Presidential Column

“It was the best of times, it was the worst of times…”: Navigating the paradoxical current state of clinical psychology

By Jonathan S. Comer, Ph.D.

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Although Charles Dickens wrote the seemingly contradictory opening lines of A Tale of Two Cities about the lead-up to the French Revolution, these renowned words also apply to the current tensions and state of our field.

It was the best of times: The past 40 years have witnessed remarkable scientific advances that have firmly established clinical psychology as a sophisticated and rigorous discipline. Innovations in intervention science, progress in the formal specification of clinical strategies, and increasingly refined clinical trial methodologies and data analytic techniques have collectively led to a proliferation of evidence-based psychological treatments for a wide range of well-defined mental disorders. Research has demonstrated how very successful psychological treatment methods can be, and has begun to examine the underlying mechanisms responsible for their success.

It was the worst of times: To date, the remarkable advances in clinical psychological science have not yielded a meaningful public health impact. The vast majority of individuals affected by emotional or behavioral problems do not receive any mental health care. Among the minority of affected individuals who do receive care, median delays in treatment initiation after initial onset of problems often spans several decades. Geographical shortages in the mental health workforce, racial and ethnic disparities in care, stigma-related concerns about visiting a mental health facility, lack of parity in mental health coverage, and transportation obstacles all interfere with the availability, accessibility, and acceptability of mental health care. Long waitlists and high staff turnover at underfunded mental health facilities further slow the speed of service delivery, and limited success in the dissemination of evidence-based treatment practices has constrained the quality of care typically received. When our most well-supported treatments are successfully implemented in everyday settings, clinical outcomes rarely outperform usual care. Further, treatment-related symptom reductions do not always translate into improved patient functioning or quality of life.

Being right, versus having reach and relevance – can clinical psychology have it all? As clinical scientists, perhaps we have clung a bit too tightly to beingrightatthecostofpursuingreachandrelevance. Intervention science has historically prioritized internal validity over external validity. Targeting defined symptom clusters with highly-specified treatment protocols under tightly controlled settings with selected/recruited samples has afforded powerful causal conclusions about the impact of psychological treatments. When a tightly controlled clinical trial demonstrates superior outcomes of a psychological treatment over a control condition, we are able to determine that it was the psychological treatment itself, and not other extraneous or confounding factors, that was indeed responsible for the successful outcomes. We can confidently conclude we were right about the efficacy of the psychological treatment. Such rigorous demonstrations have been—and continue to be—essential in establishing clinical psychology as a rigorous science, validating the heroic work of frontline practitioners, and supporting the tremendous value of psychological services in the context of less-than- favorable reimbursement/payer decision-making.

Given the strength of our science and the extent to which its rigor has allowed us to conclude that we are right about treatment effects, it can be tempting to approach non-replications with skepticism and even scorn. When a specific treatment has been supported in numerous clinical trials and then fails to outperform a control condition in a new trial, we appropriately question whether the new trial implemented the treatment correctly, whether participants received the treatment as intended, whether outcomes were measured correctly, whether participants were appropriately screened, and a host of other key factors. Sometimes we even question whether there may have been a level of bias in the design or interpretation of the new trial. These are all important academic questions that can help account for unexpected findings. But none of these questions probe the treatment itself or its potential lack of generality across alternative contexts. When we know we are right, we tend to look outward, not inward, to explain the unexpected.

When the “new trial” is everyday mental health care, being right is not enough. Being frustrated with those who fail to replicate our rigorous findings is misguided when the (non)replicators are in fact the very populations of providers and patients to which we are trying to apply our work. Explaining poor uptake, satisfaction, and outcomes in terms of how positive the effects could have been had things only been set up differently is relatively futile when pushing up against the realities, limitations, and constraints of our existing mental health care system, patient preferences, provider capacities, and implementation feasibilities. Sometimes our field comes across like a physicist with a laboratory on the surface of the moon who has repeatedly and elegantly demonstrated how long a baseball can remain in air after beingtossed up. The measurements and predictive models may indeed be perfect, but they nonetheless lack relevance to the realities of mechanical relationships on Earth. Bemoaning the downward force of gravity on the surface of the Earth will accomplish little.

In recent years, we have seen increasing investments in the development and evaluation of treatment innovations in the actual contexts in which they are to be ultimately applied, pragmatic clinical trials, and hybrid effectiveness-implementation studies. These have been critical steps for optimizing the potential reach and relevance of our work, forcing us to confront the realities and constraints of our mental health care system, provider capacities, and patient preferences and valued outcomes at the earliest stages of evaluation. In addition, some of the most exciting unfolding innovations in clinical psychology are technology-based strategies that leverage passive sensing devices and machine learning algorithms to monitor and directly intervene upon previously inaccessible aspects of human functioning. Such “Just-in-Time Adaptive Interventions” (JITAIs) can afford unprecedented reach into the everyday lives of our patients and can provide opportune smart promptsandrelated“micro-interventions”inmoments of maximal relevance. Advances in micro-randomized trials (MRTs), in which individuals are randomly assigned to alternative micro-interventions (e.g., smart prompts) hundreds or even thousands of times across a study, are providing rigorous methodologies with which to test these promising JITAIs. Along these lines, I’m excited to share that this Spring one of the Division 12 presidential taskforces I initiated on technology-based treatments will be holding an all day in-person meeting to make progress on developing standards for appropriately evaluating behavioral intervention technologies.

Perhaps the most essential front in improving the reach and relevance of clinical psychology pertains to improving the diversity, representation, and cultural responsiveness of our work and workforce. Disappointing progress in this respect over the years has been one of the most disappointing failures of our field and a key obstacle to achieving a meaningful public health impact. As I complete my term as President of the Society of Clinical Psychology, I’m so very excited that Dr. Elizabeth Yeater is taking the reins and using her presidential term to squarely focus on the extensive and much-needed work to be done improving the diversity, representation, and cultural responsiveness of our work and workforce. This is exactly the direction in which we need to be moving as a Society and as a field.

If our field continues to navigate forward on our most recent path of simultaneously embracing both rigor andrelevance, I expect that the tale of clinical psychology will soon come closer to approximating “a tale of one city” – one in which realities, constraints, and practical obstacles are directly informing and shaping our science, and in which our scientific progress is indeed achieving a meaningful public health impact.