I recently replied to a list-serv request (from the Society for a Science of Clinical Psychology) concerning opinions about the future of the “clinical science” movement in psychology. The following represents my thoughts (edited and expanded from my actual response) on this topic.
1. How do you think the field of clinical science will be different 10 years from now?
Honestly, not much different. Scientists and clinicians are poised to continue to be rewarded by different mechanisms—and unfortunately, by not working with each other. As a result, things likely will remain more or less the same. Call me a pessimist, but I think I’m being realistic here: little progress will occur without structural change in which scientists are rewarded for working collaboratively in real-world treatment settings and/or our already burned-out and overburdened clinicians are rewarded to better incorporate science into their practice.
I do see at least a little more attention to these structural barriers than there was 10 years ago, so I suppose that’s some progress. But clinical scientists appear to be overly optimistic about the future. It is common for clinical scientists to prophesy that genetic and neuroscience research will save the day, and yet similar claims have been made for decades. In spite of billions of research dollars on genetic markers, neuro-imaging, and so forth, remarkably little of practical and clinically sustainable value has come to fruition. (Some have argued quite persuasively that the progress in practical terms has been almost nil; see, for example, the work of Laurence Kirmayer.) How many more decades of promissory notes will be given?
I am reminded of the wild optimism of artificial intelligence scientists in the 1950s. In the Dartmouth conference of 1956, many AI scientists “predicted that a machine as intelligent as a human being would exist in no more than a generation and they were given millions of dollars to make this vision come true. Eventually it became obvious that they had grossly underestimated the difficulty of the project” (Wikipedia, “History of Artificial Intelligence”). Moreover, they also had flawed conceptions of human intelligence, as philosopher Hubert Dreyfus and others have shown.
Likewise, I fear that many in the clinical science camp underestimate the complexities of psychopathology and clinical practice, as well as have flawed conceptions of clinical practice. I do not have the time to outline this argument here, but there are at least three ways in which questionable assumptions (i.e., assumptions with little if any evidence to support) are made: (a) that psychopathology is fundamentally biological in etiology, along with the corollary search for a “holy grail” cure through biological / pharmacological / technical means (thereby allowing many aspects of psychosocial practice to be bypassed); (b) that clinical decision-making can be collapsed to techniques and algorithms, through which the best available research can be readily identified and seamlessly applied with minimal attention to clinical expertise and client context (thereby allowing for clinical training to more closely mimic the “book learning” that the academy knows best); and (c) that the organizational infrastructures in which most clinical practice takes place can—with a little pressure or shaming—be made to resemble the artifices of the clinical laboratory.
Whereas many clinical scientists might see slow progress as a result of the complexity of the brain and the stubbornness of clinicians (for which there is certainly some truth), I am raising the possibility that progress will continue to be thwarted due to faulty or at least oversimplified conceptions of psychopathology, clinical practice, and human service organizations. Moreover, I would be willing to wager that these problematic assumptions endure not because of evidence to support them, but because they are also assumed by major decision makers (e.g., funding sources and journal editors) who are inoculated from or not accountable to critical voices (not due to lack of intellectual merit of the critiques, but because these voices happen to be punished by funding agencies and “high impact” journals). I don’t mean it’s a conspiracy; it’s simply capitalism: A market (funded by college students, the public’s taxes, and increasingly large corporations) allows for journals to keep publishing, universities to keep hiring, and funders to keep funding—but with remarkably little accountability for whether their fruits impact the world outside of the walls of universities and the most capitalist of enterprises (e.g., Big Pharma). It is a perfect storm for scientific efficacy to be conflated with relevance.
I’m not a total pessimist. There has been increased humility among clinical scientists in the past five years, along with less demonizing of practitioners and more recognition of the complexities of implementation. I have some recommendations below that if followed would make me even more optimistic.
2. How can the field of clinical science grow in exciting directions?
We’ve heard of the “decade of the mind” and the “decade of the brain.”
I would like to see a “decade of clinical practice.”
We know remarkably little about clinical practice, both in terms of clinical decision-making and the infrastructures in which most day-to-day practice occurs. And yet we are eager to bring home fancy furniture when we’ve neglected to measure whether it will fit in our living rooms. For example, in my area of substance use disorder treatment, although the vast majority of practice is done in group settings (and that’s not going to change anytime soon), the vast majority of research (and evidence-based treatments) is done with individuals. Everyone who has worked with groups knows that it is very different from working with individuals; it is not an easy transfer from manuals and materials designed for work with individuals. To add to the complexity further, many if not most groups for substance use disorders are open-enrolling, which would greatly complicate use of a treatment manual that builds on itself for a finite number of sessions. And yet, in spite of billions of research dollars spent on addictions, this fairly obvious disconnect between research and practice has hardly been recognized; we pretend it doesn’t exist.
How has this happened? Because we have underestimated the complexity of clinical practice. We could learn from our colleagues in anthropology and sociology (some of whom do fascinating treatment research that is too often ignored by psychologists and “harder” scientists) who take the time to chart complex human and organizational behavior in painstaking detail, using innovative ethnographic and qualitative methods. I suspect one reason for our insularity is a narrow approach to research. A decade of clinical practice, then, would require clinical scientists to open up their epistemological and methodological toolboxes more widely.
A decade of practice would also mean drawing closer to clinicians and clinical work, not further apart. My clinical experience and ongoing empirical data collection suggests that most clinicians are very willing to incorporate more science into their practice but (quite rightly) feel that there is not enough support for them to do so. We simply do not have the luxury of building an entirely new treatment infrastructure, at least not any time soon.
Finally, a decade of clinical practice would mean moving beyond lip service in our attention to individual and cultural differences. I am happy to be corrected otherwise, but my experience is that many clinical scientists give little concern beyond lip service to cultural diversity, sometimes pejoratively labeling such as “advocacy.” In this regard, they are seemingly ignorant of the scientific research that ought to impel them towards more concern with social justice. This attention may muddy the walls of the academy, but it’s only because these walls were too white to begin with.
I am curious about what others think about these brewing thoughts and concerns. This post is intentionally provocative, and it’s certainly possible that I am overstating some things. I realize, too, that much of what I say is “opinion” and “mere hypotheses.” To this I would add, however, that what I am disputing are also opinions and hypotheses (e.g., the three questionable assumptions I addressed above), and ones with little supporting evidence. But in any case, I am sincere when I say that I would love to hear your comments – especially your disagreements. The Division is trying to get this blog up and running, so I am sure it would welcome reply posts as well.