Also, just in case anyone is curious, here's what I told Constance Holden at
Science about the report (excerpted below). Holden had a very brief blurb on
it too in this week's Science.
Her brief piece in Science is immediately below, followed by my (much)
more extended comments to her. Cheers....Scott
Shrinking the Shrinks (Constance Holden, Science)
Many training programs for clinical psychologists in the United States should
be scrapped, an organization of psychologists says. In a report to be released
this month, the Association for Psychological Science (APS) calls for more
scientific rigor in psychotherapy. "Clinical psychology resembles medicine at a
point in its history when practitioners were operating in a largely
prescientific manner," it says. Therapists' "lack of adequate science training
... leads them to value personal clinical experience over research evidence."
The report lambastes the American Psychological Association (APA)-which
comprises mainly clinical psychologists-for lax accreditation standards and
proposes a new mechanism for certifying Ph.D. training programs.
Psychologist Scott Lilienfeld of Emory University in Atlanta praises the
report, saying, "Far too many practitioners are administering unsubstantiated
or untested intervention." But he worries that its proposals would freeze out
Psy.D. programs, nonresearch degrees begun in the 1970s, which now turn out
about half of the nation's clinical psychologists.
Jeffrey Zeig, a clinical psychologist and director of the Milton H. Erikson
Foundation in Phoenix, says psychotherapy is much too diverse to be constrained
by APS definitions. "There are more than 1,000,000 therapists in the U.S., and
only a fraction" have Ph.D.s, says Zeig, who predicts the report "will have as
much effect as a breeze has on a leaf."
But report co-author Timothy Baker of the University of Wisconsin School of
Medicine and Public Health in Madison predicts that it "will ultimately reshape
clinical psychology just as the [1910] Flexner Report reshaped medicine,"
leading to the closure of almost half the nation's medical schools.
My full comments to Holden:
The report, I suspect, is destined to become a classic. It is a
magisterial and hard-hitting examination of the current state of mental health
practice and what is wrong with it. The authors are right on the mark that the
present state of much of graduate education in mental health today resembles
that of medicine in the early 20th century. Surveys demonstrate that far too
many practitioners are administering unsubstantiated or untested interventions,
and not nearly enough are administering interventions that have been shown to
be efficacious or promising. The authors are also correct that scores of
programs accredited by the American Psychological Association are doing an
inadequate job of teaching their students to think and practice scientifically.
Just as medicine sorely needed Flexner to clean house, our field sorely needs
reforms to place graduate training in clinical psychology and allied
disciplines on surer scientific footing. This report goes part-way to doing so
(but see below).
Ironically, Zeig's defensive comments illustrate the problem and
inadvertently help to make precisely the point that Baker and colleagues are
making. Like many (but by no means all) practitioners in the field, Zeig
wishes to privilege subjective personal experience above rigorous scientific
data when it comes to adjudicating questions of what treatments to administer,
ignoring hundreds of studies demonstrating that raw intuition and subjective
experience are subject to a host of biases to which we're all prone. Zeig's
remarks ignore the crucial point of the PSPI monograph: Scientific methods,
like randomized controlled designs, are the best safeguards we have against a
myriad of sources of human error. These research designs are the very
embodiment of epistemic modesty, as they are an explicit admission we need
systematic protections against our all too natural tendency to see what we want
to see. Zeig is factually incorrect that scientific findings have not informed
psychotherapies; much of the work on efficacious behavioral interventions,
which have helped tens of thousands of individuals with autism, phobias,
obsessive-compulsive disorder, bulimia, and many other conditions, derived
largely from basic scientific research in the laboratory. Certainly, Zeig is
right that clinically-inspired innovations have sometimes emerged without the
benefit of formal scientific findings, and I don't anyone who disputes that.
But how have we ascertained whether these innovations are efficacious? Through
controlled scientific research.
