Clinical Psychology, Psychological Science, and Neo-liberal Times
Clinical psychology first emerged as a formal subdiscipline within psychology in the aftermath of World War II. During the war, psychologists were initially hired by the military to play a role assessing recruits for psychological stability, combat readiness, and potential for officer training. They were also charged with the task of evaluating whether soldiers exhibiting symptoms of psychological trauma were experiencing bonafide psychological problems or malingering. Over time as the massive prevalence of psychological trauma became apparent, the demand for professionals capable of providing psychological treatment far exceeded the supply of available psychiatrists, and psychologists increasingly came to play a role as treatment providers as well.
The scientist-practitioner model
At the end of the war the federal government set aside substantial amounts of money to train and hire psychologists to play a central role in the assessment and treatment of emotionally traumatized veterans. In 1949 a conference was convened by psychologists in Boulder Colorado to develop a training model for the clinical psychologist of the future. The consensus was that future clinical psychologists were to be trained as scientist-practitioners. This designation for the training model reflected a commitment to embracing the identity that the profession of North American psychology had adopted early in its development as an experimental science, akin in important respects to the natural sciences. Clinical psychology training was to entail teaching graduate students both the scientific skills that experimental psychologists acquire, and the practical or applied skills that are relevant to assessing and treating patients in real world settings. In addition, the scientist-practitioner model specified that clinical psychologists would be trained to evaluate the research evidence relevant to assessing and treating patients, and that their experience as practitioners would play a critical role in generating clinical theories and principles of intervention that they could then evaluate through systematic empirical research.
Clinical psychology Ph.D. training programs fit a type of hybrid academic/professional school profile. Some of the coursework is academically oriented and some is skills oriented. In addition to coursework and Ph.D. dissertation research, students spend a considerable amount of their time acquiring supervised experience assessing and treating patients. This applied aspect of their training, which takes place in both classroom and clinical settings throughout graduate school, culminates in a one-year full-time placement in a clinical setting (often a hospital). Ph.D. candidates are paid a small salary over the course of this one-year pre-doctoral internship at an accredited site. In return for clinical experience and supervision, they provide a relatively inexpensive form of labor.
The predoctoral internship must be completed in a satisfactory fashion before candidates are formally awarded their Ph.D. degrees. Application for these internships has always been a competitive process. Graduate students apply to internship programs throughout the country and are interviewed if they make the first cut. Internship sites rank the students they have interviewed, and the students rank the sites. In the end internship offers are made, on the basis of the same type of computer based “match system” used for residency placements in medicine.
Over the last decade, the reduction in funding for mental health treatment has been an important factor contributing to a growing imbalance between the number of clinical psychology graduate students applying for internships, and the number of positions available. In recent years, average national match rates (i.e. proportion of applicants who are able to find pre-doctoral internship positions in a given year), range in the area of 65-70%. The persistence of this pre-doctoral internship shortage is one of the many crises confronting the field. In order to maximize the likelihood of finding internship positions, clinical graduate students are spending increasingly more time obtaining relevant clinical training in a range of settings prior to applying for internship. This is making it progressively more difficult for students to graduate in a timely fashion. In the end, there is always a risk that after investing substantial amounts of time and money being educated, students may not be able to graduate with their Ph.D.s in clinical psychology.
The scientist-practitioner model of clinical psychology has been the dominant model of clinical training for many years. In practice, however, it has always been a difficult ideal to fully realize. Although the stated objective of scientist-practitioner programs is to provide trainees with the expertise that will allow them to be equally at home in academia and the applied world, the majority of clinical psychologists have always chosen to seek employment in clinical settings rather than academia. Clinical psychologists in applied settings rarely continue to do research, nor do they as a rule continue to read the research that is published. Survey after survey has found that practitioners in the real world tend to find that research findings have limited relevance to their clinical practices.
One obstacle to integrating the roles of the researcher and clinician is practical in nature. It is difficult to find the time to become both a skilled clinician and a successful researcher. Another is that the two roles draw upon different sets of skills. The activities of the researcher draw heavily on the use of rational, problem solving skills, although creativity and intuition do have their roles. Clinical work can involve a type of problem solving, but ultimately it is a human encounter that entails the application of a type of practical wisdom, and requires the capacity for interpersonal attunement, responsiveness and improvisation.
