When he issued his “Manifesto” a decade ago, Indiana University’s Richard McFall was unknowingly helping to set the stage for one of the more influential entities in psychological science – the Academy of Psychological Clinical Science, which has risen to become a force for revolutionizing training in psychology and by extension, psychological practice.
APCS describes itself as “an alliance of leading, scientifically-oriented, doctoral training programs in clinical and health psychology in the United States and Canada. Academy membership is open to doctoral programs with strong commitments to, and established records of, successful clinical science training.”
This was his challenge to the psychological community:
“The time has come … 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.”
And, if clinicians must be scientists, he said, it follows that “the primary aim of doctoral training is to train competent clinical scientists who function under these principles.”
This belief in a commitment to scientific training in clinical psychology was the bedrock upon which the Academy was built a few years later. Its seeds were planted 30 years earlier, however, when McFall was himself a student at Ohio State University and his mentor was Julian B. Rotter, now professor emeritus at the University of Connecticut.
“The philosophy of the program at OSU was that they were training people for careers in clinical research,” McFall recalls. “I think the rest of the world is now catching up with that point of view.”
THE TRUTH IS OUT THERE
In his concluding paragraph, Rotter had sounded this alarm: “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 a result of their own failure to do what ethical and scientific considerations require.”
McFall echoed the alarm: “I was saying, ‘if we don’t get our own house in order and regulate ourselves, somebody else will do it for us.’”
“I don’t think the public has an idea what’s going on out there,” McFall says, remembering how, when he took his ideas to his own local community mental health board, the members “couldn’t believe we weren’t already delivering only scientifically proven treatments.”
That local board adopted his proposal and established two specialty clinics, in anxiety disorders and depression, based on the best treatments available as supported by empirical evidence. So unusual was this at the time that the community center won a national award for excellence. Says McFall, “To me, what seemed self-evident was really exceptional.”
A corollary to the scientific approach, he says, is truth-in-advertising. If one is going to offer services as a scientist, then follow four rules: “Describe the services clearly. State clearly how patients can expect to benefit from them, and be explicit; don’t just say, ‘You’re going to feel better.’ Tell them what the evidence is that the claimed benefits are actually going to be delivered. And explain any side effects they ought to worry about – the downside, the risks. This is what we expect of medicine. These are basically the U.S. Food and Drug Administration principles.”
SUMMIT LIKE IT HOT
In 1992, after years of trying to change the existing accreditation system from within, a Summit meeting was held for the purpose of examining alternative accreditation strategies. The Summit was organized under the auspices of APS in conjunction with the Council of Graduate Departments of Psychology (COGDOP), and attended by 140 representatives of accredited academic departments.
Among the key players in the Summit were McFall, Richard Bootzin of the University of Arizona, and Don C. Fowles of the University of Iowa. Bootzin helped set up the Summit, along with Marilynn Brewer, Emanuel Donchin, Virginia O’Leary, and Richard Weinberg. Fowles and McFall sat on a steering committee charged with drafting an alternative accreditation system, along with Brewer, Donchin, O’Leary, Elizabeth Holloway, and Steve Elliott.
The alternative accreditation system reflected concerns about firmly establishing the primacy of a scientific base in clinical training. “Not all clinical training programs were enthusiastic about the alternative,” McFall remembers. “Those of us who felt strongly about the direction clinical psychology should go realized we were not going to drag the whole enterprise along with us.” Instead they discussed “forming our own little subgroup” and “even kicked around names of programs that would be exemplars of the kind of training” they believed in.
ANATOMY OF AN ACADEMY
“He was the moving force behind the creation of APCS,” Fowles says of McFall. “He did a brilliant job of bringing people together.”
Since those early days, the Academy has garnered considerable influence over the scientific landscape. Its members are now routinely included as site reviewers for the APA’s Committee on Accreditation. The Academy is responsible for overseeing the clinical track of the program for the APS Annual Convention. It is routinely consulted and advised on policy matters affecting the issues it is most concerned about – by the National Science Foundation, by the National Institute of Mental Health, and others.
