I totally get where you're coming from and I agree we need to think about novel solutions to the problem, but I think there may be some issues with your proposals.
"1. Let aspiring psychiatrists, clinical psychologists, and psychotherapists begin their specialized training during undergraduate studies."
I'm all in favor of medical training starting earlier, but I don't see a reason to limit this to mental health. If we're already making the changes you're proposing, we might as well make it easier to start medical school earlier, eg. by combining undergrad and medical school into a 6 year program or something like that, which I think some places already do.
"2. Offer undergraduate programs in psychiatry and clinical psychology with direct pathways into these advanced degrees.
3. Create an alternative medical school curriculum for people who want to be psychiatrists with a greater emphasis on psychopathology, neurobiology, and psychopharmacology."
Would this be an entirely separate school? Or would it be some kind of sub-curriculum within existing medical schools? If it is a separate school, how will trainees get appropriate exposure to sick & hospitalized patients, and how will they learn to work with their medical colleagues? Distancing psychiatry from the rest of medicine seems like a bad idea and will likely lead to problems similar to what the psychoanalytic community faced when it self-segregated from the broader medical/psychiatric institutions.
If it is a sub-curriculum within medical school, why should psychiatry be the only field that's so different? Wouldn't it then just make sense to completely revamp medical school and allow people to start studying psychiatry, orthopedics, radiology, or whatever else in undergrad? Also, if it is a sub-curriculum, remember that trainees in psychiatry still need to do rotations on all the other medical specialties during medical school, just like medical students who go into ophthalmology still need to rotate through OBGYN and psychiatry, etc. A huge part of medical education is not just learning your own specialty, but learning how all of it fits together, which means spending lots of time learning from other fields.
For psychologists, I guess we could experiment with 6 year combined undergrad-graduate programs, kind of like a BA and s PsyD degree combined. Maybe there's already some of those, I'm not sure. But again, something like that would mean med prescribing and having a heavy medically-oriented practice would be harder since those 6 years really aren't enough to become proficient in this stuff. Psychology programs can claim they teach pharmacology and other courses "necessary" to become proficient in prescribing medications, but without the broader medical education it still isn't enough training.
"4. Allow undergraduate psychology programs to offer a pathway to become a registered psychotherapist, such that graduates who complete the requisite coursework and practicum can practice once they graduate."
I don't think 22 year old college graduates are ready to be psychotherapists, for the most part.
"5. Enable psychologists with appropriate psychopharmacological training to prescribe psychiatric medications in all states, following the model of states that have already implemented this."
I think this will turn out badly. Learning to prescribe medication well is not easy, and everything I've seen re: psychologists, APNs, and other mid-level providers prescribing psychiatric medications has convinced me that they are not qualified to do it and the training is woefully inadequate. If anything, people need way more training, or at least better quality training.
"6. Maintain high student standards by continuing with standardized tests, comprehensive exams, and challenging practicums."
Obviously I'm in favor of high standards, but actually implementing them is difficult. Separating psychological/psychiatric training further from the medical establishment will make this goal more difficult and probably undermine it. Even within the medical establishment, we have tests and credentialing up the wazoo but it isn't clear we're getting better.
re: length of training, on the one hand I agree the time it takes to become a physician is long, but on the other hand it's not clear that more than 2 years can be cut out and still have the training be robust enough. Maybe 3 years if you're being ruthless and you know the caliber of your incoming students is high (which will be less likely if we're opening the doors for far more people to enter the profession). But once you've created combined 6 year college-med school programs, it's not clear what else you could cut out.
I think medical school could be shortened to 3 years if we're really smart about it, perhaps collapsing the 4th year into the 1st year of residency. But eventually we're going to run into the problem of having too many graduates who are inadequately trained and probably not mature enough for some parts of the job. To some extent, having a long training period and lengthy selection process may be a necessary evil.
Thanks for responding! I appreciate you taking the time to go through all the recommendations in detail and pointing out some of the issues.
