If psychiatrists can be real doctors, can psychologists be real scientists?
These are troubling times for the mental health field in the United States. A variety of historical developments have paved the road to the current predicament. Following World War II, the federal government and growing mental health lobby began an unprecedented expansion of mental heath services. This expansion in may respects continued over the next 30 years (although there were of course fluctuations influenced by fluctuations in the national economy and an assortment of political factors). It was not until the 1970’s that American psychiatry underwent its first major crisis in the post war era. This crisis was precipitated by a number of factors including the growing evidence of the lack of lack of reliability of psychiatric diagnosis, the anti-psychiatry movement that was in keeping with the counter-cultural ethos of the 1960’s, and a growing crisis of confidence regarding psychiatry’s status as a genuine medical specialty. All of these factors led to the development of the third edition of the official Diagnostic manual for psychiatry (DSM-III) which purged it of most of its psychoanalytic influences, conveyed an aura of scientific respectability, and helped to galvanize a biological turn in psychiatry (or more accurately a pendulum swing back in the direction of a long established tradition of biological psychiatry). On the heels of its scientific and biological makeover, American psychiatry entered into a new era respectability and profitability. Neuro-chemical models of psychopathology proliferated, the federal government was willing to spend money on biologically oriented psychiatry research, and perhaps most importantly the apparent successes of new psychotropic medications became a goldmine for pharmaceutical companies. True, psychiatrists had to sacrifice much of their interest in psychotherapy. But for many this was a small price to pay in order to be able to feel almost like real doctors.
But unfortunately for psychiatry the cracks are beginning to show. The internal controversies about DSM-5 (the latest edition of the official diagnostic manual) for psychiatry, led by psychiatry insiders including Robert Spitzer and Allen Frances (both chairs of former DSM task forces) began to make news in the mainstream media, and even though many of these controversies had taken place on a smaller scale with the development of DSM-III and DSM-IV, the public was beginning to suspect that that the emperor has no clothes. To add injury to insult, the growing body evidence that many of the claims for the miraculous powers of the new generation of psychiatric medications had been massively inflated began to have an impact on the pharmaceutical companies’ willingness to invest their money on research and development relevant to this area. Add to this the fact that we are in the midst of the deepest and most long lasting economic downturn since the great depression, and our national healthcare costs have become unsustainable, and it is no surprise that hospitals are being forced to merge and slash costs any way they can. And when it comes to making decisions about where to slash budgets, psychiatry departments (even those that have turned their backs on the “pseudoscience” of psychoanalysis) are the weak links in the chain.
Now I suppose psychiatry’s plight could lead a lesser psychologist than myself to experience the guilty pleasure of schadenfreude. After all, why should I worry about the plight of psychiatry? Didn’t American psychiatry prohibit the training of so called “lay psychoanalysts” (psychologists and other non medically trained psychoanalysts) until 1988? And nobody forced psychiatrists to abandon the field of psychoanalysis, or to forgo extensive training in psychotherapy of any type in residency programs. And if they want to turn the field of psychotherapy over to psychologists and social workers, so that they can spend their time prescribing medications to more seriously ill patients – so be it.
But all is not well in the house of psychology either, and many of the same forces (or at least similar ones) that are reaping havoc with psychiatry are in one way or another affecting the field of psychology as well. On top of this many of the changes taking place within psychiatry are having an important impact on psychology and other mental health disciplines. The first force to be reckoned with is that just as many psychiatrists want to be real doctors, many psychologists want to be real scientists. This type of “physics envy” has always been an important influence on the development of American psychology, but my sense is that these days, it is a force that is increasingly impinging on psychology (or at least clinical psychology) in problematic ways.
There is a strong movement afoot to push the training of future clinical psychologists in a more “science based” direction. Proponents of this movement lament the fact that too few clinicians in the real world use “evidence based” treatments such as cognitive therapy (never mind the fact that the claim that cognitive therapy is “evidence based” and other therapies are not is based on a serious misreading of the empirical literature), compare the current state of clinical psychology to the “prescientific state of American Medicine at the time of the Flexner report in the 20th century”. By way of addressing the problem they advocate for a more widespread acceptance of an alternative to the American Psychological Association accreditation system that would only accredit clinical psychology programs that are considered “science based” in nature. This emphasis on “science” is reflected in both the name of the new accreditation body, i.e. The Academy of Psychological Clinical Science (APCS), and the training model for clinical psychology that it enshrines, i.e. the clinical science model.
