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01.04.2008

Modalitati de pregatire in psihoterapie, in SUA


Cu putin timp inaintea intoarcerii din SUA, am scris o prezentare a posibilitatilor de pregatire in psihoterapie, in aceasta tara. Am scris-o in engleza pentru a putea cere unor colegi americani sa isi dea cu parerea despre acuratetea celor scrise. De atunci, mi-am tot propus sa o traduc in romaneste si, desi nu presupune un mare efort de timp, uite ca n-am reusit pana acum sa fac acest lucru. Asa ca o las asa cum e...

The purpose of this paper is to present, for Romanian psychologists and psychiatrists, the avenues of training in psychotherapy in the United States. It is not meant as an exhaustive presentation, but rather as an introductory overview. Therefore, my intention was to provide rather accurate than complete information on the topic.

There are many avenues that could be taken by someone interested in becoming a counselor or a psychotherapist . The distinction between the two professions is not clear. While counselor is a designated professional name, psychotherapist is not. In general, it is considered that counseling deals with non-pathological life difficulties, while psychotherapy deals more often with pathology. However, there is a large overlap between counseling and psychotherapy and many counselors do psychotherapy while many psychotherapists do counseling when it is necessary. For convenience, heretofore I will use the term psychotherapy for both types of psychological services.

Who is practicing psychotherapy in US? Counselors (and there are school counselors, rehabilitation counselors, career counselors, addition counselors and … just counselors), social workers , psychiatrists , psychologists (counseling psychologists and clinical psychologists), and psychiatric nurses .

You may already ask what the difference between counselors and counseling psychologists is. Psychologist is a designated professional name that is reserved to those holding a doctoral degree. Therefore, counselor is someone with a master degree in counseling, while a counseling psychologist has a doctoral degree in counseling psychology.

There are many training possibilities and at times it could get confusing. There are programs accredited by the American Psychological Association and there are programs that are not accredited. There are master, doctoral, and postdoctoral degrees. A doctoral degree could be a PhD (Doctor of Philosophy) or a PsyD (Doctor of Psychology). There are counseling programs, there are clinical psychology programs, and there are social work programs at both levels, master or doctoral. The choice depends very much on the interests, the time, effort and money one is willing to invest in such a pursuit.

Those programs that are accredited by APA are more or less similar in the content of their curricula (therefore they are rather standardized in their training modalities and suffer from a lack of personality) but are more recognized and appreciated on the market job. Non-accredited programs are more individualized but less appreciated by employers.

What is the difference between PhD and PsyD? Both are doctoral level programs in psychology, but a PhD program has a scientist-practitioner philosophy, while PsyD programs are strict practice oriented. This scientist-practitioner model, highly appreciated by the American Psychological Association, is aimed at consecrating psychology, in general, and psychotherapy in particular as sciences. To quote from the published philosophy of a doctoral program in counseling,

“Students are expected to develop competencies and gain experience in the science of Counseling Psychology, incorporating methodological, measurement, critical thinking, and data analytic skills. At each opportunity in their development, efforts are made to link science and practice by emphasizing a critical, thoughtful, and reasoned approach to both practice and research issues, bridged by theory. Encouraging students to actively employ the criteria of logic and science, while integrating their own unique experiences and ways of knowing and learning, is a value of the program faculty.”

I know from my informal discussion with doctoral students that many of them are really not that interested in research and, everything else being equal, they would have preferred a PsyD program. The problem is that these PsyD programs costs a lot of money (anywhere between 40,000 and 120,000 dollars). The PhD programs have similar price tags, but they offer assistantships to almost all their students. This means that, for 20 hours of work with a professor, a student gets a reasonable monthly stipend and school is for free.

What about the orientation of these programs? Most of these programs do not explicitly state their theoretical orientation, with the exception of some postdoctoral degrees. The explanation would be that, at least theoretically, students have the freedom to choose their own orientation, while the program teaches the commonalities of all therapies. However, clinical psychology programs are well-known for their cognitive-behavioral orientation, while counseling programs are considered to be more existential or client-oriented in their approach. Even so, there is a subtle pressure on all students to adopt orientations that are designed to be applied in short-term format, like the cognitive-behavioral and solution-focused therapy. This is so due to the influence of managed care and the emphasis on empirical validation of treatment modalities that represents the trend, the fashion in American psychology today. I shall explain later.

