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Note. Psychology is both a science and a profession, and these two aspects of the field sometimes come into conflict. This paper was presented at a conference celebrating the centennial of clinical psychology, sponsored by the University of Pennsylvania, held in October 1996. An earlier version was presented at the annual meeting of the American Psychological Association, New York, August 1995, as part of a Presidential Panel, "Healing the Science-Practice Wars", cosponsored by Divisions 42 (Psychologists in Private Practice), 12 (Clinical Psychology), and 29 (Psychotherapy). A fuller, edited version was published in a volume, The Science of Clinical Psychology: Accomplishments and Future Directions, edited by D.K. Routh and R.J. DeRubeis (Washington, D.C.: American Psychological Association, 1998).

 

Integrating Science and Practice 

in an Environment of Managed Care

 

For clinical psychology, at least, there is no conflict between science and practice.

Clinical psychology is an applied science, like engineering; if it is an art, it is an art like architecture.

Psychotherapy in general, and clinical psychology in particular, are institutions under attack.

Clinical psychology has an opportunity to shape managed care.

Like it or not, managed care (or one of its close relatives) is here to stay.

References

 

The relations between science and practice within psychology are currently strained, but this celebration of Lightner Witmer and the Fernberger Psychological Clinic reminds us that they were not always so, and they need not be so in the future.  This is because:

For clinical psychology, at least, there is no conflict between science and practice.

At the beginning of clinical psychology, 100 years ago, science and practice were thoroughly intertwined. When Witmer established the first psychological clinic, in 1896 at the University of Pennsylvania (Witmer, 1907/1996; see also Benjamin, 1996; Fagan, 1996; McReynolds, 1996; Routh, 1996), William James (1890/1980) had already published his seminal Principles of Psychology, making extensive use of clinical material in his chapters on consciousness and the self. And even before Ebbinghaus (1885) made the nonsense syllable famous, Theodule Ribot (1884) had published Diseases of Memory, attempting to derive basic psychological principles from observations of clinical cases of amnesia.

The modern field of clinical psychology had its origin in the years just after World War II, with the emergence of the Veterans Administration (VA) and the National Institute of Mental Health (for summary histories, see Hilgard, 1987; Humphreys, 1996; for enlightening personal histories, see Maher, 1992; Shakow, 1969). The framework for the new profession was provided by the 1949 "Boulder model" of the scientist-practitioner. In the early VA system, psychologists were mostly supervised by psychiatrists who had little research training, and whose viewpoint was essentially psychoanalytic. According to the Boulder model, which dominated clinical training for at least the next two decades, competence in general psychology, and in research methods and statistics, was essential to the training of clinical practitioners.

In the Boulder model, the whole point of clinical psychology was to put psychotherapy, psychological assessment, and ancillary procedures on a firm scientific base and to make sure that the scientists who were creating this base had contact with the living material of the field. Clinical practice was to be part of a dialectical enterprise, responding to and contributing to, advances in knowledge of basic psychological processes (Davison & Lazarus, 1995). Practitioners were supposed to be active researchers -- using the best techniques at hand but also actively engaged in improving these techniques. All practitioners were to be scientists, and while not all scientists were to be practitioners, at least there was a sense that scientists and practitioners were engaged in a common enterprise. As a result, training in clinical psychology culminated in the award of a scholarly degree, the PhD. Reinforcing the sense of common purpose, most clinical psychologists were employed in academic departments of psychology, medical schools, and state and VA hospitals, instead of in private practice.

All this began to change in the late 1960s and the early 1970s, as the Community Mental Health Centers Act of 1963 expanded the opportunities for the employment of psychologists. The community mental health centers, and the prospects of national health insurance, raised the further question of whether clinical psychology should declare its independence of psychiatry. When this question was answered in the affirmative, many clinical psychologists began to move into private practice in large numbers, and clinical psychology began a slow but inexorable shift away from the Boulder model.

The departure from the Boulder model has been exacerbated by recent shortages in academic positions, the further closing of inpatient facilities, and retrenchment in the medical schools -- which together have made the private practice of clinical psychology even more attractive as a career option. Moreover, the scientific community must bear some of the responsibility for this state of affairs: all too often, scientific psychologists have treated their clinical colleagues with benign neglect, to the point where, in many of our best departments, either clinical psychology does not exist at all or it has been segregated from the rest of the discipline (Beutler, Williams, Wakefield, & Entwistle, 1995). Either way, the effect has been to reduce the opportunities for interaction between scientists and practitioners to the detriment of each.

The idea of the scientist-practitioner has not been abandoned, but it is increasingly being ignored. Where in the years immediately following 1949 there was only one model for clinical training and practice, the recent Gainesville conference (1990) set out a number of alternatives to the Boulder model, some amounting to a pure practitioner model which emphasizes the acquisition of competence in specific clinical techniques, and the ingenuity of the individual practitioner in addressing the problems presented by the individual patient or client. In the pure practitioner model, research skills are deemphasized because most clinical psychologists do not have the time or opportunity, or perhaps the inclination, to engage in research. But that does not mean that science is irrelevant to practice or that clinical practitioners can safely avoid training in general psychology, scientific methods, and statistics. The fact is that clinical psychology derives much of its status, including its independence from psychiatry and its claim to third-party payments for services rendered, from the assumption that its practices are firmly based on scientifically validated principles and techniques. Thus, there is -- in fact, there can be -- no conflict between science and practice, so long as clinical psychology wishes to retain its identity, autonomy, and status as a profession.

