by David A. Sbarra, Ph.D., University of Arizona & Howard Berenbaum, Ph.D., University of Illinois at Urbana-Champaign
Let’s begin with a thought experiment. Close your eyes and try to forget everything you know about what clinical psychologists do and how they are trained. Forget clinical hours. Forget internship. Forget classes, requirements, advisors, and advisees. Just let your mind focus on one incredibly important but ugly fact: As a scientific field and an applied profession, clinical psychology has not made, over the last 60 years, a serious dent in the incidence, prevalence, or burden of most forms of mental health conditions (Kazdin & Blase, 2011). Now, with your mind clear of everything you know about clinical psychology training, how would you set out to significantly reduce the burden of mental illness? What can you imagine the clinical psychologists of the future doing to achieve this goal? And how might these future clinical psychologists be trained? … OK, time is up… How do we go about modernizing the field of clinical psychology? Where do we begin? What should we do now?
Recently, a large group of co-authors published a paper in Clinical Psychology: Science and Practice titled “Accelerating the Rate of Progress in Reducing Mental Health Burdens: Recommendations for Training the Next Generation of Clinical Psychologists.” Although we didn’t sit around a room with our eyes closed engaging in the same thought experiment, the essence of the paper is quite similar. We began by checking all of our assumptions about training in the field and asking why it is that we are still, more-or-less, doing the same thing we’ve done for the last 60 years. What prevents us from making a meaningful dent in the burden of global mental illness? Answering this latter question forms the basis of our paper and how we envision a forward-looking, responsive, and modern training in clinical psychology.
The Backstory: How Did We Get Here?
Before describing some of the proposals in our paper, we wish to share a little about the road we have traveled thus far. Our paper emerged from a 2017 meeting of the Coalition for the Advancement and Application of Psychological Science (CAAPS; https://www.caaps.co/caaps-mission), whose guiding principles include “Give priority to the public’s welfare over all other competing interests (e.g., guild, personal).” CAAPS created a workgroup to make recommendations about how to train clinical psychologists to best serve public health. Accordingly, our paper started with a blank slate. We charged ourselves with attempting to rebuild clinical psychology training from the bottom up — encouraging a training model that is most relevant for this particular moment in time. Because we were a large group, we did not always see eye-to-eye. In fact, the paper reflects months and months of conversations and compromises. From the outset, we wish to acknowledge that our paper does not have all the answers. In fact, it may turn out not to have any of the answers, but we can no longer avoid our shortcomings (as a scientific field and as a profession). Our paper is a call to action, and the action we seek is a large-scale national conversation about what we truly need to accomplish in order to improve mental health, both in the United States and, if possible, around the globe.
The Essence of Our Proposal
The central idea of our paper is that the current training model in clinical psychology, in which clinical psychologists are expected to achieve expert-level skills in service delivery via doctoral training followed by an internship year, is outdated. Our thesis is simple: We have failed to make a meaningful dent in the burden of mental health problems largely because clinical psychology currently focuses primarily on disease management rather than health promotion. Our system of training relies exclusively on one model in which many of the central training activities are geared toward preparing students for internships that focus almost entirely on entry level practice (i.e., the provision of psychological assessments and treatments for people who have already developed mental health problems). Think how much time and energy in doctoral education is spent preparing for entry level practice— hours and hours of clinical placements preparing for a year-long, full-time internship.
Our re-envisioning of graduate education in clinical psychology begins with making the internship post-doctoral. As we describe in our paper, all doctoral students will need a minimum level of clinical competency in the assessment and treatment of common mental disorders, but a clinical pathway, which involves a traditional internship, will become just one of many possible career pathways. The removal of this requirement frees students and programs to focus their time on an almost limitless range of other activities, many of which will be dependent on local expertise and available resources. If a student wishes to pursue a primarily applied, clinically-oriented career, internship is available as a postdoctoral trainee; if a student wishes to pursue a clinically-oriented treatment development research program, internship may still be relevant and will be available to them as a postdoctoral training activity. In this sense, an essential part of our hypothesis is that the freeing of time and resources (from the pursuit of internship preparedness and even the very need to do an internship) will create opportunities for the kind of innovative training, education, and research experience that can propel the field and profession forward into the 21st century.
The Road to Come
The ideas in our paper are mere proposals—they’re a starting point, a place to begin discussions, and likely just a small representation of many excellent ideas that can help advance the field. What comes next? This largely depends on you and the ways in which people engage with the ideas in the paper. We need a national conversation about the ideas in the paper and how to better serve the public via our doctoral-level training. A large national conversation will emerge from smaller happenings, beginning with the discussion forum on the CAAPS website (https://www.caaps.co/caapsdiscussion/feedback-on-the-new-proposed-model). We invite all manner of comments on this forum from every corner of our field—don’t hold back, share your thoughts! Ultimately, it will take a lot more than an online message board to advance the field. We need students, faculty, professional societies, and our two main accrediting bodies to sponsor conferences, hold working meetings, and coordinate special issues of journals. We need people in all corners of the discipline to think about, entertain, and debate new ideas. In short, we need stakeholder engagement, including from members of the public, especially from members of the public with lived experiences of mental health conditions and those who advocate for them.. If our paper is to be remotely successful, it has to galvanize action. Don’t let that action be another person’s responsibility. Jump into the fray. Take a leadership role. Organize discussions. Summarize the big themes. The future of the field depends on what we do next, and because today’s students are tomorrow’s early career clinical scientists and professionals, we urge you to act now and to promote the changes you feel are most essential for the advancement of our field.
Let’s conclude with another thought experiment. Imagine the field of clinical psychology 20 years from now. In your mind’s eye, what does training look like? How has it changed? What did you do to make that change happen?
Disclaimer: The views and opinions expressed in this newsletter are those of the authors alone and do not necessarily reflect the official policy or position of the Psychological Clinical Science Accreditation System (PCSAS).