Psy.D. training: the practitioner-scholar model
In recognition of the fact that many clinical psychologists will not become researchers, an alternative to the scientist-practitioner model was developed in the early 1970s. This training framework, referred to as the practitioner-scholar model, places less emphasis on acquiring research skills than the scientist-practitioner model, and more emphasis on clinical training. Graduates of practitioner-scholar programs are awarded a doctorate of psychology (abbreviated as Psy.D.) rather that the doctorate of philosophy degree traditionally awarded to graduates of clinical psychology programs. Unlike clinical psychology Ph.D. programs which follow a hybrid academic/professional training profile, Psy.D. Programs are professional schools. Most (although not all) are free standing programs, outside the university system. Most support themselves exclusively through student tuition. For this reason, students are not funded and class sizes are large. These large class sizes are another factor contributing to the growing imbalance between available pre-doctoral internship positions, and internship applicants. Although the Psy.D. model of clinical psychology training has been reasonably successful and continues to be a popular training option for many aspiring clinical psychologists, the Ph.D. in clinical psychology is considered somewhat more prestigious in the field.
The clinical-scientist model
The most recent model of clinical psychology training to be developed is referred to as the clinical-science model. The emphasis in the clinical-science model is on training clinical psychologists to be scientists first and foremost. While the clinical science model assumes that graduate students will receive some clinical training, it clear that this should take a back seat to the activities of mastering the skills of conducting systematic empirical research, applying for grant funding, and publishing research findings in professional journals. An important goal for proponents of the clinical-science model is to increase the proportion of graduates who apply for university positions. Since the clinical science model is relatively new, it is too early to know how things will play out in this respect. What is clear at this point, however, is that the clinical science model is becoming increasingly prevalent in North America.
There are number of cultural, historical and political forces that have contributed to the development of the clinical-science model. The first is the growing emphasis on accountability in the healthcare system. This emphasis is consistent with the global shift toward neoliberal policies that elevate principles of market exchange to an ultimate value. In terms of the specifics of how these forces played out within clinical psychology, we need to go back to the 1970s when HMOs first began emerging, as part of a cost-containment strategy implemented by health insurance companies in order to maintain financial profits. By the early 1990s the American Psychiatric Association had already published guidelines for evidence-based treatment of psychiatric/psychological problems that emphasized medications to the virtual exclusion of psychotherapy. It became clear to the Division of Clinical Psychology within the American Psychological Association (APA), that if they did not take the initiative for developing evidence-based guidelines for psychotherapy there was a serious risk of either 1) losing insurance reimbursement for psychotherapy of any kind, or 2) having insurance agencies develop their own standards for determining criteria for reimbursement of psychotherapy.
The move towards developing these accountability guidelines, along with a list of psychotherapies considered to be empirically supported was highly controversial within APA for a number of reasons. First, a more substantial body of empirical research has been collected by behavioral and cognitive-behavioral therapists than by proponents of other therapeutic approaches (e.g., psychoanalysis or humanistic therapies), who traditionally have been less interested in conducting empirical research. Critics of the empirically supported treatment movement argue that absence of evidence is not the same as evidence of absence. Second, they point out that it is considerably easier to conduct systematic empirical research on cognitive and behavioral approaches than on psychoanalytic or humanistic/existential approaches since they tend to be short term, entail the application of clear-cut techniques, and aim to make changes that can be easily defined and measured. And third, different researchers draw different conclusions from the same research. While some investigators read the research as consistently favoring the cognitive-behavioral approaches, many other researchers (myself included) read the research as showing that 1) psychotherapy is helpful for a range of different problems, and 2) no one form of psychotherapy is consistently more effective than others. For example, there is actually a substantial body of evidence demonstrating that well designed studies comparing short-term psychoanalytic approaches to short-term cognitive behavioral treatments fail to find differences in treatment effectiveness. But this body of evidence is typically ignored or discounted by proponents of cognitive-behavioral therapy.
Although controversies about the virtues of the evidence based treatment movement have not abated, by the late 1990s the list of empirically supported therapies developed by APA had taken on a life of its own. The majority of therapies on the list are short-term cognitive-behavioral therapies that have been tested in highly controlled settings with patients who, for the most part, are not representative of patients seeking help in the real world (patients with complex diagnostic profiles are typically screened out of research studies). In a addition, the psychotherapy conducted in research studies is delivered by therapists who are trained to adhere to structured, well defined treatment manuals, so that researchers can be assured that the treatment that is being delivered is indeed the treatment being tested. These manuals are referred to in derogatory terms as cookbooks by many practicing clinicians, who maintain that in real world settings, skilled clinicians respond in a context sensitive fashion to the emergent clinical situation rather than delivering manualized treatments in a rigid manner.
