Split Personality?

Cynthia McLoughlin, Ph.D.

Within Division 39, there has been much debate in recent years about whether psychoanalytic psychologists are psychologists first or psychoanalysts first. While this debate is organizational shorthand for a variety of vexed issues, it is also closely connected to a much larger and longer-standing debate within the APA over clinical psychologists’ identity as scientists versus practitioners.

In a 1991 article Richard M. McFall remarked that psychology has a “split personality” (see page 6 for extended excerpts from this article). Within the APA, he said, those who see themselves primarily or exclusively as scientists live in an uneasy state of tension with those who see themselves primarily or exclusively as practitioners.

This tension is at least as old as the Boulder Model—a compromise position on psychological training adopted by the APA in 1949. The Boulder Model asserts that clinical psychologists are and must be both scientists and practitioners. In their recent article, “Integrating Science and Practice,” Kihlstrom and Kihlstrom (1999) (full text available at http://www.institute-shot.com) observed that:

In the early VA system, psychologists were mostly supervised by psychiatrists who had little research training, and whose viewpoint was essentially psychoanalytic…. In the Boulder model, the whole point of clinical psychology was to put psychotherapy...on a firm scientific base…. Clinical practice was to be part of a dialectical enterprise, responding to and contributing to, advances in knowledge of basic psychological processes....All practitioners were to be scientists, and while not all scientists were to be practitioners, at least there was a sense that scientists and practitioners were engaged in a common enterprise.

Despite this integrative ideal, large numbers of psychologists have remained stubbornly divided. The side of the divide more familiar to psychoanalytic psychologists rings, for example, with the complaints of practitioners who say that training programs, accreditation standards, and licensing exams contain too much that is irrelevant to the work they do as therapists. But dissatisfaction among scientifically oriented psychologists is equally strong, including complaints that the Boulder Model reflects a general compromise within the APA in which science is treated as merely one aspect of psychology as opposed to being seen as the basis of all psychological knowledge. This compromise, some argue, condemns psychology to permanent second-class status in the scientific community. In 1988 disaffected scientifically oriented psychologists split off from the APA to form the American Psychological Society, which is committed exclusively to research-based psychology “and its applications.”

But the 1988 split by no means carried off all of the disaffected empiricists. Many remain firmly committed to pursuing their goals within the APA. One such group is the Society for a Science of Clinical Psychology (or SSCP—Section III of Division 12—Clinical Psychology), which was formed in 1966 as a result of APA debates over the legitimacy of (practitioner-oriented) schools of professional psychology. The stated purpose of the SSCP is to promote the tightest possible connection between science and practice in clinical psychology:

The clinical psychologist is a behavioral scientist, whether he is doing clinical work, research, teaching or consulting. His role is the development of principles and their application in the assessment and modification of human behavior. The validation of the former depends on the latter; the utility of the latter depends on the former. They cannot be separated. (Oltmanns & Krasner, The Clinical Psychologist, 46:1, 1993)

In the 35 years since its creation, this energetic and committed group has greatly increased its influence. Among other things, it has been successful in changing the standards for accrediting graduate programs in clinical psychology (Kihlstrom & Kihlstrom, 1999); it has become an increasingly powerful voice within Division 12, whose website prominently features the findings of the Task Force on Empirically Supported Treatments and recommends that individuals inquire, when seeking psychotherapy, what diagnosis best fits them and what kinds of therapy have been scientifically proven to be effective in treating persons with that diagnosis; it has argued that government grants and third-party payer monies ought to go only to practitioners of “empirically supported treatments” (EST); and it has undertaken the project of keeping track of research that, according to its standards, has proven one or another form of psychotherapy effective for a particular diagnosis.