“We are more recognized,” says Bootzin, the current APCS President, “and we are asked to the table more often on a variety of issues. Our advice is often sought on policy issues that either affect graduate training or help advance psychological clinical science. For example, when NIMH was going through reevaluation a year or so ago, they had a task force that included some of our members. NIMH came to an Academy meeting to give a presentation and solicit suggestions, and a year later gave another presentation about the task force conclusions.
“This happens fairly often, and certainly wouldn’t have happened before because we didn’t exist. There is now a place for federal organizations and others to ask advice and solicit feedback, a mechanism for information exchange that might affect our members’ programs that wouldn’t otherwise have been available.”
The Academy’s influence is underscored by Alan Kraut, APS executive director, who says that “whenever APS encounters an issue involving clinical training, the Academy is the first place we go to for guidance, because we know they represent the leading edge of science-based clinical training programs. In fact it was an idea generated at the organizational meeting of the Academy that gave me the idea to approach NSF to ask that NSF open its Fellowship programs more specifically to clinical psychology students. Based on input from the Academy, I argued that, whereas NSF should not support applied research or training, there is a basic science in clinical psychology, just as there is a basic science in any subdiscipline, that NSF should support. They agreed.”
“We evaluate all membership applications,” says Bootzin, an APS Fellow and Charter Member who has been researching sleep disorders for three decades. “No one was ‘grandfathered’ in.” The peer-evaluations, he says, “focus on the missions of the programs, how the knowledge base is advanced, how students are trained for doing the science and how that knowledge is applied.”
Not only are programs reviewed by a committee of peers when they first seek membership, the APCS president says, “We’re about to start reevaluating programs that are already members, because things change in any program. It’s a way of strengthening ourselves.” That practice, he says, is to begin next year.
The Academy currently has 37 member doctoral training programs. “There are certainly additional programs we think would be appropriate,” Bootzin says, “but we have the large majority of such programs. Those that have joined are prototypical of the type that we feel are appropriate. We’re hopeful that other programs that identify with our goals would want to join.”
The primary concern of the Academy has always been that in clinical psychology there’s a balance to be struck between trying to advance the knowledge base of the field and applying that knowledge, says Bootzin.
“That balance shifts from time to time, as well as from program to program. It was the observation of a number of individuals during the last 10 years or so that ‘guild’ issues were getting a lot of attention, to the point we thought the science base was being neglected. We wanted accreditation and licensing done in a way that facilitates the goal of advancing knowledge. The Academy was formed as a way of providing a coalition and support for programs that focused more on the science, to make sure that the advancement of science wasn’t neglected.”
INTERNS OF ENDEARMENT
Incoming president Fowles agrees. “The internship is a critical part of clinical science training,” the APS Fellow says. “It can all too often happen that students are exposed to clinical science in their graduate curriculum but then clinical science is not supported in their practicum training. We need an integration of the academic and clinical side, not a discontinuity or ‘blown fuse.’ Thus, internship faculty play a crucial role in instilling a clinical science approach to clinical psychology.
“The faculty in internship settings also represent an important and powerful group on the national scene. To have them advocating for clinical science is invaluable. In many ways, PhD program faculty and resources and internship faculty and resources complement each other nicely. Together we can be more effective.”
Part of the problem, Fowles says, is visibility: “I would guess that there are more internships than PhD programs that do not know about the Academy, and we would like to publicize the Academy to those internships.”
APCS Treasurer Marc Atkins knows firsthand the importance of recruiting internship programs to APCS. Atkins, an APS member, directs the clinical child psychology internship of the Institute for Juvenile Research at the University of Illinois at Chicago, an internship year that offers intensive clinical training to doctoral candidates in clinical psychology.
“Most internship programs foster clinical practice, as opposed to a clinical science,” he says. “This often results in a large gap between what is taught in graduate school and what is learned during the internship year, often perceived as a year in which science is not relevant and students who have not amassed large numbers of clinical hours in graduate school will be less successful and, due to a shortage of internship slots, possibly not placed.”
