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Is your therapist a little behind the times?

By Timothy Baker, Richard McFall and Varda Shoham
Sunday, November 15, 2009

A young woman enters a physician's office seeking help for diabetes. She assumes that the physician has been trained to understand, value and use the latest science related to her disorder. Down the hall, a young man enters a clinical psychologist's office seeking help for depression. He similarly assumes that the psychologist has been trained to understand, value and use current research on his disorder.

The first patient would be justified in her beliefs; the second, often, would not.

This is the overarching conclusion of a two-year analysis that we recently published on the views and practices of hundreds of clinical psychologists.

The practice of clinical psychology -- which includes psychotherapy -- is akin to medicine as it was practiced a century ago. For at least 2,000-years, medicine was locked in a struggle between those who viewed it as an art and those who saw it as a science. Until the last century, most medical practitioners were guided by intuition and tradition, not by science. Healers commonly used ineffective and often injurious practices such as blistering, purging and bleeding. Such techniques were used year after year, and century after century, with physicians firmly convinced that they were helping their patients.

While psychologists certainly do not use such harmful practices, a similar dynamic appears to be at work in clinical psychology today. Many psychotherapists openly state that scientific research is largely irrelevant to their practice. Most say that their clinical techniques largely reflect their own insights and experience; they tend not to use the most effective types of treatments available; and they admit to little in the way of scientific training.

For instance, very few clinical psychologists -- about 15 percent -- use what's called exposure therapy to treat post-traumatic stress disorder. This is an intervention in which individuals with PTSD are trained to imagine or experience feared situations and stimuli (such as memories of a traumatic event) until their fear subsides. There is strong evidence that this treatment is highly effective, but seven in 10 clinicians, according to a recent report in the journal Behaviour Research & Therapy, have not been trained to use it.

This sort of disconnect exists in other areas of treatment as well: for depression, obsessive-compulsive disorder and alcoholism. Clinicians continue to use treatments that have less research support.

We believe that graduate education is largely to blame for this dismal situation. Graduate programs in psychology do not select science-oriented students to begin with and do not train students to understand and use science once they are enrolled.

But we can change this situation, and a new accreditation system will help. The Psychological Clinical Science Accreditation System is designed to recognize only graduate programs that deliver high-quality, science-based, doctoral clinical training. This system, which we are all working with, is intended to "brand" clinical psychologists so that the public, licensing boards and others can identify those who have been trained to use scientifically validated treatments.

This new system, which began reviewing applications this month, may not seem sufficient to tackle a problem of this size. But accreditation systems can lead the way for change -- the history of medicine shows us that. Prior to the early 1900s, most physicians in the United States were not trained in any way that resembles today's rigorous course of medical study. Many got their "credentials" from for-profit diploma mills, a number of which lacked libraries, laboratories and scientifically trained faculty.

But medicine reformed itself; reputable, scientifically trained physicians were outraged at the shoddy state of medical education. They saw that it meant patients were denied effective treatment and suffered needlessly. These reformists were almost all on university faculties, and under the auspices of the American Medical Association, they launched a campaign to transform medical education into an applied science. They created a commission, which in 1906 scrutinized the 162 existing medical schools -- and concluded that only 82 were acceptable.

Based on these findings, the AMA commissioned a more thorough analysis by the Carnegie Foundation for the Advancement of Teaching, which reiterated the results in its famous Flexner Report of 1910. That report forced the proprietary schools, where students essentially paid for their degrees, into a take-it-or-leave-it choice: They could either raise their standards, which meant fewer paying students and less profit; or they had to face public stigma, which also meant fewer paying students and less profit. Many closed as a result, and others merged with universities. By 1915, 95 medical schools remained in the United States, but these were meeting increasingly rigorous standards.

There are now about 160 medical schools in this country, including schools that grant M.D. and D.O. degrees. They meet rigorous standards of evaluation through relevant professional organizations, such as the Liaison Committee on Medical Education, which considers a wide range of criteria such as student-faculty ratios and clear training objectives.

But about half of clinical psychologists are trained today in for-profit schools that are not associated with universities, and many such programs explicitly play down science. Relative to university-based programs, these schools have very large class sizes, faculty with marginal scientific credentials and low admission standards.

These schools typically train students to receive a Psy.D., or doctor of psychology, degree rather than a Ph.D. Not all Psy.D. programs are weak, of course, and not all Ph.D. programs are strong. But Psy.D. programs are usually much less selective, accepting doctoral candidates at about four times the rate of Ph.D. programs. Moreover, Psy.D. students tend not to do as well on graduate admissions exams or on the national licensing exam. Both students and faculty in Psy.D. programs are much less likely to engage in productive research activities, such as publishing in scholarly journals, than students and faculty in Ph.D. programs.

In essence, many of the students being trained by graduate schools are not prepared to understand or use research evidence, let alone contribute their own. Nevertheless, the number of Psy.D.s has burgeoned in recent years. One analysis of clinical doctorates awarded from 1988 to 2001 shows little or no increase in the award of Ph.D.s but an increase of almost 170 percent in Psy.D.s being granted.

Our report and prescription is an attempt to serve as the equivalent of the Flexner Report for clinical psychology. We hope it leads to increased scrutiny of the programs that train psychotherapists. This is our field, one we trained in and care deeply about. We know that these suggestions may make us a few enemies. But we see no other choice.

There are many highly effective treatments for mental health disorders. Psychology can be reformed so that more psychotherapists use these treatments and help their patients live healthier, happier lives. A new science-based accreditation system will mean that, eventually, patients entering a psychologist's office can expect to receive the best care that psychological science has to offer.

Timothy Baker, a professor of medicine at the University of Wisconsin school of medicine and public health, Richard McFall, professor emeritus of psychology at Indiana University-Bloomington, and Varda Shoham, a professor of psychology at the University of Arizona, are the authors of a new report on clinical psychology published in Psychological Science in the Public Interest.

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