Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
MANIFESTO FOR A SCIENCE OF CLINICAL PSYCHOLOGY
Richard M. McFall
What follows are excerpts from Richard M. McFall's presidential address to Section III of Division 12. The full text of this Manifesto (and much more information about the SSCP) can be accessed on the website of the Society for a Science of Clinical Psychology at http://pantheon.yale.edu/~tat22/mission&history.htm. These excerpts are reprinted with permission.
Traditionally, this Presidential Address has been devoted to a discussion of the speaker's personal research interests. I am deviating from that tradition, focusing instead on a topic of more general concern: the future of clinical psychology, Section III's mission in shaping that future, and an agenda for pursuing that mission into the 1990s. . . .
[T]he time has come. . .for Section III members to take a more active role in building a science of clinical psychology. Specifically, I believe that we must make a greater effort to differentiate between scientific and pseudoscientific clinical psychology and to hasten the day when the former replaces the latter. Section III could encourage and channel such activism among its members—and among clinical psychologists generally—by developing and publishing a "Manifesto," which would spell out clearly, succinctly, and forcefully what is meant by "a science of clinical psychology," and outline the implications of such a science for clinical practice and training.
What follows is my draft proposal of such a Manifesto for a Science of Clinical Psychology. On its face, it is deceptively simple, consisting of only one Cardinal Principle and two Corollaries, but its implications for practice and training in clinical psychology are profound. I am not so foolish as to expect that everyone will agree with my analysis of the situation or with all of my proposal. If I focus attention on Section III's mission and stimulate constructive discussion of how best to achieve this mission, however, then I will have served a worthwhile purpose.
This first principle seems clear and straightforward to me—at least as an ideal to be pursued without compromise. After all, what is the alternative? Unscientific clinical psychology? Would anyone openly argue that unscientific clinical psychology is a desirable goal that should be considered seriously as an alternative to scientific clinical psychology?
Probably the closest thing to a counterargument to this proposed Cardinal Principle is the commonly offered rationalization that science doesn't have all the answers yet, and until it does, we must do the best we can to muddle along, relying on our clinical experience, judgment, creativity, and intuition (cf Matarazzo, 1990). Of course, this argument reflects the mistaken notion that science is a set of answers, rather than a set of processes or methods by which to arrive at answers. Where there are lots of unknowns—and clinical psychology certainly has more than its share—it is all the more imperative to adhere as strictly as possible to the scientific approach. Does anyone seriously believe that a reliance on intuition and other unscientific methods is going to hasten advances in knowledge?
. . . .The implication commonly attributed to the hyphenated [scientist-practitioner] Boulder Model is that there are two legitimate types of clinical psychology: clinical science and clinical practice.
This is the dichotomy one hears, for example, from undergraduates who are applying to graduate training programs in clinical psychology and are struggling with making what they perceive to be the difficult, but necessary, career choice between science and practice. . . . What I am saying to them, of course, is that all forms of legitimate activity in clinical psychology must be grounded in science, that all competent clinical psychologists must be scientists first and foremost, and that clinicians must ensure that their practice is scientifically valid.
Regrettably, many students dismiss my advice. They are convinced by the official pronouncements of psychological organizations, the characterizations of clinical psychology put forward by prominent textbooks, and the depictions of clinical psychology promulgated by other psychologists with whom they consult that the conventional distinction between scientists and practitioners is the correct one and that my counsel is completely out of touch with reality. My advice scares them, I suspect. Their futures are on the line, after all, and they are not about to lose out by following the advice of someone who seems so at odds with the dominant view.
It would go beyond the scope of this presentation to trace the history of clinical psychology's split personality, as manifested in the Boulder Model, but psychologists committed to science somehow have allowed the perspective they represent to be characterized as just one of the acceptable alternatives within clinical psychology, with no greater claim to legitimacy or primacy than any other. . . .
Can you imagine a similar state of affairs in any other scientific discipline? Imagine, for instance, an undergraduate chemistry major discussing her choice of graduate schools with her advisor. The student announces that she has decided to apply only to those doctoral programs in chemistry that will require the least amount of scientific training; after all, she explains, she plans to do applied chemical work, rather than basic research, after she completes her degree. Or imagine another student applying to medical school. Because he is interested in applied medicine, he is considering only those schools that require the fewest science courses. These examples are ludicrous; yet academic advisors in psychology regularly hear such views expressed by prospective graduate students in clinical psychology. What makes this situation even more disturbing is that some advisors have come to accept such views of clinical psychology as reasonable and legitimate.
