Clinical Psychological Science, Dissemination, & the Society of Clinical Psychology
By Terence M. Keane, Ph.D.
Over the past two years as President-Elect and President of the Society of Clinical Psychology (SCP) I’ve encountered multiple complex problems facing our profession. The Internal Report on torture was certainly complex and continues to adversely affect the APA; yet an ongoing problem of equal importance for clinical psychology is the growing distance between the new knowledge generated in academic psychology and the needs of practitioners in health care settings across the country and the world. Practicing in clinical settings (Medical Centers, Psychiatric Facilities, Private Practice, the Department of Veterans Affairs, Rehabilitation Sites, and other clinics) is changing rapidly as the healthcare system experiences important directions secondary to the affordable care act or Obamacare. The pace of science and particularly clinical science is by its very nature slow and unable to keep up with the demands of this change. Science moves gradually and scientific findings take about sixteen years or more to permeate healthcare practice. We are facing a serious conundrum. Can academic science in psychology influence the delivery of psychological health care? By the time grants are funded; data collected; analyzed; written and published will the findings be relevant to clinicians? How do we proceed to address this challenge for those of us actively engaged in clinical science?
The virtue of working as a clinical researcher in VA is that one is never very far away from the complexities of clinical care delivery, the changing nature of the patients seeking care from the healthcare system, and the demands for clinicians to see more and more patients with efficiency and effectiveness. When speaking to clinicians who are predominantly involved in clinical care and teaching, it is easy to become humble about the most recent exciting findings stemming from my amazing colleagues in the National Center for Posttraumatic Stress Disorder. How do our increasingly molecular findings (at the behavioral and genomic levels of analysis) affect the day to day work of clinicians practicing in America’s contemporary healthcare system? My fear is that our scientific findings do not have the impact we desire. The stunning findings of Brian Nosek of University of Virginia that two-thirds of social psychological and experimental studies with humans do not replicate adds to the burden of those of us in clinical psychology to demonstrate that the work we do can improve the mental health in this country and does contribute to enhancing the practice patterns of our students and colleagues who work in these many clinical settings.
Too frequently, I hear that the problem is with the practicing psychologists in the community. If only they paid more attention to the scientific literature. I don’t believe this and I never did; surely this growing gap between academic researchers and practitioners is a shared responsibility. As someone involved in clinical psychological science in a healthcare setting for nearly forty years, I am well aware of the pressures on clinicians and the pressures on academics. More patients need to be seen by one group; more papers and grants need to be generated by the latter group. Yet, it is my belief that the burden is on those of us in clinical research to reach out to those in practice to make the scientific work we generate readily and easily consumable. How might we do this? Such is the challenge in front of us.
Chris Fairburn and David Barlow, respectively, are turning to principles of therapy that are transdiagnostic in nature. This seems eminently reasonable to me; practitioners cannot have multi-module manuals guiding the care of every patient they see. The position by Fairburn and Barlow is that there are generalizable principles that transcend the specific nature of the problems observed in a given patient and that these evidence based principles are what need to be taught and practiced. Evidence is accumulating on this approach, but the devil is always in the details. It will take considerable time to understand if this transdiagnostic approach to human problems will be successful. I am rooting for each of these investigators, because the growing number of diagnostic problems and treatment modules for each of these problems makes for an impossible task for practitioners. Can it be a surprise to any of us that those in practice cannot keep up with the proliferation of treatment manuals? With the newest approaches to psychological and neuropsychological assessment?
Among the most gratifying aspects of my years of service to SCP was watching the team of people led by the indomitable Deb Drabick of Temple University to build a brilliant sequence of continuing education courses for our membership. Following the guidance of Past President, Gayle Beck, this Continuing Education Committee meets monthly to identify talented and capable speakers to deliver 90 minute webinars (for fifteen dollars!). This is an enormously successful effort that will continue well into the future. Perhaps this is one avenue for real time delivery of new information to practitioners? But the number of attendees isn’t there yet to think we are positively affecting clinical practice in the country. Of course, it is always one practitioner at a time, with the promise that we will eventually get there. Maybe.