One of the embarrassing problems that has emerged for strong proponents of the empirically supported treatment approach is that many clinicians in the real world stubbornly refuse to read the most recent research, and to the extent that they are familiar with it, refuse to be swayed by it, especially if it contradicts their own clinical experience. This inconvenience is referred to as the dissemination problem. And this frustrating dissemination problem leads researchers who have invested important parts of their careers attempting to advance the science of psychotherapy, to throw up their hands in dismay, and suspect that something has gone wrong with the traditional clinical psychology training model, since apparently many psychologists who are products of this model never developed the attitudes of real scientists (or if they did, they must have lost them shortly after graduating).
Advocates of the clinical-science model hope that as it gains more and more traction within the profession of psychology, the so called dissemination problem will diminish, since an increasingly large proportion of the clinical psychologists in the field, will have received the kind of training that inculcates the scientific attitude in them. My guess, however, is that this is unlikely to happen since 1) some clinical psychologists will always continue to train in Psy.D. programs or in those remaining Ph.D. programs that have not adopted the clinical-science model, and 2) graduates of clinical-science programs who decide that they are interested in doing clinical work are going to have to go out and acquire clinical training after they graduate. When this happens, unless their graduate training programs have done a damn good job of inoculating them, their scientific attitudes are going to become contaminated by the unsterile conditions of real world settings with real patients who need their help.
I and like-minded colleagues are concerned that the clinical-science model will have a detrimental impact on the future of clinical psychology. The high degree of polarization between clinical psychologists in academia and those in applied settings has always been problematic. Our concern is that the clinical science model will further exacerbate this polarization. If this happens, practicing clinical psychologists are likely to become increasingly less interested in and less well informed by academic clinical psychology. Another concern is that because of its isolation from clinical practice, the clinical-science model will foster the development of research initiatives that are increasingly irrelevant to the concerns of real world clinical practice. We are also concerned that the limited amount of clinical training that that students in clinical-science programs do receive is exclusively cognitive-behavioral in nature, and that they tend to indoctrinated into a pseudo-scientific bias against all therapeutic approaches that are not cognitive-behaviorally oriented.
The science of psychology
Although it is true that due to developments in the field I have described here and elsewhere, I have become increasingly concerned about the future of clinical psychology, I have always been concerned about the narrowness of the education that graduate students in clinical psychology tend to receive (my graduate education was no exception). This narrowness is in part a function of the fact that since clinical psychology has a substantial applied component, it is inevitable that an important emphasis be placed on the acquisition of technical skills. But it is important not to overlook the role that the broader discipline of mainstream psychology plays in contributing to this narrowness. As mentioned previously, American psychologists made a decision early in the development of the discipline to establish its identity as a natural science, akin in important respects to other sciences such as physics, chemistry and biology. This identification with the natural sciences was by no means a forgone conclusion.
Wilhelm Wundt, generally considered the founder of the discipline of psychology, established the first psychology laboratory in Leipzig Germany in 1879. He believed in the value of laboratory research for studying human consciousness, but he never thought of experimental research as the only viable methodology for psychology, and always believed that psychology would need to maintain an important link with disciplines such as philosophy, anthropology, linguistics and history.
William James (older brother of novelist, Henry James), the father of American psychology, held a broad view of the new discipline as well. James, who studied with both Wundt and his mentors in Germany, established the first American laboratory in experimental psychology at Harvard, but his interests and writing transcended disciplinary boundaries and included philosophy, art and religion. By the time he has published his magnum opus, Principles of Psychology in 1890, he had become increasingly dissatisfied with the growing narrowness of American psychology’s preoccupation with what he viewed as simplistic form of methodological rigor at the expense of seeking genuine understanding.
American psychology’s emphasis on its credentials as a science was from the outset essential to its claim to epistemic authority and to the profession’s presentation of psychologists as experts with a marketable product. The criteria that are emphasized for psychology’s claim to being a science have less to do with factors that are relevant to the successes of the natural sciences than they do with logical positivist reconstructions of the way science works. These include variables such as the use of aggregate data, quantification, experimentation, hypothesis testing, and the search for universal laws or principles.
One of the first markets for American psychology was the field of education. It is in this context that intelligence and aptitude testing came to play important roles. The relevant research paradigm had less to do with German experimental psychology than it did with the individual differences paradigm originating in the work of the British empiricist, Sir Francis Galton (a cousin of Darwin’s). Galton pioneered the use of statistics for analyzing large data sets in order to study the distribution of characteristics such as intelligence in the general population. Edward Thorndike and G. Stanley Hall, both students of William James, played important roles in establishing the role of American psychology’s expertise in the educational marketplace.
