AMA About Clinical Psychology (and RPGs!)

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D3M410
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Re: AMA About Clinical Psychology (and RPGs!)

Postby D3M410 » Tue Nov 04, 2014 9:07 pm

CaptainKobold wrote:This was probably asked, or should have been. What's the difference between a psychologist and a psychiatrist?
In order to be a psychologist, you have to get a Ph.D (Doctorate in Philosophy).

Really? I have not heard this restriction before.

Also thanks for doing the AMA. I'm studying therapy so I was thinking of doing an AMA on the topic when I get further along, but you have already covered a lot of ground here.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Nov 05, 2014 5:45 pm

Just on for a second because I saw there was a question I can answer pretty easily! I promise I'll be back to grab that other one I haven't done yet, this week has just been ridiculously busy.

Yes, in order to call yourself a psychologist in most states you need to have either a Ph.D. or a Psy.D. (Doctorate in Psychology). The Psy.D. is a relatively newer thing and tend to de-emphasize research (they don't need to do a dissertation).

You /can/ do therapy without a doctorate, but you generally can't call yourself a psychologist while doing it. You will, of course, still need to have licensure. Some good examples are Licensed Mental Health Counselors (LMHCs) or Masters of Social Work (MSWs). These usually take less time to get through which can be an advantage to people who don't want to or can't put in the full doctorate amount of time. Obviously there are differences other than amount of time (generally paid a little less, social work is REALLY different from psychology, LMHCs are relatively new).

Is that helpful at all, D3M410? I don't want to misrepresent things if you're in a program that I'm unaware of! Also, feel free to chime in on any questions you feel like! I'm just one view point and there are plenty of others.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Magmoo » Wed Nov 05, 2014 6:47 pm

I've heard it said that the DSM is more a guide for billing and legal language and many institutions do not rely very much on it. Is this true or was that simply in reference to the fact that there was a big gap between DSM IV-R and DSM V?
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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Nov 12, 2014 12:54 pm

Sorry it took me so long to answer these!

Ok I have a question with a qualifier first...

I work in legal aid for seniors (60+). Numerous clients I represent have perceptions and behaviors that are counter productive to protecting their rights. The client's own behaviors make it difficult (or impossible) to protect the client's rights. This can be denial of their actions, paranoia, or acting out against perceived threats (or maybe they do need to break into the managers car to remove the government speaker influences turning the manager against the client). The client really needs a social worker or mental health help, but emphatically deny that they have mental health challenges.

How can I or others best suggest mental health professionals to someone who needs the help, but they are in denial? Any strategies would help my clients.

Thanks in advance.


So the reason this took so long to get back is a combination of falling into crunch time and realizing that I needed to consult with a couple of other mental health care providers. I’ve personally not had much experience working with people who aren’t actively receiving mental health care (perhaps not surprisingly), so I didn’t feel exceptionally qualified to answer this on my own. That said, I’m now speaking with the authority of several other people behind me, so that will hopefully help my ability to answer!

One of the best ways to get someone involved with mental health is to attempt to restructure or destigmatize the idea of getting mental health care. There are several populations that have been consistently underserved not because of lack of professionals, but because they avoid getting psychological help. These underserved populations (such as the elderly, latinos, and people of African descent in America at least) generally have an even more stigmatized view of mental health than the population as a whole. There is a lot of research being done into why specific racial groups are underserved, but it’s generally agreed that senior citizens don’t want mental health treatment because of antiquated beliefs about being an outcast if you need mental health treatment; only whackos and sissies need therapy. If you are wondering whether a general stigma exists against people with psychological disorders, you’re probably living in a really pro-psych area (and if it’s NYC maybe we should game sometime!). I can talk about stigma later though, because the core thing to take away right now is that this is likely a big reason that is preventing seeking treatment.

In approaching this problem, my colleagues and I would suggest that telling people in an underserved population that they ‘need [...] help’ may increase their response to their anti-therapy feelings. My guess is that this hasn’t been the tact used, but I thought it was worth throwing it out there! Instead, a more neutral suggestion that working with a social worker or psychologist could be helpful to them may be more effective. I was given the line, “You know, people in psychology and social work have spent a lot of time learning how to navigate these sorts of legal systems. Lots of them mostly see people who don’t have psychiatric disorders, but could use just a little bit of help working through hard times or thoughts.”