Re: the first three points, I would probably be fine with shortening the pathway to becoming an MD generally and of having more specialization, but I know far less about medicine generally so didn’t want to comment. I do see your point about how sequestering psychiatry could lead it to become unmoored from the rest of medicine, which would be bad. I don’t see why in principal you couldn’t have more psychopharmacological education/training for PhDs/PsyDs and allow them to prescribe as some states do, but I now *do* see how this is in conflict with the other suggestions I am making in terms of cutting back educational requirements.
Re: point 4, the age issue, the current situation is basically the same except you’re required to take a 1-2 year master’s, so while age and experience are issues there I’m not sure the extra time adds much.
Re: point 5, the experience you’re describing makes me less enthusiastic about prescriptive authority being liberalized, and again this is a point where my ideas do conflict with one another. If it really is the case that only MDs are qualified to prescribe and that the full medical training cannot be replicated elsewhere, then prescriptive authority should be limited to them. However, if there is a way to train PhDs in this that leads to success, then I would advocate for it.
And finally re point 6, yeah upon further thought I see how separating psychiatry away from medicine would lower the standards. I’d like to think you could cut educational time and maintain high quality applicants through testing, exams, etc. but maybe those things are just part of what defines high standards and the educational time/brutal slog is an important part of selecting the most motivated people.
All in all, having read your comment I think that my recommendations, even if some make sense individually, would likely not make sense in combination, and I’m really grateful for the time you spent putting together a response, as it allows me to see the dynamics and conflicts much clearer.
Sure thing, and I'm glad you're thinking about creative solutions since we need all the good ideas we can get. I think especially re: prescribing, there's an idea in the air that it's mostly just an algorithm or decision tree, or something that someone can be easily trained to do well, eg. "they're depressed so give them an antidepressant, how hard can it be?!" (not saying you're saying this, but the idea can be implicit in these discussions sometimes). The whole "prescribing is an art" thing is partially true, since a lot of the knowledge comes from first-hand experience (maybe similar to how I could read all the law books I want but that probably wouldn't make me a good litigator, since I'd actually need a lot of on the ground experience).
Another thought is that we need to figure out what we really want. Do we have a problem with doctor/prescriber shortages? Or do we have a problem with overprescribing psychiatric medications to half the country? Or somehow both? My sense is that increasing prescribers will almost certainly lead to proportionally greater prescriptions for milder cases ("SSRIs for everyone!") but won't necessarily help those with severe illness who need higher octane meds with a prescriber who really knows what they're doing.
This line of thought leads me back to the idea that one way to deal with this problem is for us to stop viewing most mild cases of psychological distress as "psychiatric" problems that require medical treatment and instead more as "problems in living", while reserving the psychiatric labels and medications for more severe cases. Not sure how we'd accomplish this other than some slow cultural change, major changes to pharma regulations, or me finding a magic wand.
Yeah I want to write an article along the lines of "let's split mental health in half", because there really are two distinct issues, the problems in living people and the seriously mentally ill. Part of my thinking is that w/ more people in the field overall the most skilled people could pay greater attention to the cases where they're needed most, but mental health practitioners are people too and I get why many wouldn't want to go into the areas where help is needed most, or to treat people w/ the worst illnesses when more moderate or even worried well clients are available and in the case of private practice/clinicians, pay more. There's ultimately both a supply and demand problem and tackling both simultaneously likely the right way to go.
Nice POV! I appreciate this conversation. Social worker here. The lack of representation at the national level means we're excluded from this conversation and have the disturbing outcomes of the helping professions. Our foundation being systems theory and person in environment places us in the right position to be leading these conversations. We center the client and their needs at a macro, mezzo, and micro level. More than other professions, we work with people who otherwise don't have access to psychiatrist and psychologists.
But, there's no clear definition of what we do and social work standards aren't nationalized in a way that creates parity across states despite having the same educational requirements. And let's not even get into money. Our degrees are ridiculously expensive and then requires a minimum of 3 years practicing clinical social work before taking an exam, to make how much? Social workers on average make $20,000 less than nurses.