Another important marketplace for American psychologists’ expertise was the growing self-help industry. By the 1920’s, increasing immigration, industrialization, urbanization, and disruption of traditional communities, left Americans hungry for guidance in dealing with the ambiguities, competing demands and values, and stresses of everyday life. Psychologists increasingly came to be seen as experts who could provide answers. The first popular psychology magazines were published in the 1920s, and psychology became broadly disseminated by increasingly influential popular media outlets.
During this same period, psychologists’ expertise found another important market in the increasingly influential advertising industry. Edward Bernays, an Austrian-American nephew of Sigmund Freud’s, played an important role in pioneering the use of psychological principles in advertising, public relations, and the development of American propaganda during World War I. In the early 1920s John Watson, the father of behaviorism became vice president of one of largest advertising firms in the country, after losing his academic position for having an affair with a graduate student. Over time, psychologists’ expertise also came to be used increasingly in the workplace in order to motivate employees and increase productivity. Elton Mayo’s famous research conducted for Western Electric between 1924 and 1927 (commonly known as the Hawthorne studies, because they were conducted at Western Electric’s Hawthorne Plant), played a particularly significant role in developing the psychology of personnel management.
World War II was a watershed event in the development of American psychology. Psychologists mobilized for the war effort, and were recruited by the government for a range of services including intelligence, aptitude and personality assessment, organizational management, and the production of morale boosting propaganda on the home front and psychological warfare to be used against enemy troops. As I indicated previously, the establishment of clinical psychology as a professional discipline was a direct result of World War II. And following World War II the relationship between the psychology and the military continued to flourish. The emergence of the Cold War generated a growing need for psychologists to provide a variety of services, They were recruited to screen candidates for officer training and for fitness to serve in the CIA, to advise on counterinsurgency policies in third world countries, and to assist in the development of psychologically informed interrogation procedures, and skills for resisting interrogation. Psychologists have also played a significant role in devising psychological resilience training procedures for members of the military. Vast amounts of federal support have been provided to fund psychology research that might potentially have military applications in the future. Between 1945 to the early 1970s, the military was by far the largest funder of psychological research in the U.S. And the Department of Defense still continues to be a significant sponsor of psychology research at the present time. To take one controversial example, in 2010 Martin Seligman, a former president of APA, received a 31 million dollar no-bid contract from the military to conduct research on resilience training for soldiers.
Whatever professional benefits may accrue from psychology’s self-identification as a science are accompanied by a significant price tag. For one thing, it is not, for the most part, an intellectually oriented discipline. There is no doubt that the ability to come up with a clever research design requires an unique form of creative ingenuity, and that other aspects of psychology require creativity, intellectual rigor and problem solving abilities. But by and large, psychology is not a theoretically oriented discipline. This feature of psychology is no accident. Psychologists have a predilection for Occam’s razor, since complex theories are not readily testable. If anything, psychology graduate students are taught to curb tendencies toward excessive speculation and to “stick to the data,” as it were. Young psychologists in tenure track positions are discouraged from writing theoretically oriented papers or books. Promotion and tenure are contingent on publishing empirical articles in peered reviewed journals and attracting grant funding.
Certainly there are those within various areas of psychology (e.g., history and systems, personality, social) who spend their time writing theoretically oriented papers and books instead of conducting research. But they are unlikely to be offered academic positions by well-regarded mainstream psychology departments. In clinical psychology there are a subgroup of graduates who are interested in pursuing academic careers, but not in conducting systematic empirical research. There has been a growing tendency (especially in the northeast and parts of the west coast) for some of them to undergo postdoctoral psychoanalytic and to become active contributors to the psychoanalytic literature. For them the psychoanalytic world functions as a parallel academic community outside of the university system. In fact, since the mid-1980’s when the American Psychoanalytic Association began admitting psychologists to psychoanalytic institutes (previously psychoanalytic training had been restricted to candidates with medical training), American psychoanalysis has become increasingly dominated by psychologists, who have played an important role in fostering an interdisciplinary climate drawing on a range of fields including psychology, philosophy, historical studies, sociology and critical theory.
