Clinical Science in the 21st Century

I am grateful for this opportunity to tell you about the recent “Indiana Conference on Clinical Science in the 21st Century.” After presenting my own views, in the first part of this column, I present in the second half a compressed representation of the “Executive Summary” of the Conference.

Background of the Indiana Conference

The countdown has begun for the end of the 20th Century and start of the 21st. This once-in-a-lifetime calendar transition is a fascinating event; with its fresh set of zeros, it captivates us with its magical moment of ending-as-beginning, and makes secret numerologists of us all. The approaching tum-of-the-century is more than a superstitious curiosity, however; it coincides with unprecedented social, political, and economic changes that portend significant personal and professional transitions, too. Thus, the looming roll-over of the century has become a metaphor for the looming turbulence in our lives — a mixture of uncertainty and adventure, insecurity and opportunity.

One of the most significant changes we all face is the inevitable redesign of the nation’s health care system. Although Bill and Hillary Clinton have been given much of the credit, and blame, for pushing this issue to the forefront, in fact it was forced upon us by economic realities. Our health care system simply was breaking the bank and could no longer be sustained. Although we still do not know what new structure will replace the old, it seems certain that the health care system of the 21st Century will look radically different from what we have known in our lifetimes.

Opportunity for Scientific Foundations

For clinical/health psychologists, this change in health care signals the end of business-as-usual. To some, it is a threat. To others of us, however, it is a welcome opportunity to reestablish the scientific foundations of clinical training and practice. The pending changes demand a thorough and critical reexamination of our unique contributions and legitimate roles within the emerging system. The most compelling answers to these questions will arise from scientific analysis and evidence.

The ticket to participation in the new system will be empirical evidence of our capacity to offer cost-effective services for “real” problems. In recent years, mental health care has become one of the costliest and fastest-growing segments of the total health care market. At the same time, mental health providers have resisted efforts to impose quality-control standards on their professional practices and outcomes — standards that now are routine in the physical health professions. In the new health care system, quality control will be central, with watchwords such as “efficiency,” “cost,” “access,” “efficacy,” and “accountability” becoming universal. Mental health providers must embrace these concepts if they are to be included in the new system. Who better to do this than scientifically trained psychologists?

Guided by Empirical Evidence…

These concepts are not new to the faculties and students in the clinical/health PhD programs that have maintained a fundamental commitment to scientific research training over the years, ignoring fads and fashions, and refusing to succumb to expediency. Now graduates of these programs will have a vital role to play in the design, evaluation, and administration of mental health systems; they have the required skills to ensure that our nation’s mental health care system satisfies the new quality control criteria. Furthermore, because the graduates of these programs are less likely to have personal stakes in maintaining the status quo, their recommendations and decisions are more likely to be in the public interest, guided by the empirical evidence and pointing us in the right direction.

If research raises questions about the validity of our most cherished tests, for example, and challenges the validity of the “clinical judgment” that training and experience are supposed to sharpen (Dawes, Faust, & Meehl, 1989), then these clinical scientists will insist that we bring our assessment and prediction practices into line with such evidence. If research indicates that doctoral-level clinical training and extensive experience are not significantly related to therapeutic efficacy (Christensen & Jacobson, 1994), then these clinical scientists will suggest that some services might be delivered more economically, and with equivalent efficacy, by persons with less training and experience. These clinical scientists also will suggest that we might decrease our national investment in the training of psychological practitioners at the doctoral level, putting those resources to better use. In short, these clinical scientists will demand that our discipline live up to high standards. We no longer should tolerate activities, under the banner of clinical psychology, that violate the basic epistemological tenets of science, the conventions of logic, and the ethical requirements for “truth in advertising” and accountability for results (cf. McFall, 1991).