A master degree really teaches the ABC of the psychotherapy. Not all the classes are about the theory and practice of psychotherapy. In fact, most of them are about collateral knowledge, like introduction to psychological assessment, ethical issues, research, multicultural aspects, developmental psychology and counseling, career counseling, etc. Along all these classes, there is a strong emphasis on research and scientific approach to psychological services.

A doctoral degree requires in most of the cases a master degree as a prerequisite. What a doctoral program adds is an even greater emphasis on research (for instance, knowledge and use of multivariate statistics is expected from doctoral students) and new topics such as supervision, specific cognitive and personality assessments tools, advanced developmental psychology, advanced social psychology, history of psychology, advanced career counseling, behavior pathology, theories of learning, etc.

Both master and doctoral programs have, besides the theoretical classes, a practical side. It starts with the so-called laboratories, the equivalent of Romanian seminars. In my master program in counseling, the first introduction to the practice of psychotherapy was during the laboratory of “theories of personality and counseling” class. A small group of 6 or 7 students were taking turn in doing role-play therapy, with a “counselor” and a “client” in a room, and the rest of the group watching the session from behind a one-way mirror. After the session, the group gives feedback and discusses each intervention made by the “counselor.” The second step toward real therapy is taken during the so-called practicum. This is a one-semester, eight hours a week experience, usually at a local community agency, where students are given the opportunity to see real clients, but under no quite real conditions. This is so because students are watched during their session, through a camera, by their advisor and the students are wearing a small ear device so that the advisor can given them live feedback and help. It is quite strange, as a counselor seeing a client, to hear in your ear a voice saying: “do suicide assessment,” “restate the client's last saying” “comment on his posture,” etc. Nevertheless, it is supposedly very helpful for new counselors. The final step occurs during the “internship,” when students have a year long, two days a week experience of seeing real clients, usually other students, at the counseling center of their university or of other surrounding universities. The internship is the best experience for most of the students, the contact with real people, real problems, in a one-by-one format, without live supervision (only after the session supervision), being as close as possible to the real psychotherapy practice.

Doctoral students are supposed to already have all these experiences. Usually a doctoral program takes four years, with three years of theories and field work and one last year of full-time internship. The field work is similar to the internship of the master students, but it takes four semesters (which most often means two years). The last year of internship is a 40 hours a week job, almost identical to a real job (it is also paid), during which doctoral students provide individual and group therapy, do psychological assessment and, in general, take the responsibility of full-time employees. Besides the field work and the internship, doctoral students are also supervising master students, as part of their supervision class.

I mentioned before the influence of managed care. Managed care represents the term used for the system of insurances in the medical practice. Psychological services, similar to the medical ones, are covered by insurance companies. On the positive side of managed care, it should be said that it created a larger access to psychotherapeutic services of those who could not afford to pay from their pockets. On the negative side, due to their economical drive, these companies came to control and dictate much of the therapeutic work. In other words, they refuse to reimburse the therapist unless the therapist can provide a treatment plan at the beginning of therapy, can justify the interventions made in each session and come to the end of therapy in less than 12-15 sessions. Such a policy creates a tremendous pressure on therapists to use psychotherapies of short-term format, usually oriented toward symptom alleviation, and with observable, countable results. Under such circumstances, long-term psychotherapies of psychodynamic orientation fell out of popularity and demand. Even those who were not practicing in the psychodynamic format felt obligated, due to time constrains, to give up on building a strong therapeutic relationship or going beyond the presenting problem. In the academic world, this push for accountability had lead to an increased “scientification” of psychotherapy, which came to be studied and researched as a science rather than as an art. A subtle consequence of this view is that basically anybody that is intelligent enough could be taught this science, personal experiences and values becoming less and less important in the selection of candidates.

 
 
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