Clinical Science Training at a Crossroads

More than a decade ago, Richard McFall challenged clinical psychology to become more connected to science, specifically to use methods supported by scientific evidence. Among other things, his challenge inspired a movement within psychology to develop clinical training programs that are grounded in research.

In a direct outgrowth of that movement, members of the Academy for Psychological Clinical Science met earlier this year with leaders from the National Institute of Mental Health to explore issues related to clinical science training, student recruitment, and the need for translational and multidisciplinary research. The meeting was the product of several earlier planning meetings between NIMH and the Academy that were arranged by APS.

The goal of the meeting was to encourage current and new models of training that will produce clinical researchers to create new and innovative ways to diagnose, measure, and treat mental disorders, and new ways to evaluate whether those treatments will translate to the real world.

At the heart of the two days of presentations and discussions were two questions: Are students currently in clinical research training programs going to be the leading researchers and discoverers of tomorrow, and how can we ensure that clinicians and practitioners deliver evidence-based treatments?

“The clinical intervention enterprise is not well,” said APS Fellow McFall, Indiana University, a founding member of the Academy. “Many common clinical interventions simply lack any kind of empirical support. The troublesome part is that many commonly used treatments seen in our communities today are those for which there is no good empirical support. Too often, therapists typically do what they like or what they were taught and not what the current research evidence indicates.”

According to McFall, there are six challenges to traditional training:

1. the influence of managed care;
2. market forces no longer requiring PhDs to deliver treatments;
3. research training that must continue to develop psychology’s unique, research-focused niche;
4. psychology continuing to be a popular area of study while there is a diminishing number of clinical scientists;
5. the federal government’s influence as a major employer of clinical psychologists and a major grant provider;
6. an open schism between clinical scientists and clinical practitioners that is clouding the future of clinical psychology.

Psychology programs need to adapt to these challenges, McFall said, in order to continue to develop researchers and clinicians who deliver science-based treatments and interventions. McFall called on Academy members to differentiate the good programs from those not training clinical researchers and practitioners who will deliver empirically supported treatments.

“We must study the exemplars of clinical science [training programs] and reverse engineer those exemplars’ history to design a training model,” McFall said.

Lee Sechrest, University of Arizona, called for McFall’s “reverse engineering” of model clinical science programs to distill the very best characteristics of the best programs. “If we want students to do certain things, then what do we have to do in our training programs to get them to do it?” he asked.

“We should evaluate our students and programs by the best examples in the field,” said Sechrest, an APS Fellow and Charter Member. “NIMH could do us a good service with the Academy by developing a way to assess students in clinical psychology [science].”

“The difference between generic clinical training – that of professional membership – and what we’re talking about is the creation of adventurers,” McFall said. “We’re creating a generation of explorers. We [members of the Academy] need to set up a waterfront so people can go in different directions.”

McFall said the vision for the next generation of explorers should be a guide of best practices for psychology departments to follow. It shouldn’t be a rigid scripture, but a flexible list from the best programs, which can be adapted to meet the unique needs of different specialties.

MULTIDISCIPLINARY CONNECTIONS
“Our mission is your mission,” said Richard Nakamura, deputy director of NIMH. “It is clear that collaboration between APCS and NIMH will improve training of clinical researchers.”

But training in psychology must open the doors to other disciplines and cultivate a broad understanding of the interface that psychology has with those sciences, Nakamura said. In particular, he said that biological sciences and neuroscience are critical for a researcher to be able to fully understand today’s complex behavioral phenomena. If clinical psychology doesn’t foster an interface with other disciplines, training is in danger of being left behind.

An emerging key concept of behavioral research is the plasticity of the brain, Nakamura said. It is critical “to understand that the brain changes its physical structure through behavior and interaction with environment. This is a revolution that integrates the idea of nature and nurture.”

This intersection means that the brain can be directly influenced by behavior; essentially, the environment, behavior, and the brain can no longer be seen as separable entities.

“NIMH is not solely interested in advancing psychology as a discipline,” said Nakamura, who is an APS Fellow and Charter Member. “What we are interested in is developing a set of scientists and clinicians who can intervene in disorders of great and central interest in our society. What we are seeing is a group that is getting increasingly out of step in its ability to make those advances.”