A second cost to psychology’s commitment to its identity as natural science-like discipline, is a lack of self-reflexivity that can lead to obscuring the value systems that are intertwined with and enshrined by psychological knowledge claims that are supposedly based on objective findings. This may constitute more of a problem in some areas of psychology than others. For example, claims regarding the mechanisms through which perceptual processes operate may be potentially less problematic in this respect than claims about stages of moral development (an area where for many years, higher levels of moral development were equated with stereotypical masculine styles of moral reasoning), or theories of social or developmental psychology that reflect a Western cultural bias. The recent disclosures regarding the complicit role that the APA has played in condoning psychologists’ active participation in the development and use of coercive interrogation techniques by the CIA is perhaps a somewhat extreme example of the harmful consequences that can result from the profession’s lack of self-reflexivity and insistence on presenting itself as a value neural objective science.
Psychology, the construction of self and neo-liberalism
But many of detrimental consequences of psychology’s identification with certain features of the natural sciences are subtler in nature. Building on Foucault’s writing on governmentality, British sociologist, Nikolas Rose has published a series of books outlining the way in which psychology and affiliated disciplines (referred to generically by Rose as the psy disciplines) have come to play a central organizing role in our culture by contributing toward the construction of a particular form of subjectivity — the psychological self. The contemporary psychological self organizes subjectivity in a way that internalizes the principles of a neo-liberal culture, so that we all engage in a form of self-governance that perpetuates an advanced capitalist consumer culture, and maintains a power structure that privileges the wealthy elite at the expense of a growing proportion of the population that is disadvantaged. Consistent with Foucault’s general analysis of the way power operates in society, this model does not posit the existence of an active conspiracy of the elite. Instead it involves a self-perpetuating intersection of cultural, sociological and psychological forces that lead to the shaping of a particular from of subjectivity through the implementation of what Foucault terms, technologies of the self — principles of self-regulation and self-construction derived from our psychological culture that lead to the production of ourselves as commodities in a consumer culture.
The contemporary self is autonomous, agentic, and capable of making and breaking emotional bonds easily (What Zygmunt Bauman refers to as liquid love). We are predisposed toward looking inward for the source of our problems and have learned to regulate emotional expression in order to get along with others in the workplace. Problems in living are understood as stemming from personal failures or chemical imbalances, rather than as reflecting social and cultural problems. People have become increasingly accustomed to viewing themselves as commodities in the social marketplace. Happiness and contentment become goals in and of themselves, rather than byproducts of a life that is well lived. Therapists, life coaches and self-help books offer a range of different prescriptions for achieving happiness, and if psychotherapy is viewed as too ambiguous or labor intensive, mood enhancing prescription medications are readily available. These psychotropic medications are marketed to the public on television, just like cereals, shampoo, deodorant and mouthwash. Both Prozac and personal hygiene products hold out the promise of transforming the self into a more marketable commodity.
The choice of criteria for assessing whether or not a particular form of psychotherapy is effective is inevitably shaped by prevailing social values. It is no surprise then that given the neo-liberal climate that pervades our culture, the value of psychotherapy is assessed in terms of its efficiency, cost effectiveness, speed and efficiency. And it is no surprise that the criteria that are chosen are those that are easily measured. Questions regarding the nature of the good life are inevitably bypassed in any discussion of what type of psychotherapy should be made available to people or in any advice offered to the general public by mental health experts who are cited in the media. Should therapy help people adapt to the demands of a dysfunctional culture? Are therapists educated in a fashion that helps them to reflect critically on the social values that they themselves have absorbed?
If anything, the trend is towards training therapists to become psycho-technicians, who deliver standardized evidence based treatments rather than responsible moral agents whose personal values, beliefs and biases have profound effects on the people they are trying to help. Another disturbing trend is that over the last three decades pharmaceutical companies with deep pockets, aided and abetted by the profession of psychiatry, have waged a successful campaign to medicalize the inevitable anxieties and sorrows that we all experience as a part of living — to turn them into illnesses to be treated with the most recent miracle drugs on the market.
The need for a critical approach to clinical psychology
Tensions between the science and craft of clinical psychology have always existed, but these tensions are now being exacerbated by the growing pressure that academic clinical psychologists are experiencing to bolster their credibility as experts by convincing policy makers and the general public that they are real scientists. These pressures are being fueled by the growing role that neoliberal rationality has come to play in the healthcare system and in higher education. Clinical psychologists are becoming increasingly split into two camps: those who believe that they can hold on to their portion of the healthcare market share by shoring up their scientific credentials, and those who feel increasingly alienated from the discipline of psychology. In the context of the ongoing controversy about the extent to which APA has played a complicit role in psychologists’ involvement in the coercive interrogation of suspected terrorists, many of my clinical psychology colleagues who are psychoanalysts have resigned from APA. Their resignation is in part an act of protest, but it also reflects a growing sense many share that they have less and less in common with the discipline of psychology.