No real solution to the mental health crisis can be taking seriously without addressing the current barriers to social workers having a descent life while carrying the heavy load of working with and for the most needed.
That makes a lot of sense. I know less about social work than other areas but i've often heard people say that social work + psychiatric nursing are underrated in these contexts and often excluded from the discussion.
Totally agree. We have different streams here in the U.K. we can qualify as a counsellor within 3 years, with a professional diploma or degree. (I think counselling is perhaps more of a advanced profession here than in the US). Once I had qualified I went on to do my psychotherapy masters. Although the academic knowledge was more advanced, it was my first training in counselling that taught me the most about real change in therapy. I think the healing relationship is stronger and more useful when there is less pathologising of the client.
In my experience meeting a range of therapists, it seemed like the higher the qualification level, the worse the therapist! Of course that’s not always true but there are some things you can’t teach.
There is a sensible argument for some early tracking emphases. When I work with both 1st year residents and medical students I precept, they are woefully ignorant of receptor biology, psychopharmacology and such. So not being really training in this background, there is an uphill battle to acquire this quickly in the field on rotation. But…the certifying exams are enormously broad until the get past the licensing exams. The medical model is all docs know everything. Well, that is quite useful, but not super efficient. Yet, non physicians who are prescribing know very little of the medical comorbid conditions that influence mental illness. And also may be unaware of the side effects of our drugs, especially cardiac ones. It is just a difficult problem, but tracking of interested medical students could help.
I also wonder if the length of training provides a potential benefit to the trainee in terms of helping them avoid burnout in the future, perhaps by helping them develop personal skills, habits, and attitudes that will serve them well when they are practicing independently, in addition to the knowledge, experience, etc they develop. I do think there is something to the actual gruel and grind of medical training in terms of learning that I can do hard things and cope. Obs, there is lots of variability for what kind of support trainees get in this area.
I totally get where you're coming from and I agree we need to think about novel solutions to the problem, but I think there may be some issues with your proposals.
"1. Let aspiring psychiatrists, clinical psychologists, and psychotherapists begin their specialized training during undergraduate studies."
I'm all in favor of medical training starting earlier, but I don't see a reason to limit this to mental health. If we're already making the changes you're proposing, we might as well make it easier to start medical school earlier, eg. by combining undergrad and medical school into a 6 year program or something like that, which I think some places already do.
"2. Offer undergraduate programs in psychiatry and clinical psychology with direct pathways into these advanced degrees.
3. Create an alternative medical school curriculum for people who want to be psychiatrists with a greater emphasis on psychopathology, neurobiology, and psychopharmacology."
Would this be an entirely separate school? Or would it be some kind of sub-curriculum within existing medical schools? If it is a separate school, how will trainees get appropriate exposure to sick & hospitalized patients, and how will they learn to work with their medical colleagues? Distancing psychiatry from the rest of medicine seems like a bad idea and will likely lead to problems similar to what the psychoanalytic community faced when it self-segregated from the broader medical/psychiatric institutions.
If it is a sub-curriculum within medical school, why should psychiatry be the only field that's so different? Wouldn't it then just make sense to completely revamp medical school and allow people to start studying psychiatry, orthopedics, radiology, or whatever else in undergrad? Also, if it is a sub-curriculum, remember that trainees in psychiatry still need to do rotations on all the other medical specialties during medical school, just like medical students who go into ophthalmology still need to rotate through OBGYN and psychiatry, etc. A huge part of medical education is not just learning your own specialty, but learning how all of it fits together, which means spending lots of time learning from other fields.
For psychologists, I guess we could experiment with 6 year combined undergrad-graduate programs, kind of like a BA and s PsyD degree combined. Maybe there's already some of those, I'm not sure. But again, something like that would mean med prescribing and having a heavy medically-oriented practice would be harder since those 6 years really aren't enough to become proficient in this stuff. Psychology programs can claim they teach pharmacology and other courses "necessary" to become proficient in prescribing medications, but without the broader medical education it still isn't enough training.