Atkins’s program seeks to bridge that gap. “I see the Academy as an organization that is ideally suited to support this type of training. The goal of the internship is to promote a scientist-practitioner orientation, with an emphasis on the integration of applied research and clinical practice. In our program, students from Academy graduate programs are more competitive than from programs with less emphasis on scientific training.
“I believe that internship programs bring an important perspective to the Academy. We are active clinical settings and therefore ideal sites for both translation studies and effectiveness trials. Both of these are high priorities for mental health research. The Academy has been in the forefront of these issues, providing a forum for interaction among programs that is likely to promote high standards for the training of clinical scientists.”
And, adds Bootzin, with a longer list of quality, science-focused internship program members in the Academy, “graduate students in Academy programs who are looking for internships would have more information on programs that are like-minded.”
COMING SOON TO A DEPARTMENT NEAR YOU
“Psychologists are so broadly trained, to the extent Academy program graduates are distributed across many areas, they bring the kind of attitude about the development of knowledge and evaluation of knowledge that serves well, given the need to develop new programs and evaluate the programs that are in existence.”
What’s next on the Academy’s agenda? “It’s my impression,” says incoming President Fowles, “that APCS is most visible or salient among the representatives of the member programs, and that many other faculty are not involved. It seems timely to try to make contact with those faculty and find out from them what they think we can do to advance the field in important ways. What things do they care about that could be facilitated by organizational support from APCS?
“Some ideas that have been discussed include holding national conferences on focused topics, exchanging ideas about different approaches to graduate education or to specific courses, and creating committees to write a series of white papers on topics of importance to clinical science that would represent APCS’s position.”
Berenbaum: ‘Tearing Down Barriers’
In addition to translating “basic” research into improved services for clients, Academy programs are at the forefront of tearing down barriers between “basic” and “clinical” research, which I believe holds the greatest potential in the long run for improving our understanding of, and treatments for, psychological disturbances.
Members of the Academy are not “cookie cutter” programs that all look alike. As a result, they are sometimes misunderstood and given a hard time by the APA-driven accreditation process. In forming the Academy, these programs can support each other in a variety of ways, including dealing with accreditation issues.
With the caveat that most dichotomies are simplifications, it is my view that providers of mental health services (which, of course, includes clinical psychologists) can be divided into those who believe that the provision of services should be guided by personal experience (what such individuals “know” to be true based on their clinical experience) and those who believe that, in the long run, individuals with psychological disturbances will be best served by services that are informed by scientific research. The Academy, perhaps better than any other organization or group of individuals, represents the latter perspective.
Academy programs can be models of how to use psychological science to improve our understanding of, and treatments for, psychological disturbances. Because the Academy is agnostic regarding different types of assessment and therapeutic approaches (other than the desire to let rigorous research point us in the right direction), I hope the Academy can model how to apply scientific methods to study assessment and treatment procedures that have the potential to be examined scientifically, but have not been.
Member APCS Executive Committee
University of Illinois at Champaign/Urbana
Five Goals of APCS
The Academy sees the development and application of clinical science as ongoing and dynamic processes, and is committed to facilitating the evolution of clinical science. Toward that end, it has established five specific goals:
- To foster the training of students for careers in clinical science research, who skillfully will produce and apply scientific knowledge.
- Research and Theory
- To advance the full range of clinical science research and theory and their integration with other relevant sciences.
- Resources and Opportunities
- To foster the development of, and access to, resources and opportunities for training, research, funding, and careers in clinical science.
- To foster the broad application of clinical science to human problems in responsible and innovative ways.
- To foster the timely dissemination of clinical science to policy-making groups, psychologists and other scientists, practitioners, and consumers.
Incoming Academy President Don C. Fowles of the University of Iowa, an APS Fellow, says three “overlapping issues” loom large in the coming years.