In recent years my colleagues and I in the clinical psychology program at the New School have been speaking with one another and with our students about some of the concerns regarding the future of clinical psychology that I have touched on here. There is a growing consensus among many of us that we would like to infuse more of a critical, interdisciplinary and socially engaged sensibility into our training model. Some of us have been influenced by the tradition of critical theory emerging out of the Frankfurt School, some have been influenced by the psychoanalytic critique of the cognitive behavioral mainstream, some have been influenced by feminist theory, some have been influenced by a growing interest in healthcare policy and primary prevention, and some have been influenced by a focus on themes related to racial and ethnic diversity and social justice. Another influence has been the tradition of community psychology.
Clinical-community psychology: back to the future?
Clinical-community psychology emerged in the 1960s as a critique of the traditional clinical psychology model that tends to locate the problem requiring within the individual. The concern was that traditional clinical psychology’s focus on the individual, tends to ignore the social, cultural and economic factors that contribute to the development of psychological problems that people experience. This perpetuates a status quo that favors the privileged. In important respects, this tradition of community psychology went hand in hand with the Civil Rights Movement, the New Left, the counterculture and the antipsychiatry movement.
The community psychology movement in the 1960s was deeply critical of the individualist bias of traditional clinical psychology, and in important respects, socially progressive, critical and subversive in nature. It emphasized political activism, community organizing, the development of primary prevention programs, and the deinstitutionalization of psychiatric treatment. With respect to deinstitutionalization, there was a growing recognition that the type of custodial treatment provided for patients with serious psychiatric problems, had iatrogenic effects. The development of new medications made it possible to control more serious symptoms, thus reducing the need for large psychiatric institutions where people could be hospitalized against their wills for extended periods of time. The plan was to integrate these patients back into the community and to provide high quality community mental health centers and other forms of psychological and social support that would facilitate recovery.
Unfortunately, by the early 1970s federal and state money for funding high quality resources in the community to treat the released psychiatric inmates was drying up. Many of the psychiatric patients who had been discharged ended up homeless, in prison, or in a revolving door process of short term psychiatric commitment, stabilization on medication, discharge, and subsequent symptomatic relapse followed by re-hospitalization. While the community psychology movement never completely died out in the United States, its influence tended to wane in tandem with the general decrease social activism the 1970’s. While a few clinical-community programs that began in the 1960s or early 1970’s are still in existence, many contemporary community psychology programs are associated with social psychology programs, and the major emphasis is on community oriented research rather than community organization and social activism.
On personal note, when I attended graduate school at the University of British Columbia (UBC) in Vancouver, Canada in the early 1970s, the clinical program I attended was actually a clinical-community program that had been established the year before I began my training by a Canadian psychologist named Park Davidson. Park, considered by many at the time to be the enfant terrible of Canadian psychology, had risen to prominence at an early age, by publishing a series of cogent articles articulating his vision of a Canadian brand of clinical-community psychology. While I was excited to be admitted to UBC, which was considered at the time to be a university “on the rise” (with a beautifully forested campus overlooking an ocean with a sandy beach) I had never heard of Park Davidson, or for that matter, community psychology. Park’s vision of Canadian clinical-community psychology, as I came to view it over time, was shaped by a combination of 1) a pragmatic assessment of the way in which market forces would affect the profession of clinical psychology in the future, and 2) an unsophisticated understanding of the nature and complexity of clinical expertise.
Coming from a behavioral background (this was before the days when cognitive therapy has risen to prominence), Park’s perspective was that behavior therapy skills could be mastered by technicians without the type of extensive training that clinical psychologists undergo, and that in the future, employers were more likely to hire therapists who had gone through relatively short training programs, and who could be hired for less money. Given this, he believed that very few Ph.D. level clinical psychologists were likely to working as front line practitioners, and instead their primary roles would consist of a combination of training and supervising less well educated clinicians, mental health agency and healthcare administration, and consulting to mental health programs and policy makers through a combination of program evaluation (i.e. conducting research to evaluate whether agencies are achieving their objectives) and development.
I and the other five members of my clinical cohort that year — Rene and Maurice (college friends from South Africa), Howard (from Toronto), and Harold and Susan (from the Canadian midwest) were idealistic, young aspiring clinicians who had limited, if any experience working with real patients. None of us knew anything about community psychology, nor did we understand the way in which Park’s pragmatic version of it had stripped it of its radical and subversive qualities. Once we started seeing real patients, however, it did not take us long to realize that we were not getting the kind of training that would help us in the trenches. The program faculty had little clinical experience themselves and none of them were actively working with patients. We learned to apply simple behavioral interventions from textbooks, and received little in the way of real clinical supervision from our professors. We had difficulty understanding how we were to become teachers and supervisors of front line clinicians, if we had never been properly trained to do clinical work ourselves.