"4. Allow undergraduate psychology programs to offer a pathway to become a registered psychotherapist, such that graduates who complete the requisite coursework and practicum can practice once they graduate."
I don't think 22 year old college graduates are ready to be psychotherapists, for the most part.
"5. Enable psychologists with appropriate psychopharmacological training to prescribe psychiatric medications in all states, following the model of states that have already implemented this."
I think this will turn out badly. Learning to prescribe medication well is not easy, and everything I've seen re: psychologists, APNs, and other mid-level providers prescribing psychiatric medications has convinced me that they are not qualified to do it and the training is woefully inadequate. If anything, people need way more training, or at least better quality training.
"6. Maintain high student standards by continuing with standardized tests, comprehensive exams, and challenging practicums."
Obviously I'm in favor of high standards, but actually implementing them is difficult. Separating psychological/psychiatric training further from the medical establishment will make this goal more difficult and probably undermine it. Even within the medical establishment, we have tests and credentialing up the wazoo but it isn't clear we're getting better.
re: length of training, on the one hand I agree the time it takes to become a physician is long, but on the other hand it's not clear that more than 2 years can be cut out and still have the training be robust enough. Maybe 3 years if you're being ruthless and you know the caliber of your incoming students is high (which will be less likely if we're opening the doors for far more people to enter the profession). But once you've created combined 6 year college-med school programs, it's not clear what else you could cut out.
I think medical school could be shortened to 3 years if we're really smart about it, perhaps collapsing the 4th year into the 1st year of residency. But eventually we're going to run into the problem of having too many graduates who are inadequately trained and probably not mature enough for some parts of the job. To some extent, having a long training period and lengthy selection process may be a necessary evil.
Thanks for responding! I appreciate you taking the time to go through all the recommendations in detail and pointing out some of the issues.
Re: the first three points, I would probably be fine with shortening the pathway to becoming an MD generally and of having more specialization, but I know far less about medicine generally so didn’t want to comment. I do see your point about how sequestering psychiatry could lead it to become unmoored from the rest of medicine, which would be bad. I don’t see why in principal you couldn’t have more psychopharmacological education/training for PhDs/PsyDs and allow them to prescribe as some states do, but I now *do* see how this is in conflict with the other suggestions I am making in terms of cutting back educational requirements.
Re: point 4, the age issue, the current situation is basically the same except you’re required to take a 1-2 year master’s, so while age and experience are issues there I’m not sure the extra time adds much.
Re: point 5, the experience you’re describing makes me less enthusiastic about prescriptive authority being liberalized, and again this is a point where my ideas do conflict with one another. If it really is the case that only MDs are qualified to prescribe and that the full medical training cannot be replicated elsewhere, then prescriptive authority should be limited to them. However, if there is a way to train PhDs in this that leads to success, then I would advocate for it.
And finally re point 6, yeah upon further thought I see how separating psychiatry away from medicine would lower the standards. I’d like to think you could cut educational time and maintain high quality applicants through testing, exams, etc. but maybe those things are just part of what defines high standards and the educational time/brutal slog is an important part of selecting the most motivated people.
All in all, having read your comment I think that my recommendations, even if some make sense individually, would likely not make sense in combination, and I’m really grateful for the time you spent putting together a response, as it allows me to see the dynamics and conflicts much clearer.
Sure thing, and I'm glad you're thinking about creative solutions since we need all the good ideas we can get. I think especially re: prescribing, there's an idea in the air that it's mostly just an algorithm or decision tree, or something that someone can be easily trained to do well, eg. "they're depressed so give them an antidepressant, how hard can it be?!" (not saying you're saying this, but the idea can be implicit in these discussions sometimes). The whole "prescribing is an art" thing is partially true, since a lot of the knowledge comes from first-hand experience (maybe similar to how I could read all the law books I want but that probably wouldn't make me a good litigator, since I'd actually need a lot of on the ground experience).