The core idea here would be that therapy isn’t just for people with problems. Many senior citizens view mental health as similar to medical health; you go to the doctor when you are sick, not because you aren’t in Batman-esque peak physical condition. Restructuring this mental process into an understanding of what mental health can be for people who /aren’t/ “mentally ill” could be really helpful. Really what tends to be the agreed upon trick is psychoeducation. Most people don’t know much about psychology; they still picture the patient on the couch next to a bespeckled fellow with a big beard or worse, Hannibal Lecter, the Scarecrow, or American Horror Story. When it is described as learning skills that can be used in real situations without the idea of the patient needing to be fixed, it can be much more salient to people.

I hope this has been helpful! I’m a little worried it’s not great, especially given the wait. I can keep pestering my contacts who work with these sorts of groups.

I've heard it said that the DSM is more a guide for billing and legal language and many institutions do not rely very much on it. Is this true or was that simply in reference to the fact that there was a big gap between DSM IV-R and DSM V?

There are a couple of viewpoints on the DSM, so I’ll try to work them out separately because luckily, I’m not charged by the word on these responses. Most people fit into a couple of these at the same time (the first and fourth especially). I’m going to put them in order of cynicism regarding the DSM for easier use.

DSM as Bible: I’m not going to give this much air-time because it’s a fairly limited number of people who believe in this (some psychiatrists and lots of undergrads) and honestly it’s such a ridiculous thing to go for that it’s hardly worth mentioning. There are some few people who believe that mental illness should be treated like physical illness; when someone has the flu, you give them… flu… medicine… (this metaphor was poorly conceived given my lack of medical knowledge), when someone has depression, you give them SSRIs (Selective Serotonin Reuptake Inhibitors) and tell them how nice life is. It’s just kind of naive.

DSM as Guidelines: Any therapist worth their salt will tell you that you aren’t trying the disorder, you are treating the patient. Given this, it may seem that giving a diagnosis wouldn’t be helpful. However, most of the empirically supported treatments (science-backed stuff) have specific manualized treatments (kind of like outlines of treatment) for specific disorders. CBT for Anxiety is very different from CBT for Specific Phobia is very different from CBT for Bipolar. Although the person should be taken holistically, it is helpful for the scientific discipline to be able to describe a constellation of behaviors and thought patterns so that everyone can know what you are referring to. It would be really hard to publish a paper entitled ‘Treatment Of Bob: All the Treatments I Tried To Do With This One Guy Specifically’ and such a paper wouldn’t be particularly helpful for other clinicians. By being able to say quickly that a child has ODD (Oppositional Defiant Disorder), the mental health team can get on the same page and offer scientifically validated treatment.

DSM as Load of Crap: I’m about to drop some truth-bombs. The people who write the DSM are not the average psychologist or mental health care provider. Many of the people involved are absurdly rich psychiatrists. Almost everybody involved has ties with pharmaceutical companies. Is it any surprise that they want to pathologize all of human behavior (maaaan)? The DSM (especially this most recent one) has a tendency of pathologizing things so that Big Pharma can line their greedy pockets. You know who likes the DSM? Big Pharma and Medicaid.

DSM as Necessary Evil: This is kind of a more nuanced view of DSM as Crap and what you were referring to with legal language and billing. Out of all of the views, this is probably the one I’ve hit upon the most often (though admittedly with a good dose of the second as well). Insurance companies aren’t really sure what to do about mental health because it’s hard for anyone to be completely mentally healthy. Everybody has their hang-ups, fears, anxieties, etc. Because of this, insurance companies want people to get better (like you would at a medical hospital) and then stop taking their money. In order for someone to get paid through insurance, they need to have a DSM diagnosis. Additionally, your reference to law also applies; ‘Periods of high anxiety and distress coupled with occasional hallucinations’ doesn’t get people off during trials, schizophrenia can. Because of this, the DSM becomes something of a necessarily evil cycle. If psychologists want to get paid, they need to give DSM diagnoses. This need for diagnoses provides incentive for the writers of the DSM to pathologize more behavior (did you know you can get diagnosed with Internet Addiction in the DSM-V?). Then psychologists get paid, patients get care, and insurance companies pull hours of useless paperwork out of people who could be helping. I’ll tell you definitively that when I’ve worked with in-patient adults that one of the very highest reasons for discharge was Medicaid running out.