1. Managed Care. The emphasis on cutting health care costs “has reduced the demand for PhD level providers of clinical services in psychology, both in terms of trying to limit psychological services to contain costs and in terms of substituting MA level psychologists and social workers. In some ways that affects our programs less than more practitioner-oriented programs, but it still is a changing environment for our graduates.”
“Our programs were already in a better position to provide better ways of evaluating efforts and program development,” adds current APCS President Richard Bootzin of the University of Arizona, an APS Fellow and Charter Member. “Changes in the health care environment have been challenges for everyone, but they also are an opportunity for many of our programs to strengthen some of the things that were already moving in that direction.
“Managed care narrowed the focus and made it much more evidence-based. That required having an evidence base. If you’re going to provide only those interventions demonstrated to be effective in the literature, you need that literature. Our membership helps provide the evidence for more effective applications and better understanding of the problems. In that sense, although it’s a frustration to deal with managed care in many ways, the focus on evidence-based interventions actually supports a major aspect of our program.” It also means the role of psychologists in applied settings should broaden, involving the evaluation of services and possibly even administering programs.
2. Developing guidelines for empirically supported treatments (EST). “On the one hand,” says Fowles, the need for such guidelines “is strongly consistent with clinical science and is easily defended in the context of managed care. On the other hand, such research tends to reify the DSM-IV (fourth edition of the Diagnostic and Statistical Manual), because much of the research validates specific treatments as applied to DSM-diagnosed disorders.
“To show that a given treatment does work with a group of individuals meeting criteria for a specific diagnosis is not to say that the treatment does not work with other individuals, or that other treatments would not work with the same individuals. Also, common factors account for a portion of the effectiveness of treatments and it is not always clear that a given EST is actually effective because of specific features in that approach.”
The unanswered questions need further research, Fowles says, but sometimes “the scientific debate takes place in a heated political atmosphere. Some practitioners feel threatened by the EST movement, because it restricts the types of treatment-patient combinations likely to be reimbursed, and they may want to oppose all attempts to develop standards for ESTs. Some advocates of EST may have a political agenda of achieving recognition for psychological treatments and parity with pharmacological treatments. In some ways, then, support from managed care organizations for ESTs may support a clinical science approach, but it is important to understand that their primary agenda is cost containment, not science.”
3. Prescription Privileges. “As everyone knows, there is a politically strong movement for prescription privileges for psychologists, and a fairly intense national debate about the merits of such a development. At least in part, this is a response to the reduced demand for services as a result of managed care. The vast majority of faculty I’ve heard comment are strongly opposed to it, but obviously a great many clinical psychologists support it. If the movement for prescription privileges is successful, it would have a major impact on graduate training, as well as the field in general.” The Academy has taken no position on prescription privileges for psychologists.
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….
ON CLINICAL PRACTICE
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?…
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 tranquillity at the expense of integrity….
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….
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.
Everyone seems to have opinions about what makes for effective scientific training, but such views seldom are backed by sound empirical evidence. Even where evidence exists, it may exert little influence on the design of clinical training programs. It ought to be otherwise, of course; those who train scientists should be reflexive, taking a scientific approach themselves toward the design and evaluation of their training programs. Unfortunately, the structure and goals of graduate training in clinical psychology tend to be highly resistant to change. Institutional, departmental, and personal traditions, alliances, and empires are at stake, and these tend to make the system unresponsive to logical, empirical, or ethical appeals.
Training program faculty members 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….
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….
ON PROGRAM EVALUATION
…(F)or clinical psychology to have integrity, scientific training must be integrated across settings and tasks. Currently, many graduate students are taught to think rigorously in the laboratory and classroom, while being encouraged – implicitly or explicitly – to check their critical skills at the door when entering the practicum or internship setting….
ON ‘BREAKING AWAY’
Excerpted from “Manifesto for a Science of Clinical Psychology,” by Richard M. McFall, The Clinical Psychologist, 1991, Volume 44, Number 6, 75-88.
For full text: http://pantheon.yale.edu/~tat22//manifest.htm
References and Further Reading:
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