The time has come for Section III— whose mission it is to promote a science of clinical psychology—to declare unequivocally that there is only one legitimate form of clinical psychology: grounded in science, practiced by scientists, and held accountable to the rigorous standards of scientific evidence. Anything less is pseudoscience. It is time to declare publicly that much of what goes on under the banner of clinical psychology today simply is not scientifically valid, appropriate, or acceptable. When Section III members encounter invalid practices in clinical psychology, they should "blow the whistle,' announce that "the emperor is not wearing any clothes," and insist on discriminating between scientific and pseudoscientific practices.
Understandably, the prospect of publicly exposing the questionable practices of fellow psychologists makes most of us feel uncomfortable. Controversy never is pleasant. Public challenges to colleagues' activities certainly will anger those members of the clinical psychology guild who are more concerned with image, profit, and power than with scientific validity. However, if clinical psychology ever is to establish itself as a legitimate science, then the highest standards must be set and adhered to without compromise. We simply cannot afford to purchase superficial tranquility at the expense of integrity.
Some might argue: "But who is to say what is good science and what is not? If we cannot agree on what is scientific, then how can we judge the scientific merit of specific clinical practices?" This is a specious argument. Most of us have become accustomed to giving dispassionate, objective, critical evaluations of the scientific merits of journal manuscripts and grant applications; now we must apply the same kind of critical evaluation to the full spectrum of activities in clinical psychology. Although judgments of scientific merit may be open to occasional error, the system tends to be self-correcting. Besides, this system of critical evaluation is far better than the alternatives: authoritarianism, market-driven decisions (caveat emptor), or an "anything goes" approach with no evaluations at all. It is our ethical and professional obligation to ensure the quality of the products and services offered to the public by clinical psychology. We cannot escape this responsibility by arguing that because no system of quality assurance is 100% perfect, we should not even try to provide any quality assurance at all.. . .
This need for quality assurance is the focus of the First Corollary of the Cardinal Principle in my proposed Manifesto for a Science of Clinical Psychology:
1. The exact nature of the service must be described clearly.
2. The claimed benefits of the service must be stated explicitly.
3. These claimed benefits must be validated scientifically.
4. Possible negative side effects that might outweigh any benefits must be ruled out empirically.
. . . . Explicit standards of practice, such as I am recommending here, are a direct implication of the proposed Cardinal Principle. Adopting such standards is a prerequisite to moving clinical psychology out of the dark ages. Rotter  offered this analogy:
Most clinical psychologists I know would be outraged to discover that the Food and Drug Administration allowed a new drug on the market without sufficient testing, not only of its efficacy to cure or relieve symptoms, but also of its short term side effects and the long term effects of continued use. Many of these same psychologists, however, do not see anything unethical about offering services to the public—whether billed as a growth experience or as a therapeutic one—which could not conceivably meet these same criteria. (p. 1)
“Excellence,” “accountability,” “competence,” “quality”—these are key concepts nowadays in education, government, business, and health care. It is ironic that psychologists, with their expertise in measurement and evaluation, have played a major role in promoting such concepts in other areas of society while ignoring them in their own back yard. One is reminded of the old saying: “The cobbler's children always need new shoes.” The failure to assure the quality of services in clinical psychology—whatever its causes—cannot continue. Rotter (1971) sounded this warning in his concluding paragraph:
If psychologists are not more active and more explicit in their evaluation of techniques of intervention, they will find themselves restrained from the outside (as are drug companies by the FDA) as a result of their own failure to do what ethical and scientific considerations require. (p. 2)
One of the problems facing clinical psychology is that it has oversold itself. As a consequence, the public is not likely to respond charitably when told to adjust its expectations downward. We cannot blame consumers for wishing that psychologists could solve all of their problems. Nor should we be surprised if consumers become upset when told the truth about what psychologists can and cannot do. We should expect that some consumers simply will not accept the truth, and will keep searching until they find someone else who promises to give them what they want. However, the fact that some consumers are ready and willing to be deceived is no justification for false or misleading claims; the vulnerability of our consumers makes it all the more imperative that clinical psychologists practice ethically and responsibly.
Clinical psychologists cannot justify marketing unproven or invalid services simply by pointing to the obvious need and demand for such services, any more than they could justify selling snake oil remedies by pointing to the prevalence of diseases and consumer demand for cures. Some clinicians may ask: "But what will happen to our patients if we limit ourselves to the few services that have been proven effective by scientific evidence?" Snake oil merchants probably asked a similar question. The answer, of course, is that there is no reason to assume that patients will be harmed if we withhold unvalidated services. In fact, in the absence of evidence to the contrary, it is just as reasonable to assume that some unvalidated remedies actually are detrimental to patients and that the withholding of these will benefit patients.