More than a half-century ago, Woodworth (1937, 1992) worried that leaders in the field of clinical psychology might not be able to maintain and raise the standards of the profession because the field would be flooded with half-trained, semi­scientific practitioners, some of whom he regarded as “out-and­out charlatans.” He raised these concerns before the dramatic growth of the profession following World War II; before the Veterans Administration and the National Institute of Mental Health (NIMH) started funding clinical training; before APA started accrediting clinical training programs in 1947; before the convening of the Boulder Conference in 1949; before there were state licensing boards in psychology; and before the boon of third-party payments for psychological services. Unfortunately, all of these subsequent developments have made it even more difficult to maintain high standards.

…Into the 21st Century

Now, however, as we approach the threshold of the 21st Century, changes in the health care system offer clinical scientists in psychology a window of opportunity. It seems clear that science-based training and application should become the minimum standard for clinical/health psychology. The first step might be for doctoral programs with long-standing commitments and traditions in scientific research training to hold a conference aimed at building a coalition for this future.

Executive Summary

On April 21-24, 1994, Indiana University-Bloomington hosted a conference on “Clinical Science in the 21st Century.” It was attended by invited scientists from 25 research-oriented PhD training programs in clinical/health psychology, one representative each from APS and NIMH, and the students and faculty of Indiana University’s NIMH-supported Research Training Program in Clinical Science. Ten additional program representatives who had been invited, but were unable to attend, asked to be informed of the conference results and to be included in future developments. The aim of the conference was to analyze the changing landscape surrounding scientific clinical/health psychology, and to chart a common course of action for advancing clinical science.

By the end of the Conference, participants had reached a clear consensus in support of several actions. The most important was the creation of a new organization, the Coalition for Psychological Clinical Science. Initially, the Coalition will consist of those training programs invited to the Conference whose faculties have declared their interest in joining. The Coalition is viewed as an interim structure serving only as a stepping stone to the creation of a more open and permanent organization, the Academy of Psychological Clinical Science. The Academy will admit to membership any applicant PhD program that meets its minimum standards for scientific training in clinical/health psychology. The Academy not only will recognize training programs offering scientific training, but also will work actively in a variety of ways to advance clinical science in psychology.

Conference participants adopted the following resolutions relating to the proposed Academy:

Definition: “Clinical Science” is psychological science directed at the assessment, understanding, and amelioration of human problems in behavior, affect, cognition, or health, and at the application of knowledge to such problems in ways consistent with scientific evidence.

Perspectives: Clinical Science may occur at diverse levels of analysis; for instance, using biological, developmental, social, or cognitive science perspectives.

Goal: The primary goal of clinical psychology training programs in Clinical Science is to prepare students for careers in clinical science research. Such programs should produce students who skillfully produce and apply scientific knowledge.

Organization: An elected six-person Coalition Steering Committee is charged with developing a plan for the Academy — its charter, criteria and procedures for membership, governance structure, and organizational mission and agenda.

Immediate Actions: Conference participants were expected to communicate with their home program faculties about the Conference, seeking support for its aims and products, and inviting the programs to join the interim Coalition. To date, feedback to the Steering Committee concerning the responses of faculty members at home universities has been very favorable.

Future Actions: Participants agreed to convene a meeting of the new Coalition in the fall of 1994 (dates and location still to be arranged), with the intent of moving as quickly as possible to the establishment of the Academy. The Coalition Steering Committee is in the process of obtaining start-up funds, and has begun the process of building the new organization.

References

Christensen, A., & Jacobson, N.S. (1994). Who (or what) can do psychotherapy: The status and challenge of nonprofessional therapies. Psychological Science, 5, 8-14.

Dawes, R.M., Faust, D., & Meehl, P.E. (1989). Clinical versus actuarial judgment. Science, 243, 1668- 1674.

McFall, R.M. (1991). Manifesto for a science of clinical psychology. The Clinical Psychologist, 44, 75-88.

Woodworth, R.S. (1992). The future of clinical psychology. Journal of Consulting and Clinical Psychology, 60, 16-17. (Reprint of an original 1937 article in the Journal of Consulting Psychology, 1, 4-5.)