So I know I should give my view on all of this as well as the general viewpoints. I think that the DSM isn’t a very good book. I think it does a really bad job of explaining several disorders (Autism, OCD, and Antisocial Personality Disorder come to mind) and that it is an obvious ploy to make money for pharmaceuticals. I think the board needs to be essentially replaced in full. That said, it helps to know what you are working with and the DSM can provide that. Also, I’d like to be able to be paid, so I gotta deal with it.

Sorry about the delay on all of these! I should now be back and posting stronger! If there are any questions, feel free to ask them. Also, post your own AMAs or ask people things!
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Magmoo » Wed Nov 12, 2014 4:00 pm

Thanks for the indepth answers CK. Clearly you're putting some serious thought and time into them and it is appreciated.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Nov 12, 2014 5:48 pm

Absolutely, Magmoo! I'm enjoying spreading some of my knowledge and opinions. I very much enjoy babbling about psych.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Magmoo » Wed Nov 12, 2014 6:21 pm

What are the indicators of Borderline Personal Disorder and at what point should a layperson even consider that a friend has that or any other personality disorder?
I ask because with personality disorders friends often end the friendship rather than deal with the person and this can lead to them never having the support needed to confront such issues.
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Re: AMA About Clinical Psychology (and RPGs!)

Postby Peetiedog » Wed Nov 12, 2014 11:15 pm

Thank you for the well thought out response. Can I have your permission to cut and past some of your suggestions into a memo for my staff and interns? I believe this will helps us help people.

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Re: AMA About Clinical Psychology (and RPGs!)

Postby CaptainKobold » Wed Nov 26, 2014 4:04 pm

Hey! Sorry I disappeared there for a bit! I was messing around with emails and forwarding and somehow ended up not letting the FtB forum emails get through! Should be back now, in case people have questions!

What are the indicators of Borderline Personal Disorder and at what point should a layperson even consider that a friend has that or any other personality disorder?
I ask because with personality disorders friends often end the friendship rather than deal with the person and this can lead to them never having the support needed to confront such issues.


You are absolutely right that many people with severe personality disorders often end up losing quite a few friends. Unfortunately, the sort of behavior that is associated with borderline personality disorder is really difficult for people to be around. Even some psychologists will avoid treating people with borderline personality disorder because frankly, they are difficult. Luckily fairly recently there have been some really promising seeming treatments (Dialectical Behavioral Therapy primarily, but Third Wave treatments in general to a lesser extent) that may do some good.

A couple of the big indicators of someone who may be borderline are extremely labile (quickly fluctuating) affect and simultaneously clingy and rejecting relationships. There's a lot of belief that they are being abandoned by people (which is worsened by the fact that their erratic behavior /can/ lead to actual abandonment). Additional things that could be flags are dangerously impulsive behavior (driving fast, getting in fights, punching through glass, drug use, abusive relationships, etc.) and suicide attempts or non-suicidal self-injury. These last couple bits are what frequently ends up being what brings someone with borderline personality disorder into a hospital.

There are lots of people who hear this kind of description and go 'Oh! I have like... 10 friends like that! They are so clingy and sometimes irrational!' While it is certainly possible (borderline isn't an exceptionally rare disorder), those who would qualify for the disorder tend to be on the extremes of it. If someone is just kind of clingy, they likely are fine and don't need treatment. But pretty much anyone who is involved in highly dangerous lifestyle choices, NSSIs, or other parasuicidal activity could probably use some help.

Did that answer the question? I'm concerned I may have hedged a little around it rather than giving it straight.

Thank you for the well thought out response. Can I have your permission to cut and past some of your suggestions into a memo for my staff and interns? I believe this will helps us help people

You absolutely can! I hope that this is helpful to people!
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Re: AMA About Clinical Psychology (and RPGs!)

Postby javascripter » Wed Dec 31, 2014 7:51 pm

According to WebMD, social anxiety is an unreasonable fear of social situations. What about reasonable but high fear of social interaction, is that just not a very good definition? And what is unreasonable?

Also, why does it seem like introvert and antisocial are considered synonymous (I thought they were for a long time) even though they are completely different?

Have there been any psychological researches into why different people like different music and/or different lyrics?

EDIT: Also, I like reading your textwalls.

EDIT: I just remembered why I first was going to post: Why do I hoard consumables/one-time use items but never use them?


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