I began graduate work in psychology 50 years ago. Psychotherapy, undefined then and undefined now, and psychometrics were the primary, almost only, tools of the clinical psychologist. As the century closes, it is interesting to contemplate the changes in what we call psychotherapy.
In the first half of this century, there was psychoanalysis. This brilliant contribution of Freud set three important precedents for the future of psychotherapy. First, it identified human information processing as the critical dimension of mental and emotional disorders. Second, it implied that there was one comprehensive treatment solution, psychoanalysis. Third, it established a soft science rather than a hard science base to the field–the id, ego, and superego can never be seen under a microscope. The way clinical psychology has responded to these precedents has defined it, characterized psychology during the second half of the century, and set the stage for the future.
During World War II, probably the most impactful event in the history of clinical psychology, four-year analyses and five patients per analyst did not serve the practical need to return shell-shocked troops to the front lines in a timely fashion, or to treat thousands of service-connected veterans. Academic psychologists were recruited, and were relatively successful, with deconditioning, behavior modification, and other information-driven but non-psychoanalytic approaches. Seeing psychology’s wartime impact, the Veterans Administration offered to subsidize the training of Ph.D. psychologists and give them staff positions in its medical facilities. With that offer, the Ph.D. became the defining professional degree, and an internship in a medical facility became the modal practicum experience.
The field of clinical psychology thus gained momentum as the first half of the century ended, a vigorous but intimidated bastard offspring of jealously arrogant Mother Academia, secure in her ivy covered walls and disdainful of practical applications, and demigod Father Medicine, arrogant and superior as an entitlement life style, expert in practical applications but ignorant of behavioral science.
By 1950, other approaches to psychotherapy had begun to evolve. Multiple variants of Freudian analysis had arisen. Carl Rogers was popularizing Client Centered Therapy. The guidelines of Behavior Modification were developing. Other approaches, including EST and Primal Scream, were being proposed. Each (at that time) shared with Freudian psychoanalysis the assumption that it alone was the one and only true psychotherapy, suitable for all problems. All were based on information processing as the effective change agent. All were underwritten by soft science rather than hard science conceptualizations. Even Behavior Modification, which claimed a hard science base, refused to look for structural mechanisms within the black box and clung exclusively to its circularly defined and mechanistically unanchored stimulus-response-reinforcement explanation. None of the approaches undertook the hard science search for underlying truth of the nature of emotional disorders, wherever that search might lead. Both then and now, and in spite of its scientist-practitioner commitment, clinical psychology left that effort to the academicians and medical school scientists.
Clinical psychology became a popular graduate offering. APA-accredited programs began exposing students to experts in several psychotherapy approaches. That exposure to multiple gospels created confusion as well as enlightenment. Students, of necessity, mishmashed a semi-eclectic, usually rather personal, survival mode for practice. For example, an active listening Client Centered style might be combined with directive probing, relaxation techniques, and behavioral contracts to address anxieties growing out of repressed traumas. These early newly-minted clinical psychologists each became his/her own expert, each a unique guru. Types of psychotherapy proliferated. A patient referred from Cleveland to San Diego played a roulette wheel of what to expect at the other end. Therapies ranged from the most conservative to encouragement of open marriages, LSD, and free love. And it was all called psychotherapy.
Two trends destroyed the anarchy. Statutory recognition was almost universal by the 1970s. Public recognition brought with it public regulation and the national licensing exam, both of which exerted strong pressures toward conventionality and predictability. During this same period, fee for service was replaced by third party pay in medicine, and psychology coat-tailed. While managed care lay a couple of decades in the future, third party payers nevertheless brought more constraint and consistency than existed when the contract was solely between the psychologist and the client.
With these changes, psychotherapy began to conform to a professional standard of practice, nebulous though that was, and to reflect less the idiosyncratic ideas of the individual therapist. A referral from Cleveland to San Diego could almost be made with some confidence of what services would be offered at the other end. At the same time idiosyncrasy was being curbed, so too was the one-size-fits-all approach. Experience had begun to differentiate, somewhat, what worked when and which approach served what problems.
These middle years were a nostalgic age for clinical psychology and psychotherapy. We tended to know what we were doing and what our colleagues were doing. Third party pay was dependable, and statutory accreditation provided respect. Psychiatry was remedicalizing, largely leaving the field of psychotherapy to psychology. Social workers, counselors, and psychiatric nurses were not heavily into the field yet and were largely non-competitive. We were effective professionals and masters of our own fate, or so it seemed.
Then came medical cost escalations and the cultural demands for economic accountability. Psychiatry’s remedicalization had anticipated this trend but psychologists were caught flat-footed. Managed care replaced third party pay. Medical necessity replaced client request. Mental health problems, especially psychology’s bread and butter issues of the worried well and the walking wounded, became the sacrificial lambs to the cause of cost containment. So, too, did psychology’s cognitive approach to mental and emotional disorders, an approach that third party payers set aside as being too inclusive, too expensive, and not medical. It was replaced with conditions that could be defined by biologic aberrations and treated by medication. When psychotherapy was medically indicated, lesser trained and less expensive counselors and social workers were getting credentialed and were being treated as the Wal-Mart bargains to psychology’s alleged Tiffany prices. The gates of Eden were opened and psychology was being unceremoniously kicked out.
As the century closes, we have lost the comfort of a one-approach-fits-all philosophy, and are struggling to find techniques that fit marketplace opportunities. We are finding psychotherapy, as an information-processing based activity in the weakly supported mental health arena, to be an endangered economic species. We still do not seem to have a clue that our soft science approach is philosophically challenging but very bad preparation for the future. We cannot state with rigor what is an emotion, unconscious process, personality, or a host of other fundamental constructs on which we base our field, or why our Ph.D. is any better for the client than is the counselors MA.
The struggle for market place opportunities should be constructive. What we do is expensive, and should earn its own way. As we struggle with how to earn our way in the impartiality of the marketplace, we will probably discover skills and expertise and potential that we have long ignored but need to use. Our Ph.D. or Psy.D. does make a difference, that should begin to tell early in the new century.
Similarly, the managed care emphasis on biological rather than information processing mechanisms should help in the long run. Information processing is just as biologically anchored as is neurotransmitter biochemistry, indeed is the manifest expression of and raison detre for it. Information drives biochemistry, just as biochemistry underwrites information processing. Mental and emotional problems fundamentally consist of faulty translation of incoming information into behavioral responses, such as to produce dysfunctional behavior. It should not take much playing of the exclusive medication game for the public to discover that much mental and emotional disorder is software, not hardware, driven. For such conditions, medication may oil the wheels but will not write the proper code. For many other conditions, medication will be unable to correct the biochemical aberration. A software work-around will be needed, and can often be provided by appropriate psychological help. Perhaps most critically, the public and professional psychology both may discover that the walking wounded and the worried well also hurt, need and will pay for help, are far more numerous than the seriously mentally ill, and are the natural clients for a truly psychologically based profession, with or without prescription privileges.
As for the problems of clinical psychology s artsy-craftsy philosophical soft science underpinnings, in which precise characterization of psychological problems and measurement of any kind, including outcome measurement, is almost non-existent, change seems to be at best a faint glimmer on the horizon of the new century.
David A. Rodgers, Ph.D., an activist in psychology for a half century, helped author the psychology licensing law in Ohio, has served twice as president of the Ohio Psychological Assn. and is now retired from the Cleveland Clinic Foundation. He can be contacted by email at DARODGERS@aol.com