All that said, I am disappointed by one aspect of the report, namely the
new accreditation system. I voiced my concerns at a meeting of the Academy of
Psychological Clinical Science a few years ago, and am disappointed to see them
unaddressed. Put simply, the authors' diagnosis is accurate, but their
prescription is incomplete. Regrettably, the new accreditation system will
only certify programs that produce clinical researchers, not practitioners. As
a consequence, programs that do an excellent job of training
scientifically-minded psychotherapists - those who rigorously trained to
scientifically evaluate the research literature on the effectiveness of
interventions and trained to apply evidence-based interventions - will not be
eligible for accreditation. Indeed, the accreditation principles (see
http://www.pcsas.org/principles.html) explicitly state that "Programs with a
chief mission of training psychologists for specialized careers in applied
clinical work-no matter how science-based such applied training may be-are not
appropriate candidates for PCSAS accreditation." This decision is, in my view,
deeply misguided, as it sends a clear message that the authors aren't
interested in helping to reform programs whose principal mission is to train
practitioners. As a consequence, the authors missed a golden opportunity to
narrow the scientist-practitioner gap, as they forfeited the chance to place
their stamp of approval on programs that specialize in training
scientifically-minded practitioners - those who are good critical thinkers and
apply the best available research evidence to their clinical work. Yet as the
authors themselves note, these are precisely the practitioners whom we sorely
need. They are also, I should note, the practitioners who have the potential
to best disseminate evidence-based interventions to the clinical community. In
all of these respects, the analogy to the Flexner report is not entirely
accurate, as the Flexner report revamped the practice training of physicians.
In contrast, the present report leaves practice-oriented clinical programs in
the dust and more or less gives up on them, focusing instead on training
clinical researchers. As a consequence, it is unlikely to exert much impact on
the scientific training of most psychotherapists, which is regrettable. It
also risks widening, not narrowing, the scientist-practitioner gap by confusing
"clinical scientists" with "clinical researchers." In my view, clinical
scientists are not limited to clinical researchers; they are individuals who
apply scientific approaches to whatever they do, whether it be research,
psychotherapy, assessment, teaching, and the like. The report could have made
a powerful statement by recognizing and endorsing clinical scientists who are
operating on the front lines of everyday practice, but it elected to ignore
them.
-----Original Message-----
From: Dr. Bob Wildblood [mailto:[email protected]]
Sent: Sunday, October 04, 2009 11:43 AM
To: Teaching in the Psychological Sciences (TIPS)
Subject: Re: [tips] clinical workers and evidence
Gerald Peterson wrote:
>Here is an interesting article about the problems of evidence-based clinical
>workers. I don't like them calling all therapists psychologists, nor the
>subtitle of psychologists rejecting science, and it's a bit of
>over-simplification, but might be of interest to some. See:
>http://www.newsweek.com/id/216506
>
Having been a counselor/therapist for 33 years, there is lots in this article
to agree with. Many clinicians and physicians do rely more on intuition than
on science in making decisions as to how to treat a client/patient with a
particular disorder (taking into consideration that diagnosis is, itself, not
very scientific in many cases, especially psychology/psychiatry). That being
said, there are manhy of us who do rely on the use of "evidence based
therapies" especially those which are supported strongly by research. In fact,
our beloved insurance companies are beginning to know what kind of therapy is
being used for what diagnosis, and I have heard (anecdotes, to be sure) that
some people have been refused reimbursement if certain therapies are not used
with certain diagnoses. Interestingly (to possibly start a firestorm here) one
of the therapies which has as much or more research than any other is EMDR and
its use in PTSD resulting from a multitude of causes, because!
w!
e don't know what sense there is behind it that can explain how it might work.
Since I am an advocate of EMDR, have read the research, and have seen the
results with my own clients starting with Vietnam veterans (in my experience
since about 1994, not immediately after the conflict was finally abandoned) I
submit that it is an evidence based therapy and as to how it works, I submit
that we know as much about how it works as we do about how aspirin works.
In sum, not a bad article although it is a bit simplified.
Robert W. Wildblood, PhD
Riverside Counseling Center and
Adjunct at Germanna CC, Fredericksburg, VA
[email protected]
The soundest argument will produce no more conviction in an empty head than the
most superficial declamation; as a feather and a guinea fall with equal
velocity in a vacuum.
- Charles Caleb Colton, author and clergyman (1780-1832)
Not thinking critically, I assumed that the "successful" prayers were proof
that God answers prayer while the failures were proof that there was something
wrong with me.
- Dan Barker, former preacher, musician (b. 1949)
We have an obligation and a responsibility to be investing in our students and
our schools. We must make sure that people who have the grades, the desire and
the will, but not the money, can still get the best education possible.
- Barack Obama, President of the United States of America
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