The APCS has become one of the dominant forces in the direction that training in clinical psychology is likely to be taking in the future. And the clinical science model appears poised to replace the scientist-practitioner model as the most common model of training in clinical psychology. What are the differences between these two models? The scientist-practitioner model, established in 1949, holds that clinical psychologists should be well trained in both clinical practice and research, and the goal is to integrate or bridge these two worlds, in one’s professional activity – whether as a clinician, a researcher, or both. The clinical science model deemphasizes or abandons the goal of integrating clinical practice and research, and instead has an overarching emphasis on “contributing to knowledge” by conducting empirical research and publishing it in professional journals. In fact one of the major criteria for accreditation by the APCS consists of demonstrating that both faculty and students in the program have good track records of publishing research in peer-review journals and attracting external funding.
Needless to say, the majority of clinical science programs train students in cognitive therapy (to the virtual exclusion of other therapeutic approaches). But perhaps even more important is the fact that the curricula for clinical science programs place very little emphasis on the providing students with clinical training. In some sense this is understandable. Whether or not this de-emphasis on the importance of clinical training reflects a tendency to believe that clinical skills are easily acquired without extensive training (which it does), from a practical perspective, a Ph.D. student in clinical psychology who is going to be prolific enough to have a first rate publication record, and a good track record of securing external funding by the time he or she graduates is going to have very little time for extensive clinical training. At the present time more than fifty clinical psychology programs have been accredited by the APCS, and the number is growing exponentially. Many Directors of Clinical Psychology who I have spoken to have told me that although they continue maintain their accreditation with the American Psychological Association, they are also seeking accreditation through the APCS because they see it as the “wave of the future.”
What are some of the practical implications of this development? Increasingly the clinical psychologists who end up with faculty positions in clinical psychology programs, will have had very little clinical training prior to graduating, and will be highly unlikely to have clinical practices once they graduate. In some respects this development is simply an intensification of a trend that has been taking place for years now, that has been widening the chasm between practicing clinicians and the academic clinical psychologists who train clinical psychology students in graduate school. But it is an amplification of a trend that will have serious implications for the future of clinical psychology.
Increasingly the clinical research that is likely to be published in professional journals is going to become less and less relevant to clinicians in the real world as the proportion of academic researchers who know anything about real world clinical practice decreases. A second impact of the growing influence of the clinical science model is that future clinical psychologists trained in clinical science program are going to be less likely to become skilled clinicians. In addition to growing impact of the clinical science model within clinical psychology, there is another development taking place in the mental health field at large that is important to note. What I am referring to here is growing emphasis that both psychiatry and psychology are placing on brain science research at the expense of other important fields of research that emphasize psychological, social and cultural levels of analysis.
With the remedicalization of American psychiatry in the 1980’s and the apparent successes of a variety of new psychotropic medications, the disease model of psychopathology has become increasingly entrenched as a dominant cultural narrative. The consolidation of this narrative has been fostered in no small part by the pharmaceutical companies, which are allowed to market psychiatric medications directly to the general public for a variety of mental health problems such as anxiety and depression, “the common cold of mental illness.” Over time the consolidation of this cultural narrative and the understandable desire of the National Institute of Mental Health to continue to attract its fair share of the federal funding allocated to healthcare research, has led to a situation in which an increasingly large proportion of public funding for mental health research has come allocated to brain science research and the identification of “biological targets” that can be influenced directly through the right medications or neural stimulation of one type or another.
This shift is well documented, and for those who are interested in getting a general sense of how funding priorities have shifted, all you need to do is to look us the website for the National Institute of Mental Health and examine the type of language that is used in funding announcements. What implications might this have for the future of psychotherapy? Quite simply put, funding priorities shape the programs of research pursued by scientists, and thus the type of research findings that are published in professional journals and disseminated to the public. This in turn shapes the curricula in psychiatry and clinical psychology training programs, which shapes the way in which mental health professionals understand and treat mental health problems. It also influences healthcare policy decisions and the type of coverage provided by third party insurers.
In the last 20 to 30 years universities have increasingly come to prioritize the importance of securing external grant funding for faculty members in medicine and psychology. There are important practical reasons for this. Because of decreases in government funding for post secondary education in the United States, and the general shift of university culture towards a corporate mentality, university administrations have become increasingly dependent upon cash inflow that come from indirect costs linked to grants secured by faculty from external funding agencies. And given the fact that psychologists have traditionally been able secure larger grants than colleagues in some of the other social sciences, securing external funding has become one of the most important criteria for decisions regarding both hiring and retention.
What this means is that academics in clinical psychology who want to find and hold on to university positions had damn well better be serious about securing grant funding. And if the majority of the grant funding for mental health research is likely to be allocated to research with a significant biological component, it is inevitable that clinical psychology programs in universities will increasingly be staffed by clinical faculty with limited experience or interest in doing clinical work and with the expertise to secure external funding for brain science research. Now I have no doubt that brain science research is of value. But there is good reason to believe that the extravagant claims regarding the current yields of brain science research are massively inflated. There is a type of reductionistic monoculture emerging which at times verges on subsuming both psychiatry and psychology into the field of neuroscience.