Most of us picked up smatterings of clinical training in clandestine ways, and much of our learning took place through trial and error with the patients we were treating. I personally thought that Park’s forecast of the way in which market forces would substantially diminish the role of Ph.D. level psychologists as front line clinicians was overly pessimistic. In retrospect I think he was right in important respects, even though the timeline he projected was premature by about forty years.
In any event four of the six members of my cohort ultimately graduated with our Ph.D. s in clinical-community psychology (Harold and Howard left the program after receiving their master’s degrees). Those of us who went on to become clinicians learned our clinical skills in a variety of ways in spite of our graduate training. While we didn’t receive much in the way of clinical training in graduate school, we were exposed to the writing of some of the first generation of American community psychologists. If anything, however, I think we developed somewhat of an allergy to the term community psychology, because for us, community psychology came to mean “not real clinical psychology.” It is only in the last few years, as I have become increasingly concerned about what is happening to the mental health field, and where the future of clinical psychology is heading, that I have begun to reread the community psychology textbooks from graduate school days that I can still find on my bookshelves, and to reengage with some of the more critical and subversive ideas that lay at the roots of the tradition.
What is critical psychology?
Interestingly, there is a tradition of psychology emerging in various forms in different parts of the world that is coming to be designated generically as critical psychology. There is no one straightforward definition of critical psychology, and psychologists who identify with this perspective have been influenced by a variety of different traditions. These include the tradition of critical theory emerging from the Frankfurt Institute for Social Research, the work of Klaus Holzkamp (1927-1995) and colleagues at the Free University of Berlin, feminist thinking, Foucault’s analyses of the relationship between power, knowledge, and society, and a revival of the American community psychology tradition of the 1960s. Other important influences consist of the traditions of liberation psychology and liberation theology that emerged in Latin America in response to the dictatorships in the 1960s and 1970s.
Some of the key themes associated with the emerging tradition of critical psychology include: an interest in examining and critiquing developments in psychology from the perspective of other disciplines (e.g., philosophy, politics, sociology, history, anthropology and economics), an emphasis on analyzing the social and cultural ideologies that shape the construction of psychological theory and prevailing research paradigms, an interest in understanding the way in which prevailing ideologies serve to protect the interests of the privileged, an emphasis on social justice, and a commitment to combining research and theory development with social action.
Consistent with the tradition of community psychology, critical psychologists emphasize the importance of understanding the individual in social and cultural context, and of recognizing that focusing exclusively on psychological problems at the level of the individual can function to maintain problems at the social and community level. This does not mean that interventions at the individual level cannot be helpful, but it does mean that there is the ever-present danger of “psychologizing” problems rather than challenging problematic social institutions and norms. In short, there is an overall emphasis on analyzing challenging assumptions and practices within mainstream psychology that help sustain unjust political, economic and other societal structures.
There are a growing number of psychology graduate programs around the world that identify themselves as either critical psychology programs, community psychology programs, or both. But as a rule they are not linked with clinical psychology programs. For example, there is a critical psychology program at the Manchester Metropolitan University. Ian Parker, who teaches there is one of the more prolific writers in the area and is strongly influenced by both Marxist and psychoanalytic thinking. There is another critical psychology program at the University of Edinburgh, and one at the University of East London. There is a community psychology program with a strong critical psychology emphasis at Wilfred Laurier University in Canada, a Center for Critical Psychology at The University of Sydney in Australia, and a community psychology program with a strong critical psychology emphasis at the University of Melbourne. There are community psychology programs at Georgia State University, the University of Illinois, and DePaul University in Chicago Closer to home there is a Critical Social and Personality Program at the City University of New York Graduate Center (CUNY). More than one of our current graduate students in the clinical program at the New School have told us that they considered attending the CUNY program before deciding to come to the New School, but ultimately began the New School M.A. program in general psychology (the only gateway to our clinical program), assuming that the New School Psychology Department would reflect the critically progressive and interdisciplinary legacy of the New School.