If the practices of clinical psychologists were constrained, as proposed in my First Corollary, where would that leave us? That is, what valid contributions, if any, might psychologists make to the assessment, prediction, and treatment of Clinical problems? This question highlights the major reason why scientific training must be the sine qua non of graduate education in clinical psychology. Faced with uncertainty about the validity of assessments, predictions, and interventions, clinicians would be required by the First Corollary to reduce that uncertainty through empirical evidence before proceeding to offer such services. The Corollary explicitly states that clinical scientists may administer unproven psychological services to the public, but only under controlled experimental conditions. While untested services represent the future hope of clinical psychology and thus deserve to be tested, they also represent potential risks to patients and must be tested cautiously and systematically. Until scientific evidence convincingly establishes their validity, such services must be labeled clearly as “experimental.” Only those psychologists with scientific training and expertise will be in a position to participate in this critical evaluation of clinical services.
It should be added that clinicians-in-training are unproven commodities, as well, even when they are administering services that have been proven to be effective in the hands of experienced clinicians. Therefore, the validity of the services offered by these apprentice clinicians must be evaluated systematically before each individual therapist—an integral component of the clinical service—is moved from the “experimental status” to the “approved” list. Even “approved” and “senior” clinicians must be cognizant of the limits to their personal validities and take an experimental approach to validating changes in their clinical roles.
In short, the First Corollary requires that clinicians practice as scientists. This brings us to the Second, and final, Corollary of my proposed Manifesto for a Science of Clinical Psychology:
This point follows logically, I believe, from all that has been presented thus far. It also should require little elaboration. In a practical sense, however, it is not entirely clear what the most effective methods are for training clinical psychologists to be scientists. . . .
First, the Boulder Model, with its stated goal of training, “scientist-practitioners,” is confusing and misleading. On the one hand, if the scientist and practitioner are synonymous, then the hyphenated term is redundant. On the other hand, if the scientist and the practitioner represent two distinct goals, either as competing alternatives or as separate but complementary components, then this two-headed view of clinical psychologists is inconsistent with the kind of unified scientific training being advocated in the present Manifesto. Therefore, the Boulder Model's dualistic, hyphenated goal should be replaced by one that stresses the unified and overriding goal of training clinical scientists.
Second, scientific training should not be concerned with preparing students for any particular job placements. Graduate programs should not be trade schools. Scientists are not necessarily academics, and persons working in applied settings are not necessarily nonscientists. Well-trained clinical scientists might function in any number of contexts—from the laboratory, to the clinic, to the administrator's office. What is important is not the setting, but how the individual functions within the setting. Training program faculty members need to break out of the old stereotypic dichotomous thinking represented by the Boulder Model. They need to stop worrying about the particular jobs their students will take and focus instead on training all students to think and function as scientists in every aspect and setting of their professional lives.
Third, some hallmarks of good scientific training are rigor, independence, scholarship, flexibility in critical thinking, and success in problem solving. It is unlikely that these attributes will be assured by a checklist approach to required content areas within the curriculum. Increasingly, however, there has been a tendency—prompted largely by the need to ensure that the criteria for state licensing and certification will survive legal challenges—toward taking a checklist approach to the accreditation of graduate training programs in clinical psychology. Too much emphasis has been placed on the acquisition of facts and the demonstration of competency in specific professional techniques, and too little emphasis has been placed on the mastery of scientific principles; the demonstration of critical thinking; and the flexible and independent application of knowledge, principles, and methods to the solution of new problems. There is too much concern with structure and form, too little with function and results.
Ideally, we would have been taking a scientific approach to answering the question of how best to train clinical psychologists; unfortunately, this has not been done. For the present, then, there simply is no valid basis for deciding what is the "best" way to train clinical scientists in these desired attributes. The political move to homogenize the structure and content of clinical training programs not only is inappropriately premature, but it also is likely to retard progress toward the goal of developing truly effective training programs. The state of knowledge in our field is primitive and rapidly changing; therefore, efforts to establish a required core curriculum for clinical training, based on such uncertain knowledge, would result in "training for obsolescence." Similarly, efforts to standardize prematurely on training program structures and methods simply will perpetuate the status quo, discourage experimentation, and inhibit evolutionary growth. Until we have good evidence that one method of training is superior to any others, how can we possibly decide (except on political or other arbitrary grounds) that all training programs should cover a fixed body of content and technique, follow a set curriculum, or adopt a common structure?. . .
Until we have a valid basis for choosing among the various options, our policy should be to encourage diversity—to “let a thousand flowers grow.” Out of such diversity, we might learn something valuable about effective training methods. Of course, diversity by itself is uninformative; it must be accompanied by systematic assessment and evaluation. The ultimate criterion for evaluating a program's effectiveness is how well its graduates actually perform as independent clinical scientists. Thus, program evaluations should focus on the quality of a program's products—the graduates—rather than on whether the program conforms to lists of courses, methods, or training experiences. How a program's graduates perform becomes the dependent variable; program characteristics serve as independent variables. If the aim of our graduate programs is to train clinical scientists, then every program's faculty ought to model scientific decision making when designing and evaluating its program.