With the rise of managed care, with escalating liability risks in our litigious society, and with the growing governmental regulation of psychology as a profession, the view of clinical psychology promulgated by the Society for a Science of Clinical Psychology has gained increasing support within the APA. Intense competition among the various mental health professions in the managed care marketplace has led to unprecedented efforts to demonstrate the efficacy of various types of psychotherapy. A science of clinical psychology that directly parallels the medical sciences is seen by many psychologists as the only way to keep psychology viable against the cheaper and quicker “fixes” of psycho-pharmacology:

The fact is that clinical psychology derives much of its status, including its independence from psychiatry and its claim to third-party payments for services rendered, from the assumption that its practices are firmly based on scientifically validated principles and techniques. Thus, there is—in fact, there can be—no conflict between science and practice, so long as clinical psychology wishes to retain its identity, autonomy, and status as a profession. (Kihlstrom & Kihlstrom, 1999)

The success of the SSCP and like-minded groups throughout the APA has generated concern among clinicians whose relationship- and/or insight-oriented approaches to psychotherapy do not lend themselves to the methodology of randomized controlled clinical trials, psychotherapy manuals, and treatment guidelines for specific DSM disorders. Many family-systems, existentialist, humanist, feminist, psychodynamic, and psychoanalytic therapists find their own ways of thinking about human experience incompatible with the model of empirical support used by EST advocates. Increasingly they are wondering, not only how they are going to make a living, but whether the work they do is threatened in more direct ways by the movement toward “empirically supported treatments.”

In a recent Psychologist-Psychoanalyst article, Karen Shore (the psychoanalyst-activist president of the National Coalition) writes:

There is a major threat both from within and outside our field from many people with influence who strongly believe that there should only be insurance coverage for psychotherapies that are ‘empirically validated’ and conform to research protocols applicable to cognitive-behavioral therapies (manualized treatment, randomized clinical trials, symptom-focused)…. Worse yet...some influential psychologists believe that it should be considered malpractice to do psychoanalysis or psychodynamic therapy with conditions shown to improve quickly through cognitive-behavioral therapy….

The EST movement assumes that the problems that bring people to psychotherapy are “mental disorders” which psychologists seek to alleviate or cure. A recent article in the APA Monitor highlighted the difficulties of humanistic psychologists (Division 32) who wish to define themselves as practicing something other than medical-model psychotherapy. Maureen M. O’Hara, a past president of Division 32, was quoted as saying, “We don’t believe the medical system is the right place for people to address questions of meaning, career choice, ethics, values, self-development and improvement. These kinds of questions are best framed in a language that has nothing to do with pathology and cure” (March 2000).

As advocates of EST gain ground, practitioners of traditional talking therapies face a dilemma. Can they, should they attempt to prove the value of their work on the terms provided by medical science? Reactions within the APA Divisions whose members are likely to be negatively affected by widespread acceptance of the EST approach range from (1)arguing that the idea is a good one, but the particular scientific standards used are unfairly weighted against insight-oriented therapies, to (2) arguing that there should be a variety of practice guidelines and approaches to empirical support that reflect the wide variety of existing approaches to therapy, to (3) arguing that the demand for empirical validation of insight-oriented psychotherapies is equivalent to insisting that English students be subjected to randomized controlled trials to see whether reading Shakespeare is a worthwhile activity (i.e., that if the person doing it finds it worthwhile, it is worthwhile).

The views of most psychoanalytic psychologists probably fall along a broad middle range in the EST debate: trained in Boulder-model programs, many of us are strongly identified both as scientists and practitioners and believe that outcome studies are bound to show the value of what we do because we know what we do is valuable. Insulated by the very familiarity of psychology’s “split personality” (in which it has been taken for granted, over the years, that scientific types don’t pay much attention to us nor we to them) traditional practitioners have been slow to recognize the direct challenge to their ways of working being posed by advocates of EST.

Leaders of the EST movement make no apology for their position and they have thrown down the gauntlet: Prove, through empirical studies, that the kind of therapy you do is effective in alleviating the symptoms of persons with a given disorder or stop (except under strictly experimental conditions) offering that form of treatment. Anything else, they argue, is harmful to the public and no more to be tolerated in psychology than it would be in cardiology or oncology. Their view is receiving increasing support from government and health-care industry leaders. Clearly, this is a debate to which we need to be attending and one that should prompt each of us to re-visit the questions about what we know and how we know it that lie at the heart of organized psychology’s “split personality.” 

This article was first published in the newsletter of the Michigan Society for Psychoanalytic Psychology in February 2001.  It is reprinted here with permission.  The author may be contacted through LEAPchair@AcademyProjects.org

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