Mark Goldman, associate director of the National Institute on Alcohol Abuse and Alcoholism, who also attended the meeting, said that one key to securing psychology’s relevance as a science-based discipline is establishing connections with other fields.

The question is not whether other sciences see psychological science as relevant, but whether psychology has enough answers to keep it relevant to other sciences, said Goldman an APS member who was the director of clinical training at the University of South Florida. Psychological science needs the larger domain of science to leverage the value of behavioral research.

“Other scientists are in fact looking for behavioral science,” he said. “But they are seeing boundaries in biological science that are being placed on them by the fact that they don’t have enough behavioral science to answer their questions.”

CLINICAL SCIENCE IN THE 21ST CENTURY
In summarizing the meeting, APS President-Elect Robert Levenson identified the following priorities:

• Distinguishing the clinical science model from its predecessors (Boulder Model, Scientist-Practitioner Model, Practitioner-Scientist Model);
• Training for Big Science (clinical trials; designing, managing, and directing multisite and multidisciplinary projects);
• Evaluating training outcomes;
• Identifying critical roles for clinical science in the era of neuroscience and genetics;
• Increasing bidirectional communication and influence between clinical science and clinical services delivery;
• Identifying promising areas for “discovery” in clinical science;
• Developing new treatments for mental illness: Where will they come from and what will they look like?;
• Defining clinical science’s role in increasing the rate of progress in reducing the burden of mental illness;
• Preparing undergraduates and graduate students for careers in the clinical science of the 21st Century.

“The idea would be to embrace these challenges,” said Levenson, “recognizing that clinical (and psychological) science is going to have to change markedly to take advantage of advances in neuroscience and genetics, and to outline a vision of how clinical science will evolve to play an increasingly important role in this new kind of integrative science.” One idea under consideration is to commission a series of essays on these and related topics.

This issue of the Observer features profiles of the innovative clinical science training programs at Indiana University and the University of Oregon. On a related topic, Della Hann, director of the NIMH Office of Science Policy and Program Planning at NIMH, said better communication is the key to overcoming interdisciplinary barriers in research and training.

Mixed Results: Indiana’s Hybrid Teaching Model Is Clinical Science’s Best

By Eric Jaffe
Staff Writer

In the early 1980s, the research training in clinical science program at Indiana University at Bloomington received an NIMH training grant to help explore a hybrid model of teaching, one that combines both clinical and scientific studies to create a “clinical science.”

Richard McFall

“What we’re pushing for is that [a student] should embody basic science and technology, and focus on clinical problems,” said APS Fellow Richard McFall. “That’s what we’re talking about with this kind of hybrid model.”

The approach has evolved to the point where Indiana students are fully trained in clinical studies as well as cognitive science, neural science, and behavioral genetics, an achievement accomplished with a success rate of 90 percent.

McFall defined “clinical science” as distinguished by its focus on a problem and epistemological approach to solving the problem. “Anyone working to advance knowledge on such problems is a clinical scientist,” McFall said. “The more good scientists working on these problems, the faster the progress. And the broader, more rigorous, and integrative the science, the better the product.”

Indiana’s hybrid program includes, from beginning to end, a focus on research training. In addition to departmental requirements, such as statistics, and elective seminars, there are four clinical core courses: Epistemological Foundations of Clinical Science, Psychopathology, Assessment, and Intervention and Evaluation.

The goal of the program is to “breakdown the balkanization of psychology,” McFall said. “We do this by training students first as psychological scientists, then arming them with the best theories and methods from all of psychological science.” The hope is to foster collaboration across traditional content areas – to bridge traditional boundaries without losing any subtle expertise.

One way Indiana fosters such a transdisciplinary environment is by hiring faculty members who belong to multiple areas. “No ‘area’ owns faculty slots,” McFall said. “We hire at the interface of areas, and the entire faculty are responsible for hiring decisions.”

But McFall stressed that while Indiana’s model of hybrid clinical training is a thorough and explicit one, it is not the only option. In fact, he urged the need for competing programs, in order to fuel the growing trend’s inspirational fire.

“In the end, [Indiana’s model] may not be the best for everyone. Other models deserve to be considered,” he said. “We need to study the top exemplars of clinical science, and then design these histories into our training models. We need to ensure that the graduates of our program have these kinds of experiences.”

