Clinical Psychology and Honky-Tonk

In 1982 Logan Wright was president of the American Psychological Association’s Division 12 (Clinical Psychology). His presidential address was entitled Please Don’t Tell My Mother I’m a Clinical Psychologist—She Still Thinks I Play Piano in a Brothel. It was a witty, heartfelt rant about clinical psychology’s poor standing as a profession as compared to medicine. Wright attributed that failure to the proliferation of for profit schools for psychology practitioners and the absence of clear, enforceable standards for what constitutes doctoral training in clinical psychology.

Wright’s address did not remark on an important difference in the evolution of medical education and that for psychology practitioners, a difference that has had important consequences.

Until the 20th century, medical training in the United States was largely carried out in proprietary schools owned by practicing physicians, following the model of apprenticeship training.  In 1910, Abraham Flexner’s Carnegie Foundation report detailed the variability and shortcomings of that situation, precipitating a migration of medical training into universities and a pattern of pre-medical undergraduate university studies.

Clinical Psychology’s story is different.  That story begins in speculations by the philosophers of antiquity about the nature of things, including human nature.   These ancients argued views of how life should be lived, but the views were not research based.  

Formal research in psychology began in the university. The first psychological laboratory was founded by someone who did not call himself a psychologist, Wilhelm Wundt . He established the laboratory at the University of Leipzig in 1879. His first students did not call themselves psychologists either. They earned doctoral degrees in philosophy or physiology. Their focus was not on how to live well nor on healing, but on how to objectively note, i.e., to measure, the contents of consciousness.

William James introduced psychology to American universities. Like Wundt, he saw psychology as the study of the human mind. His famous description of the “stream of consciousness” and his theories about origins of emotion were not laboratory-based. He and his students, like those of Wundt, saw themselves as identifying the contents of the human mind, not as healers.

Thus the 20th century began with psychology situated in the university, as a specialty within philosophy or physiology, not as a healing practice.  Once situated in the university, given its heritage of objective measurement, psychology was not entirely comfortable as a philosophical specialty. It looked for things to measure objectively and developed specialized areas of study—group behavior, human development, cognitive styles and the like.  And psychology began to spin out of the speculative orbit into a “scientific” enterprise.

A Frenchman, Arthur Binet, carried measurement oriented psychology into the public sphere. In 1904 he was commissioned to help determine how many and which primary school students would need special education.  He devised an age-indexed list of abilities, giving birth to the intelligence test and IQ, intelligence quotient, as its measure.

IQ, and the notion of it as genetically determined (and racially linked) quickly spread. That idea was seized upon by Cyril Burt in England, and H. H. Goddard in the United States in the first part of the century, and more recently by Herrnstein and Murray in their controversial The Bell Curve. The link between intelligence and eugenics—how to improve the human race—Is complicated and problematic, but not central to Psychology’s story

World War I and II intervened, changing the course of history and of psychology.

Rapidly raising armies required the American government to assess inductees’ suitability for military service. University psychologists, trained to measure intelligence and other skills, were pressed into service, giving tests to evaluate trainees and guide their placement in the war effort. Eventually, these applied psychologists began to find employment in the Veteran’s Administration and in the state institutions for the mentally ill or disabled. 

As WW II unfolded, Nazi Germany identified Freudian psychoanalysis as a “Jewish Science,” driving psychoanalyst refugees to America.  In the mid-twentieth century, psycho-analysis became, albeit until the rise of psycho-pharmacy, the queen of American psychiatric therapies. Intelligence testing, already identified as the purview of psychologists, was supplemented with personality testing. Universities began to train psychologists in giving paper and pencil tests for vocational and diagnostic classification and “projective” tests, like Rorchach’s Inkblot test and Murray’s Thematic Apperception Test, designed to permit inferences about unconscious motives and conflicts. 

Tensions emerged in university programs training of these applied psychologists—now called clinical psychologists— magnified by psychology’s academic origin. The university teachers of clinical psychologists were required to earn pay and promotion on the basis of publications and grant-supported research. In other words, competition for university resources pitted academic psychologists against the “hard” sciences, and required academic psychologists to demonstrate their worth, based on criteria transplanted from the fields against which they were competing. 

 On the other hand, their students needed to learn how to provide a help to clients and customers in the form of diagnostic and treatment services. Concretely, academic psychologists had to do experiments and publish the results. And they wished to teach their students, who were looking forward to providing clinical services, to do the same—do experiments and publish the results—in order to have a cadre of research assistants. Training in how to do research took priority because of the obvious value of research assistants to researchers. And there was a further constraining circumstance.  Due to the practical and moral difficulties of imposing strict experimental controls on human subjects, quasi-experimental and multivariate models came to characterize psychology’s scholarly journals and became the research mode in which graduate students were trained.

There were attempts to deal with the conflict between research and applied training.. David Shakow introduced the scientist-practitioner model at the 1949 Boulder conference on the training of clinical psychologists. A follow-up 1965 conference in Chicago emphasized the importance of clinically trained full time faculty being responsible for university and internship training in clinical psychology. The American Psychological Association’s Education and Training Board incorporated the recommendations of the Chicago conference into its standards for accreditation, and federal agencies, including the VA, made APA accreditation a requirement for funding. 

But as funding dried up, as Professor Wright’s cri de coeur indicates, the conflict between research and clinical priorities festered.

Profoundly unfortunate results ensued.  One is the propagation of a cripplingly truncated view of scientific inquiry in psychology.  Scientific inquiry in university departments is operationally defined as establishing the statistical probability of the truth of an hypothesis. Little or no attention is given to systematic observation and subsequent inference in the formulation of hypotheses. Absent the nourishment of inference, psychological theory building cannot flourish and hypothesis testing can become a trivial ritual.

Secondly, discomfort with graduate training that focuses on an attenuated model of scientific rigor at the expense of hands-on experience with patients has stimulated the development of proprietary doctoral programs of the sort that beg the comparison that Dr. Wright protested.

Not only that, but clinical psychologists, having found employment in fee for service, insurance compensated practice or in institutional settings, must seek ways of demonstrating the worth of their work, the value of their services. That urgency finds expression in a current mantra of “evidence based approaches.” But what is offered as evidence are data generated by the impoverished model of science just described. 

Perhaps the saddest and most unfortunate outcome may be this. Curiosity about human nature is central to being human, and for that reason, almost always and everywhere, introductory psychology is one of the most popular of undergraduate courses. Curiosity about human nature is also central to the liberal arts.  But eschewing its philosophical roots, and confined by the attenuated model of science described above, introductory psychology courses in the public and private non-profit schools present students with accounts of the procedures and products of the truncated approach described above: quasi-experimental studies of social, cognitive, developmental, and their variants. 

The result is that students hungry to explore what it means to be human are deprived. And general education in the liberal arts is diminished.