Lecture 17. October 21 and 22.
Afterthoughts. Some questions and remarks after class suggested I should clarify what I meant about the peculiarity of the Boulder Model scientist-practitioner model of training in clinical psychology.
An important feature of modernism is the introduction of rationality and science as conferring social authority. Authority is an important concept — it confers legitimacy on a person’s or institution’s influence on others. It is much more than mere power. For example, a physician can write a prescription for you, but he or she cannot force you to take it (and the use of force on inmates in psychiatric facilities has been the subject of much controversy, lawmaking, and litigation on precisely this point). Prior to the rise of science, the most important sources of authority were religion and tradition, the authority of the priest and the aristocrat targeted for extinction by Voltaire. But (see Condorcet) the Enlightenment introduced a new, potentially highest, authority, reason, and the institution that embodies this authority above all is science. As Dr. Wenkman says, “Back off man, I’m a scientist!”
But what gives science authority? One is first tempted to answer, knowledge: Workable, valid, knowledge about how the world works. So you trust the doctor because he or she knows more about the causes and cure of diseases than you do. But we must think more deeply. We trust the knowledge of science because of how it was obtained — rationally, through scientific research. Scientists go to a great deal of trouble to ensure that their conclusions are reached through rational procedures. That is why, for example, articles go through peer-review and instances of fraud evoke such horror among scientists. Journals don’t just publish every article that comes in the mail, and scientists who commit fraud are drummed out of the scientific community. Science is a collection of practices that happens to produce knowledge, not just an accumulated collection of facts. Scientific authority is rooted in its practices, not the body of ideas currently found in texts. Ideas may be wrong, and are replaced by new ones, but the practices of science remain to continue to weed out false ideas and create better ones.
After World War II, psychology saw the opportunity to create a new profession, that of clinical psychologist practicing psychotherapy, previously the exclusive bailiwick of psychiatrists. Let’s go back to the physician, remembering that psychiatrists are physicians. Physicians have ample biological knowledge, and it is in that knowledge that their claim to authority lies. However, the typical physician is not trained as a scientist, in the practices of scientific research, and has probably not carried out any original research. The physician is a practitioner of a craft, medicine, not a research scientist. Thus the physician’s authority is second-hand, rooted not in the rational practice of science but only in the study of the fruits of that practice.
If clinical psychologists had been trained as physicians were, they would have no more authority than that of psychiatrists, and indeed would have less, as they would have no training in medicine. Moreover, psychiatry was an already existing, high-prestige, profession. One way to increase the authority of clinical psychologists, then, was to make them scientists, producers of knowledge, not just users of knowledge. Their training as PhDs places them one step closer to the rationality of science than that of MDs, and thus they can say what an MD cannot, “Back off, man, I’m a scientist!”
Forethoughts. Other questions concerned careers in clinical psychology. Clinical psychology faces serious challenges today on 3 fronts. First, there is managed care, which seeks to reign in medical costs, and has subjected psychotherapy, whose outcomes are hard to test and often of marginal effect size, to especially stringent controls. In connection with this, second, there is the rise of licensed clinical social workers (and to some degree PsyD holders), who also performs psychotherapy, but whose training is briefer and who can be produced in much larger quantities than PhD clinical psychologists (just compare the graduating class sizes of VCUs School of Social Work with our Department’s Clinical Program). Third, there is the ongoing biological revolution in psychiatry, because of which it’s possible to treat mental disorders with medications only an MD can prescribe. Simply put, the market for PhD clinical psychologists has shrunk over the past few decades and is likely to shrink farther. The APA is trying to cope with all these changes (e.g., by working to get clinical psychologists prescription privileges), but the glory days of clinical psychology practice are probably over.