Bound to Be Limitless: Oregon’s Clinical Science Training Gives Students, in Most Cases, Free Reign

By Eric Jaffe
Staff Writer

Those interested in the clinical science training program at the University of Oregon – particularly those with more freewheeling dispositions – will be happy to know that exploration within the program is limited only by a student’s imagination.

Scott M. Monroe

“We [Oregon] have the emphasis on not wanting to have boundaries that divide ideas,” APS Fellow Scott M. Monroe said.

Monroe outlined the program’s four major themes as recruitment and admissions, mentorship, curriculum sequencing, and clinical science training, placing special attention on the first.

“The front end is very important,” he said. “This seems obvious, but it often gets lost.” During recruitment, Oregon’s main concern is keeping the program philosophy clear and consistent. This includes (but, of course, is not limited to) a recruitment weekend in which 10 to 15 students are invited and edified as to the program’s model, some typical applicant misperceptions, and the sense of common purpose and community Oregon proudly endorses.

In addition to a positive recruitment, admissions rely heavily on a demonstrated track record of research, a factor Monroe said, “will often far outweigh other predictors.”

Oregon’s mentorship model underscores the program’s flexible core by providing an intellectual and personal base within which students are free to seek outside research experiences. However, students may not need to go very far to receive all the psychological awareness they need, as a core curriculum is a year-long first-year seminar that covers all the major areas of psychology.

“This reflects a departmental emphasis on putting psychologists first and specialties second,” Monroe said. “It’s a nice way to expedite the formal academic training” without forcing students into lengthy, undesired courses or risking the possibility of holes in their psychological tapestry.

In the second year, research opportunities expand, and “students are encouraged to work in multiple laboratories across traditional specialty boundaries,” Monroe said. The effort is designed to drive students toward developing independent, cogent research programs of their own.

The training is capped by two evidence-based year-long practica taught by core faculty. During this highly formative year, Monroe said the faculty do their best to model the integration of science and practice.

But like the construction that invariably lines open highways across the nation, there are certain limitations to the program that are, fortunately or not, inevitable. Despite its efforts to widen the proverbial academic fences, Oregon’s program faces some of these challenges. At times it seems the requirements, though few, reflect a checklist mentality of specialty training, that, “doesn’t recognize the extensiveness of clinical research training,” Monroe said.

“It’s just a product of too much to do, too little time,” he said. After all, “why should we be limiting our students?”

Academy for Psychological Clinical Science Meeting Participant List

• Marc Atkins, University of Illinois at Chicago
• David Barlow, Boston University
• Richard Bootzin, University of Arizona
• Dianne Chambless, University of Pennsylvania
• John Curry, Duke University
• Don Fowles, University of Iowa
• William Iacono, University of Minnesota
• Andrew Kessler, American Psychological Society
• Alan Kraut, American Psychological Society
• Ann Kring, University of California, Berkeley
• Peter Lang, University of Florida
• Robert Levenson, University of California, Berkeley
• Richard McFall, Indiana University
• Scott Monroe, University of Oregon
• Daniel O’Leary, SUNY at Stony Brook
• Jacqueline Persons, San Francisco Bay Area Center for Cognitive Therapy
• Vicky Phares, University of South Florida
• Paul Pilkonis, Western Psychiatric Institute and Clinic
• Stephen Porges, University of Illinois at Chicago
• Neil Schneiderman, University of Miami
• Lee Sechrest, University of Arizona
• Varda Shoham, University of Arizona
• Anthony Spirito, Brown Medical School
• Jose Szapocznik, University of Miami
• Teresa Treat, Yale University
• Richard Viken, Indiana University
• Elaine Walker, Emory University
• John Weisz, University of California, Los Angeles
• Antonette Zeiss, VA Palo Alto Health Care System

FEDERAL STAFF*

• Mayada Akil
• Fred Altman
• Mark Chavez
• Mary Curvey
• Bruce Cuthbert
• Nancy Desmond
• Mark Goldman
• Della Hann
• Thomas Insel
• Michael Kozak
• Enid Light
• Richard Nakamura
• Molly Oliveri
• Lisa Onken
• Mike Sesma
• Linda Street
• Debra Wynne

(*All federal staff are employees of the National Institute of Mental Health except Lisa Onken, National Institute on Drug Abuse and Mark Goldman, National Institute on Alcoholism and Alcohol Abuse.)