Chapter 3 Current Controversies in Clinical Psychology Current

Chapter 3 Current Controversies in Clinical Psychology

Current Controversies Overview Prescription Privileges Evidence-Based Practice/Manualized Therapy Overexpansion of Mental Disorders Payment Methods: Third-Party Payment vs. Self-Payment • The Influence of Technology and Cybertherapy • •

Prescription Privileges • Historically, prescribing has distinguished psychiatrists from psychologists • However, in recent decades, clinical psychologists have actively pursued prescription privileges

Prescription Privileges • Since 2002, two states have agreed to grant prescription privileges to appropriately trained psychologists – New Mexico – Louisiana • Other states have considered similar legislation, and may pass it soon

Prescription Privileges • Why psychologists should prescribe: – Shortage of psychiatrists • Especially in rural areas • Important factor in NM and LA decisions – CPs more expert than primary care docs – Other non-physicians have privileges • Dentists, podiatrists, optometrists, and some nurses, among others – Convenience for clients

Prescription Privileges • Why psychologists should prescribe (continued): – Professional autonomy – Professional identification – Evolution of the profession – Revenue for the profession

Prescription Privileges • Why psychologists should not prescribe: – Training issues • Which courses? When? Taught by whom? – Threats to psychotherapy • Would medications replace talk therapy? – Identity confusion • Especially when only some prescribe – Influence of pharmaceutical industry

Evidence-Based Practice/ Manualized Therapy • When researchers measure therapy outcome, they often use therapy manuals – To ensure uniformity across therapists – To minimize variability • When outcome data supports the use of a manualized therapy, the treatment is known as “evidence based” • Treatments formerly called “empirically validated” and “empirically supported” – “Evidence-based practice” includes the treatment and factors related to people providing and receiving the treatment

Advantages of Evidence-Based Practice/Manualized Therapy • • Scientific legitimacy Establishing minimal levels of competence Training Improvements Decreased reliance on clinical judgment

Disadvantages of Evidence-Based Practice/Manualized Therapy • Threats to the psychotherapy relationship • Diagnostic complications – “Textbook” cases vs. “real world” cases • Restrictions on practice – Mandated manuals vs. creatively customized treatments • Debatable criteria for empirical evidence

Overexpansion of Mental Disorders • DSM size and scope has increased from 1950 s to present • Overdiagnosis, diagnostic expansion, diagnostic inflation, diagnostic creep, medicalization of everyday problems, false positives, false epidemics? • Minimizing the chance that people struggling with mental illness fall through the cracks vs. overdiagnosis of normal life experiences • If diagnoses continue to expand, can anyone be diagnosed with a mental disorder?

New Disorders, New Definitions • Disorders – Premenstrual dysphoric disorder • Severe versions of the symptoms of premenstrual syndrome – Binge eating disorder • Out-of-control overeating at least once per week • Definitions – ADHD • Age by which symptoms appear raised from 7 to 12

Risks of Overdiagnosis • Unnecessary medication – harmful side effects • Unnecessary therapy – undermine coping skills • Negatively impact self-image and self-efficacy via stigma • Adversely affect health insurance enrollment and rates • Legal ramifications

Overdiagnosis and the Pharmaceutical Industry • More mental disorders = more potential pharmaceutical customers? • Significant numbers of psychiatrists involved in the creation of the DSM had financial ties to major pharmaceutical companies – 69% for DSM-5

Payment Methods: Third-Party Payment vs. Self-Payment • Early in the history of clinical psychology, clients paid for services directly out of pocket • With time, health insurance companies began covering mental health • Today, many clients use health insurance/managed care benefits to pay for services – Often called “third-party payers”

Effect of Third-Party Payment on Therapy • Surveys of psychologists suggest that thirdparty payment can result in – Negative impact on quality – Too little control over clinical decisions – Ethical problems, including confidentiality – Confusion about informed consent (what to tell clients about payment method) – Greater affordability for many clients

Effect of Third-Party Payment on Diagnosis • Surveys of psychologists suggest that thirdparty payment can result in – Increased likelihood of being diagnosed with a mental disorder – Certain diagnostic categories being used more or less often

Effect of Third-Party Payment on Psychologists’ Experience • Lower pay • Time required for paperwork, phone calls, etc. • Frustration due to denial of care psychologist believes to be necessary

The Influence of Technology: Cybertherapy and More • In recent years, clinical psychologists have increasingly used technology in the direct delivery of psychological services – Assessment – Treatment • Cybertherapy can replace or supplement face-to-face meetings • Benefits can include accessibility, affordability, and anonymity, and more

Applications of Technology in Clinical Psychology: Examples • • Videoconferencing to interview or treat Email or text psychotherapy Interactive Internet sites Online psychotherapy programs Virtual reality therapeutic experiences Computer-based self-instruction Therapist/client interaction via hand-held devices (e. g. , i. Phones, cell phones, Blackberries)

How Well Does Cybertherapy Work? • Appears to work about as well as in-person psychotherapy • Specific examples include – CBT for anxiety disorders – Health psychology • Headaches • Pain

Technology: Suggestions for Emerging Professional Issues • • Obtain informed consent about the technology Follow relevant telehealth laws Follow APA ethical code Ensure confidentiality via encryption Make efforts to appreciate culture Obtain relevant training Know client’s local emergency resources

Technology: Additional Potential Problems • Confirming the identity of the client • Confidentiality across electronic transmission • Making interpretations in the absence of nonverbal cues that would be present face-toface • Competence in technical as well as clinical skills

Technology: Effectiveness of Treatment • Early research is beginning to demonstrate that it can work • Success depends on many factors: – Which cybertherapy, disorder, device? – What setting? – How clients found or were referred to cybertherapy? – Live support available?