Another thought is that we need to figure out what we really want. Do we have a problem with doctor/prescriber shortages? Or do we have a problem with overprescribing psychiatric medications to half the country? Or somehow both? My sense is that increasing prescribers will almost certainly lead to proportionally greater prescriptions for milder cases ("SSRIs for everyone!") but won't necessarily help those with severe illness who need higher octane meds with a prescriber who really knows what they're doing.
This line of thought leads me back to the idea that one way to deal with this problem is for us to stop viewing most mild cases of psychological distress as "psychiatric" problems that require medical treatment and instead more as "problems in living", while reserving the psychiatric labels and medications for more severe cases. Not sure how we'd accomplish this other than some slow cultural change, major changes to pharma regulations, or me finding a magic wand.
Yeah I want to write an article along the lines of "let's split mental health in half", because there really are two distinct issues, the problems in living people and the seriously mentally ill. Part of my thinking is that w/ more people in the field overall the most skilled people could pay greater attention to the cases where they're needed most, but mental health practitioners are people too and I get why many wouldn't want to go into the areas where help is needed most, or to treat people w/ the worst illnesses when more moderate or even worried well clients are available and in the case of private practice/clinicians, pay more. There's ultimately both a supply and demand problem and tackling both simultaneously likely the right way to go.
lol yeah it sounds like we’re both thinking of writing basically the same article (although whether our proposed fixes are the same I’m not sure)
Nice POV! I appreciate this conversation. Social worker here. The lack of representation at the national level means we're excluded from this conversation and have the disturbing outcomes of the helping professions. Our foundation being systems theory and person in environment places us in the right position to be leading these conversations. We center the client and their needs at a macro, mezzo, and micro level. More than other professions, we work with people who otherwise don't have access to psychiatrist and psychologists.
But, there's no clear definition of what we do and social work standards aren't nationalized in a way that creates parity across states despite having the same educational requirements. And let's not even get into money. Our degrees are ridiculously expensive and then requires a minimum of 3 years practicing clinical social work before taking an exam, to make how much? Social workers on average make $20,000 less than nurses.
No real solution to the mental health crisis can be taking seriously without addressing the current barriers to social workers having a descent life while carrying the heavy load of working with and for the most needed.
That makes a lot of sense. I know less about social work than other areas but i've often heard people say that social work + psychiatric nursing are underrated in these contexts and often excluded from the discussion.
I agree with that. i’m happy to connect 🙂
Totally agree. We have different streams here in the U.K. we can qualify as a counsellor within 3 years, with a professional diploma or degree. (I think counselling is perhaps more of a advanced profession here than in the US). Once I had qualified I went on to do my psychotherapy masters. Although the academic knowledge was more advanced, it was my first training in counselling that taught me the most about real change in therapy. I think the healing relationship is stronger and more useful when there is less pathologising of the client.
In my experience meeting a range of therapists, it seemed like the higher the qualification level, the worse the therapist! Of course that’s not always true but there are some things you can’t teach.
There is a sensible argument for some early tracking emphases. When I work with both 1st year residents and medical students I precept, they are woefully ignorant of receptor biology, psychopharmacology and such. So not being really training in this background, there is an uphill battle to acquire this quickly in the field on rotation. But…the certifying exams are enormously broad until the get past the licensing exams. The medical model is all docs know everything. Well, that is quite useful, but not super efficient. Yet, non physicians who are prescribing know very little of the medical comorbid conditions that influence mental illness. And also may be unaware of the side effects of our drugs, especially cardiac ones. It is just a difficult problem, but tracking of interested medical students could help.
Interesting article and convo below.
I also wonder if the length of training provides a potential benefit to the trainee in terms of helping them avoid burnout in the future, perhaps by helping them develop personal skills, habits, and attitudes that will serve them well when they are practicing independently, in addition to the knowledge, experience, etc they develop. I do think there is something to the actual gruel and grind of medical training in terms of learning that I can do hard things and cope. Obs, there is lots of variability for what kind of support trainees get in this area.
Yeah this could be true. Ideally you could replicate that grind over a fewer years, but it's arguable that the length is an important part of it.
Also, can coaches provide a way to off load some of the "every day" mental issues?