Richard Feynman (1985), the Nobel Prize-winning physicist, used the term “Cargo Cult Science” to characterize “sciences” that are not sciences. He drew an analogy with the “cargo cult” people of the South Seas:
During the war [the cargo cult people] saw airplanes land with lots of good materials, and they want the same thing to happen now. So they've arranged to make things like runways, to put fires along the sides of the runways, to make a wooden hut for a man to sit in, with two wooden pieces on his head like headphones and bars of bamboo sticking out like antennas-he's the controller and they wait for the airplanes to land. They're doing everything right. The form is perfect. It looks exactly the way it looked before. But it doesn't work. No airplanes land. (p. 311)
….Like the South Sea Islanders, the faculties of clinical training programs cling to the belief that if only they could arrange things properly—improve the shapes of the headphones, improve the sequence of courses—their systems at last would produce results. But their preoccupation with arranging details is like rearranging the deck chairs on the Titanic. When something essential is missing, no amount of tinkering with form will make things work properly.
According to Feynman (1985), one of the essential missing ingredients in Cargo Cult Science is “scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty—a kind of leaning over backwards.”
If you make a theory, for example, and advertise it, or put it out, then you must also put down all the facts that disagree with it, as well as those that agree with it. There is also a more subtle problem. When you have put a lot of ideas together to make an elaborate theory, you want to make sure, when explaining what it fits, that those things it fits are not just the things that gave you the idea for the theory; but that the finished theory makes something else come out right, in addition .... The idea is to try to give all of the information to help others to judge the value of your contribution; not just the information that leads to judgment in one particular direction or another. (pp. 311-312)
This suggests a good place to focus our attention when thinking about how we might improve the quality of graduate training in clinical psychology. As a field, if we fail to display such scientific integrity, how can we hope to be successful in training scientists. No amount of formal classwork will replace the integrity lost by a failure, for example, to challenge exaggerated claims concerning the value to clients of a clinical service. We can give students lectures about professional ethics, but if the lecturers fail to model utter honesty by leaning over backwards to provide a full, fair, critical discussion of psychological theories, research, and clinical practice, then few students will emerge as scientists, few planes will land….
THE MANIFESTO AS A CALL TO ACTION
Different camps within clinical psychology have maintained an uneasy truce over the years, partly out of necessity (in the early days they were allies against the threats of psychiatry) and partly out of convenience, custom, and economic self-interest. But events such as the unsuccessful effort to reorganize APA, the subsequent creation of competitive organizations such as The American Psychological Society (APS), and recent challenges to APA's sole authority to accredit graduate training programs in psychology are examples of the tension, distrust, and conflict that have surfaced among the various camps over the past decade. Change is in the wind; nothing is likely to be quite the same in the future.
Today’s clinical psychologists face a situation somewhat like that of the bicyclists in the Tour de France race. We have been riding along at a comfortable pace, all bunched together, warily eyeing one another, worrying that someone might try to get a jump on us and break away from the pack. It has been like an unspoken conspiracy. As long as no one gets too ambitious and tries to raise the standards, we all can lay back and continue at this pace indefinitely. Labor unions have a name for the wise guys who won't go along with the pack: They're called “rate busters.” In my more cynical moments, I sometimes suspect that many psychologists view serious proposals for scientific standards in practice and training as a betrayal, rate busting, or breaking away from the pack.
Inevitably, a breakaway will come. Some groups of clinical psychologists will become obsessed with quality, dedicated to achieving it. These psychologists will adopt as their manifesto something similar to the one I have outlined here. When this happens, the rest of clinical psychology—all those who said that it couldn't be done, that it was not the right time—will be left behind in the dust.
The Manifesto I have outlined here is a serious proposal; I was not trying to be provocative. The time is long overdue for a breakaway, for taking seriously the idea of building a science of clinical psychology. I would like to believe that Section III members will be well represented among the group of psychologists that successfully makes the break, when it comes. In fact, I dare to wish that Section III might promote such a break by formally adopting my proposed Manifesto, or one like it, hoisting it high as a banner around which all those who are committed to building a science of clinical psychology might rally.
Dr. McFall is Professor of
Psychology at Indiana University--Bloomington, and Director of the NIMH-supported
Research Training Program in Clinical Science. He is a former president of the
Society for a Science of Clinical Psychology (Section III of Division 12 of APA).
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