In a recent meeting of the SCP Board of Directors one member who served for many years on the faculty of one of the most prestigious clinical psychology programs in the nation opined that even at that outstanding institution more than sixty percent of the graduate students ultimately found their way into clinical practice rather than conducting clinical science. I thought back to my own graduate training program that was very strong in clinical science and counted an even lower percentage over the four years that I attended Binghamton University. Three out of four were either exclusively or predominantly in clinical practice. Only one-quarter were in academic medical centers doing research or in Departments of Psychology doing research and/or teaching. Is there something imbalanced here in the focus of our training programs in clinical science?
SCP and SSCP have grappled with the problems of Continuing Education approvals by the APA for decades. This past year saw progress in doing something about the issue of giving APA credit for educational programs that strayed very far from our evidence base in clinical psychology. With Bethany Teachman in the lead, a small committee of people from SCP, SSCP, and ABCT generated a small list of candidates to serve on one of the key APA oversight Boards. Some were, thankfully, elected for three year terms. One thing emerged in service on this ad hoc Committee of the leaders of these three organizations that struck me as fundamentally crucial to our future: the academic Departments of many of the people serving on this committee were not sponsors of APA Continuing Education credits for their communities. When I pointed this out, people’s response was that it was very expensive and time consuming to run a CEU program. Frankly, this disappointed me greatly. Is there not a part of the mission of Departments of Psychology to work with members of the discipline in the communities in which they reside? If not these departments, then who will provide this leadership?
In the past two years, the alumni of Binghamton University’s Clinical Psychology Training Program created a lecture fund to honor long standing Director of Clinical Training and Director of the Departmental Clinic, Stephen A. Lisman, Ph.D. The Lisman Lecture in Clinical Psychology is to bring outstanding clinical psychologists to the Department for an annual lecture that will enhance the training of the graduate students while bringing together the faculty in the program with clinical psychologists who are practicing in the community. This past autumn, Marsha Linehan, Ph.D. of Seattle delivered an all-important lecture on the science of suicide, an area in which she’s made unique and important contributions clinically and scientifically. More than two hundred fifty faculty, clinicians and students gathered in one of the lecture halls on campus to learn from a premier clinician scientist. The Lisman Lecture met one of its key goals: to bring faculty, students, and clinical psychologists from the community together in an educational setting. As a profession, we need more integration of our clinical psychology faculty with members practicing in our communities. Clinical Psychology Programs will benefit from the integration, the community practitioners will benefit from the faculty members, and the mental health care provided in the communities across the country may improve. Binghamton University’s clinical psychology program has reached out into the surrounding community in an effort to provide demonstrable leadership. Many more departments are needed to do the same. Is it possible to start a dialogue about this? Is there room for this type of effort in our most prestigious clinical psychology training programs? Will faculty who do this be supported, rewarded, reinforced for engaging the profession in the communities in which they reside? We do need the dialogue.
Finally, the era of dissemination and implementation science is upon us in clinical psychology. Large scale healthcare systems in America, the United Kingdom, and Australia are engaging in systematic efforts to educate and train clinical psychologists in specific evidence based interventions. VA led the way with efforts at dissemination of psychological therapies in this country under the leadership of Toni Zeiss, Ph.D. who was the first psychologist to head the VA’s Office of Mental Health in that national system of healthcare. Brad Karlin, Ph.D., the incoming President of SCP, was fundamental to all of the efforts in VA while he was in a leadership role in Washington. There were and still remain many barriers and obstacles to dissemination at the practitioner level, the healthcare system level, and the actual clinic level of analysis. Yet, researchers are now working hard to understand these barriers to delivery of evidence based psychotherapy and assessment. These efforts are now called Dissemination and Implementation Science; a new and important field of inquiry. The Society of Clinical Psychology is the natural home for Dissemination and Implementation Scientists in clinical psychology. We will begin to engage those actively involved in this growing area of psychology so that they can find a welcoming home in SCP to support their work, their efforts, and their future goals.
It’s been my sincere pleasure to serve as the President of the Society of Clinical Psychology for 2015. We surely have a bright future ahead of us and I personally look forward to contributing to the profession for many years to come.
Best of luck to Brad Karlin and to incoming President Elect and Boston University colleague, Michael Otto.