The New School clinical psychology program: one possible future
In many respects, the clinical psychology program at the New School is in good shape these days. We were recently reaccredited for another seven years by APA (an outcome never to be taken for granted). Our Ph.D. students continue to matriculate through the program in a relatively timely fashion. At a time when the average national match rate for pre-doctoral clinical internships is in the area of 65-70%, we continue of have an internship match rate of 95-100%. Our graduates are well respected by psychologists in the New York area who fill key administrative positions in hospital and other agency settings. Many psychologists in these positions are alumni of our clinical program, who have a perverse sense of loyalty to their alma mater, despite the hardships they endured during their graduate training. This often comes in handy for our students when they are on the job market. And although there are growing cutbacks in the funding of mental healthcare services, our job placement statistics continue to be good.
At the same time there is a growing sense of malaise in the field. Discussions regarding the ongoing pre-doctoral internship crisis feature prominently at psychology conferences and in professional journals and newsletters. Over the last decade, APA has come to focus increasingly on identifying, developing and marketing new job niches for psychologists. The growing profusion of self-help books and workshops for training clinical psychologists to grow and market their psychotherapy private practices has become an industry in its own right.
Our students find themselves stretched increasingly thin, traveling back and forth between clinical placement sites throughout the city, in order to gain more and more clinical training in diverse settings, in an effort to increase their likelihood of being successful in the internship match. And even if the students ahead of them in the program have been successful in their job searches, it is no secret that funding for mental health care services is decreasing. A few years ago, The New York State Office of Professions passed legislation licensing four new M.A. level mental health professions: mental health counseling, marriage and family therapy, creative arts therapy, and MA level psychoanalysis. Since that time a growing number of M.A. level licensed psychotherapists have entered the job market. Although this does not seem to have had a major impact on our students’ job search prospects yet, there is good reason to think that it inevitably will.
I imagine my old mentor from graduate school days, Park Davidson, would have a rueful smile on his face if he were alive today. Despite my concerns regarding the limitations of his vision, I think that his understanding of the pragmatics of the situation were remarkably prescient in important respects. He was right that market forces would ultimately push things in the direction of hiring less highly trained (and less expensive) clinicians than Ph.D. level psychologists to serve on the front line. And he was also right (in what I infer to be implicit in his underlying logic) that it would be essential for future clinical psychologists to develop the skills to influence policy decisions if they were going to have some influence on the future of the healthcare system and on the roles that psychologists might potentially play in it. On the other hand, I believe that his prioritization of future market demands as the key orienting principle of his vision was problematic. With hindsight, I can see that it was consistent with neoliberal cultural values that were already beginning to take hold at the time.
I do believe, however, that the time is ripe for re-imagining a type of clinical psychology training that recovers some of the subversive, socially progressive spirit that lay at the heart of the original clinical-community psychology movement in the 1960’s, combined with the type of critical interdisciplinary perspective that I have discussed above. I would like to see things structured so that our students have more opportunities to engage in ongoing conversation with a variety of disciplines including anthropology, economics, history, philosophy, politics and sociology. This type of conversation has the potential to equip them with the type of intellectual tools they will need to examine what is happening in mainstream clinical psychology from a critical perspective, so that they can play a role in changing the direction of the clinical psychology of the future.
In terms of helping students acquire the skills relevant to influencing healthcare agencies and policy decisions, I believe an emphasis on the type of program evaluation and development skills that I learned as part of my clinical-community training during graduate school, are important, but too limited in scope. It will also be important for future clinical students to learn the type of skills that will help them to analyze organizational dynamics, and to function as agents of organizational change. In addition the type of participatory action research (combining applied research with active participation in both the community and the process of changing things), which was originally pioneered by the psychologist, Kurt Lewin (who was influenced by members of the Frankfurt School) is particularly relevant. I also believe that it essential for clinical psychology students to develop the type of writing, communication and media sophistication skills relevant to advocating for policy changes and to communicating with a broad audience outside the field of psychology. The skills relevant to writing up research findings for publication in a professional psychology journal, do not translate well into communicating with either policy makers or the general public.
Interdisciplinary thinking, civic engagement, critical inquiry, going beyond the mainstream, social justice, policy advocacy, public scholarship… It’s beginning to sound like the NSSR, isn’t it? In fact, I can’t imagine a more ideal institutional home than the New School, for the type of clinical psychology program that I am sketching out here in a preliminary fashion. As those who have been here for a while know…. if there are any constants at New School, they are crisis and ferment. But today’s crisis feels somehow different to me than the crises of the past. And the convergence of crisis, ferment and desire for change at so many levels — internationally, nationally, locally, and in my own field of clinical psychology, leave me feeling oddly hopeful — at least in my more optimistic moments.