotropic medication -streamlines the process -usually seeking out treatment from a psychologist and a psychiatrist, and they have to communicate with each other and see what is best, but the psychologist know you better so they might have a better idea of what you actually need than a psychiatrists you don’t see as often -Professional autonomy -Able to treat clients without having to rely on other professionals -you don’t have to rely on others, you know what the person needs, you don’t need someone else tell you what the person needs -Professional identification -Would further differentiate clinical psychology from other mental health professionals -easier for the client to just see one person -Evolution of the profession -Some argue that impeding prescription privileges is standing in the way of the field progressing -if would further differentiate LPC, because clinical and LPC can sometimes seem similar

-people say this is the next logical step for the field -Revenue for the profession -Could help offset salary decreases seen by many Clinical Psychologists over the past few decades -Strong opposition from psychiatric organizations -during the 1990s people who are in treatment for depression receiving an antidepressant increased from 37% to 74% Arguments Against Prescription Privileges -Training issues -What kind of education should clinical psychologists receive before prescribing? How in depth should it be? When should it occur? -Should psychologists be trained regardless to promote understanding/communication? -would this be part of graduate work? Postdoc or predoc internship? Extra schooling? -in depth knowledge -would this be an optional training or not? Would every clinical psychologist have to know how to prescribe medicine even if someone didn’t want medicine? -Threats to psychotherapy -The way psychologists understand and intervene with their clients may shift from behavioral, cognitive, and emotional processes to symptom reduction via psychotropic medications -no more cognitive behavioral therapy, doesn’t make as much money, I will just prescribe medicine and that’s it -would psychotherapy go away for clinical psychologists like it did for psychiatrist? -Identity confusion -Could lead to client confusion -people don’t usually know the difference between mental health professionals, if only some clinical psychologists could prescribe, would this be more confusing? -Potential influence of the pharmaceutical company -What if clinical psychologists are pressured by pharmaceutical companies to consider factors other than client welfare? -would they just push a drug because it was expensive and not because it was effective? -reports of drug companies’ attempts to increase profit (ex: by offering gifts to prescribers, funding research on medications, and controlling the publication of research results) have become widespread (Healey 2004, Lane 2007) Discussion -if you were a client, would you want your psychologist to have the ability to prescribe medication to you? -or-from the standpoint of a student in the field of psychology-do you agree or disagree with the idea of clinical psychologists prescribing psychiatric medication?

Evidence Based Practice/Manualized Therapy -how do we know if therapy works? And how do we know what types of therapy work? -For many decades, the prominent question in the field was “does psychotherapy work?” -Question has shifted to what specific forms of therapy are effective? (and what forms of therapy work best with different disorders) -what therapy works best for PTSD versus depression -How do we answer this? -Ensure that therapy techniques are generally uniform within a study -Provide detailed instructions—a therapy manual: write down goals of what therapy can give you: provide detailed instructions for therapy, session by session, this is exactly what you should talk about, what you should teach them Manualized Therapy -We have moved towards researching manualized therapies -E.g., prolonged exposure for the treatment of PTSD, dialectical behavior therapy (DBT) for the treatment of Borderline Personality Disorder -APA created a task force to compile effective interventions into a list of “empirically validated” treatments (commonly referred to now as evidence-based practice) -evidence-based practice is defined as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” APA presidential task force on evidence-based practice 2006 -A step in the right direction? -Many clinical psychologists see this as legitimizing the field -Others are concerned about the implications of manual-based therapy -evidence based on research saying yes, this is scientifically proven to work to treat (disorder) Advantages of Evidence-Based Practice/Manualized Therapy -Scientific legitimacy -Prior to evidence-based treatments, clinical psychology could be considered a “cottage industry”—every psychologist puts their own spin on treatment -we can actually prove that these approaches to therapy work -gain more respect because of empirical data -Establishing minimal levels of competence -Reducing client harm/use of ineffective approaches -someone just went through grad school and didn’t pay attention, put out detailed therapy manuals to make sure everyone can get the treatment they deserve and will actually help them -variation from one graduate program to the next, it will be standardized -this is part of the accreditation process for internships (that is why they are accredited because they have superior training) -Training improvements -Training can be very different between different graduate programs -Decreased reliance on clinical judgment -Clinical judgment is often flawed (and subjective to bias) -say what helped you in the past, doesn’t mean it will help another person

Disadvantages of Evidence-Based Practice/Manualized Therapy -Threats to the psychotherapy relationship -Much of whether or not therapy is successful tends on the quality of the therapeutic alliance -reading from a book and filling our worksheets, that will not help to get to know the client and build a real relationship, this relationship is very important -Diagnostic complications -Each evidence-based treatment manual targets a specific disorder -this one is for anxiety disorder, if we are trying to reduce variability, we would look for just generalized anxiety disorder, when in reality, a person could have panic disorder with depression and that generalized anxiety disorder textbook definition manual, will not usually happen, people are different and are almost never a DSM definition of one disorder -Restrictions on practice -Some professionals are very dismissive of any treatments that are not empirically supported -restrictions on types of therapy, you might want to do a different therapy type -Debatable criteria for empirical evidence -More difficult to measure outcomes with certain techniques (e.g., psychodynamic therapy) -criteria aren’t really fair -how can you measure if you are bringing ALL of your unconscious thoughts, conscious -we can’t accurately test this Discussion -what do you think clients prefer? -manualized treatments or not? -does it need to be either or? Overexpansion of Mental Disorders -Remember the size and scope of the DSM has increased drastically since its first edition -Number of individuals with mental disorders in the US has also increased -Authors of DSM review research and solicit feedback from professionals before including any new disorders/changing existing disorders -Concern about pathologizing normal behaviors -E.g., social anxiety disorder -if someone gets nervous before talking to large groups of people, instead of just saying they have the jitters, you diagnose them with social anxiety disorder -binge eating disorder(BED) -someone overeats every now and then and diagnose them with BED New Disorders and Definitions of Old Disorders -What might lead to overexpansion? -Introducing new disorders that capture experiences once considered “normal” -E.g., premenstrual dysphoric disorder, binge-eating disorder

- “Lowering the bar” for diagnosing existing disorders (so the criteria for a disorder might apply to more people) -E.g., changing the age that symptoms of ADHD must be present by from 7 to 12 years -Potential consequences -People may receive treatment they don’t actually need Overexpansion: Influence of the Pharmaceutical Industry -Some professionals attribute overexpansion to the pharmaceutical company -Of the panel members involved in the development of DSM-5, 69% had financial ties to major pharmaceutical companies -DSM-5 did place some limitations on involvement in terms of the amount of company stock they could own, the amount of payment they received from companies -does it really matter? -Carey and Harris (2008) studied the prescribing habits of psychiatrists in Minnesota -those psychiatrists who had received at least $5,000 in compensation from pharmaceutical companies wrote three times as many prescriptions for antipsychotic medications (as compared to doctors who had no financial ties to the pharmaceutical industry) Influence of Technological Advances -cybertherapy: the use of technology including the internet, videoconferencing, smartphones, and text-based services, in the application of clinical psychology -Examples: -Use of email/skype to provide psychotherapy or supplement it -Computer-based self-instructional programs -Smartphone apps to monitor symptoms, complete activities -Virtual reality techniques in which clients undergo therapeutic experiences (e.g., exposure) -Potential to help underserved populations -How well do technological applications work? -Very limited data available, but initially promising -Additional ethical considerations...