The Authority of Science, the Boulder Model, and Clinical Psychology

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.

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Expertise

Lecture 7.  September 11 and 17.

Afterthoughts.  In Plato’s Socratic dialogues a repeating theme is expertise, especially when the issue at hand is how a state (polis) should be governed.  In motivating his idea of rule by Guardians, Plato has Socrates ask his students whom they would consult for wisdom about health (physicians) or cookery (chefs), and then suggests that just as there are experts in health and cookery, there must be experts in government.  And, just as we follow the wisdom of physicians and chefs, we should follow — be governed by — the wisdom of the Guardians he so fully describes in the Republic.

For now, let’s put aside the question of whether or not there can be expertise in governing and look at the notion of expertise itself, because Socrates and Plato raise an important question about expertise and rational decision making more generally.  Obviously, one way to define expertise and to determine who is an expert is to look at the outcomes of a person’s decisions and actions.  An expert doctor is one who consistently makes the right diagnosis and comes up with the right treatment; an expert chef is one who consistently cooks good food.  But recall that Socrates and Plato (and Western thought in general) demand more, that intuition (right action) is not real expertise; the true expert must be able to reflect upon, and thus give a theoretical account of his or her decisions.  This argument suggests that the correctness, the rationality, of a decision lies not (or not entirely) in its outcome, but in the process of making the decision.

Let me give an example of how this separation of outcome (intuition) and process (theory) has influenced psychological studies of decision making in Socrates’ field of concern, moral decision making.  Perhaps the most influential psychologist of moral development in the 20th century was Lawrence Kohlberg.  He put to his participants a series of moral conundrums (like the trolley problem we discussed in class, though he did not use it in his research), and then asked them what they would do in such a case and to provide an explanation for their chosen action.  His procedure was very Socratic — elicit an intuition about what’s right and wrong in a specific case and then require that the decision be justified.

Based on his findings, Kohlberg claimed that children and adolescents progress through a series of stages of increasingly adequate moral judgment.  Kohlberg’s proposal was based on many considerations (such as being influenced by Jean Piaget’s theory of cognitive development), but what’s most important for us now is that he defined his stages not with regard to the moral choice made but with regard to the process by which it was made.  In Kohlberg’s account of morality, the developmental level of expertise of a decision-maker was determined not by the outcome of the decision but by an evaluation of how the decision was reached.  Viewed through the lens of the history of psychology, Kohlberg was following the path blazed by Socrates and Plato.

Forethoughts.  The tension between action and explanation is one that will haunt the rest of the course especially when we come to consider psychology’s influence on society.  Like most of us, Socrates thought that there is an explanation, or account, of an action that justifies it rationally.  Moreover, he implicitly assumed that this justification was also a causal explanation of why the action was taken, even if the actor was not aware of it.  If this is the case, then scientific psychologists could study how people make decisions, discover what the processes of good decision making are, and then distill them into methods and policies employable by the state.  Suppose, on the other hand, that good decision making is an intuitive process that cannot be turned into a rational theory stable as a series of propositions; for example, the best explanation of decision making might be neuroscientific, not rational, ones.  Are voters rational (http://en.wikipedia.org/wiki/The_Myth_of_the_Rational_Voter)? Should politicians learn psychology, economics, or neuroscience (http://www.neuroeconomics.org/)?