The troubles in psychiatry and psychology
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. It was not until the 1970s 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 reliability of psychiatric diagnosis, the anti-psychiatry movement that was in keeping with the counter-cultural ethos of the 1960s, 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 “pseudoscientific” 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 of 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 like real doctors.
But the cracks are now 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), made news in the mainstream media. Even though many of such 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, there was a growing body of evidence that many of the claims for the miraculous powers of the new generation of psychiatric medications had been massively inflated, which diminished 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. It is, then, 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 talking cure”) 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.
Yet, all is not well in the house of psychology either. Many of the same forces (or at least similar ones) that are reaping havoc upon psychiatry are in one way or another affecting the field of psychology as well, and 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 a common malady — “physics envy.” Just as many psychiatrists want to be real doctors, many psychologists want to be real scientists. This 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 the discipline(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, comparing the current state of clinical psychology to the “pre-scientific state of American Medicine at the time of the Flexner report in the 20th century.” 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. 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 determining the direction that training in clinical psychology is likely to take in the future. And the clinical science training model appears poised to replace the scientist-practitioner model as the most common in clinical psychology.
What are the differences between these two models?
The scientist-practitioner model, established when clinical psychology first emerged as a distinct field (following World War II), 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 goals are for 1) clinical research should be meaningfully informed by, and relevant to, real word clinical practice, and 2) the clinicians real world practices should be informed by their experiences as scholars and researchers.
In contrast, the clinical science model de-emphasizes 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 providing students with clinical training. In some sense this is understandable. Whether or not this de-emphasis of clinical training indicates a belief that clinical skills are easily acquired without extensive training (which it inevitably 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 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 have told me that although they continue to 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. Yet, it is important to note that this is an intensification of the long term trend which will have serious implications for the future of clinical psychology and the clinical treatment.
Increasingly the clinical research that is likely to be published in professional journals will 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. Further, future clinical psychologists trained in clinical science program will be less likely to become skilled clinicians.
And also note, another development taking place in the mental health field: the growing emphasis that both psychiatry and psychology are placing on brain science research at the expense of other important fields of research that include psychological, social and cultural analysis. A reductionist monoculture is emerging, threatening to subsume psychiatry and psychology into the field of neuroscience.