This is not to say that there is no room for creative practitioners to go beyond scientific knowledge in constructing innovations. Systematic desensitization may have sprung from Hullian learning theory, but cognitive therapy had its origins in the creativity of practitioners (Ellis, 1962; Beck, 1967) who did not know anything about cognitive psychology -- not least because at the time they were making their innovations there was so little cognitive psychology to know. Clinical innovation need not slavishly follow developments in basic research and theory; sometimes, it stimulates these very developments, so that science follows the lead of practice and not vice-versa (Davison & Lazarus, 1995). Even so, the innovative scientist-practitioner adopts an essentially scientific stance in which enthusiasm for technique is tempered by a self-critical attitude, especially about pronouncements that appear unsupported by or incompatible with well-established scientific principles and in which case reports are followed quickly by properly designed and controlled studies of outcome or validity. Put another way:

Clinical psychology is an applied science, like engineering; to the extent that it is an art, it is an art like architecture.

Much has been said and written about clinical practice as an art, in which the individual practitioner employs intuition and creativity to address the needs of the particular individuals who arrive at the clinic door. This image, which derives from the notion of a "medical art", is accurate in some sense: it takes intuition and creativity to fill in the gaps between the general principles adduced by scientific research and the particular circumstances of the individual case at hand. But this intuition and creativity is not unconstrained: it is grounded in principles uncovered by empirical science. Like engineers and architects, clinical psychologists practice their art within the confines of what is sanctioned by scientific knowledge. Engineers put scientific knowledge to practical use: in order to build a bridge that stays up and carries traffic properly, the engineer relies on principles of physics and geology.

In order to build a bridge over a certain river, we must know the details of the soil mechanics, water flow, prevailing winds, topography, traffic usage, availability of labor and materials, and so on. When we consider all these, the total picture might not be like any other bridge that has ever been built. Nevertheless, none of the principles or assumptions that go into the final decisions could be made in contradiction to the laws of physics, economics, and the like (Maher, 1966, p. 112).

Similarly, architects exercise a great deal of creativity and ingenuity in designing buildings and fitting them to their sites, but in the final analysis the test of whether the architect has done his or her job is whether the building stands up and is livable.

To give an example that is perhaps closer to home for clinical psychologists, consider radiologists, who depend on the principles of anatomy and physics to locate and destroy tumors in cancer patients. Similarly, anesthesiologists rely on principles of chemistry and physiology to make sure that their patients feel no pain.

So clinical practice is based on, and constrained by, scientific knowledge. Then what is all this talk about a "science-practice war"? There is definitely a conflict between science and practice within psychology, but this is only a small part of a wider conflict, which is that:

Psychotherapy in general, and clinical psychology in particular, are institutions under attack.

To refer to psychotherapy or clinical psychology as institutions may seem somewhat odd, but that is what they are. From a theoretical perspective, institutions are socially constructed, ordered, routine-reproduced, programs, rule systems, or patterns of behavior. Marriage, sexism, academic tenure, the handshake, the army, and insurance are all institutions (Jepperson, 1991). They have rules that have often been constructed and implicitly, if not explicitly, accepted by their members, they operate as relative fixtures in their respective environmental contexts, and are accompanied by taken-for-granted accounts (Jepperson, 1991, p. 149).

Clinical psychology and even psychotherapy can be considered institutions because most people believe that they require some level of formal education and training and that they should be guided by accepted methods of operation. For example, professional organizations like the American Psychological Association (APA) have constructed formal rules about who may practice clinical psychology, what kind of training is required, what types of settings may provide such training, and about the appropriate professional conduct of individual practitioners. Not everyone may agree with the established rules that guide clinical training programs or that govern the practice of clinical psychology. However, very few individuals who seek to engage in the practice, or organizations who train or employ such individuals (such as departments of psychology), are willing to ignore the precepts of governing bodies such as the APA.

However firmly entrenched clinical psychology might be as an institution, it is apparent that outside forces are questioning its status and attempting to change the rules by which it operates. All social institutions are vulnerable to such attacks -- consider the Roman Catholic Church after Vatican II, or the United States Army after Vietnam. Clinical practice is no exception.

So, for example the 1980s and 1990s witnessed a dramatic change in the ways in which health care and mental health care are provided. In many parts of the country, managed care is now widely accepted as a mechanism for providing mental health services. Managed care does not merely mean utilization review. Managed care encompasses a number of practices designed to regulate the utilization of health care (Dorwart, 1990; Tischler, 1990; Zimet, 1989). It is a generic term for any organized system of care that includes precertification requirements, a limited network of providers, and risk-based payment.

From one point of view, the tools of managed care -- precertification requirements, utilization review, closed panels of providers, and reimbursement mechanisms (other than fee-for-service) -- threaten the taken-for-granted rules that previously guided practice. For example, many clinicians were trained to develop treatment plans with their clients that included the type and duration of treatment that seemed best given the client's presenting problem. It was taken for granted that the clinician could be the best judge of what treatment was required by the client. Under managed care, often, precertification requirements and utilization reviewers seem to be making those judgments with little input from the clinician.

In addition, insurance companies and other third party payers, employers, and consumers of service are questioning whether the treatment that is provided is worth the cost. How can they be sure that the treatment provided is the "best" or most effective treatment? How do they know when an employee or a family member is "better"? Are treatment modalities that take longer superior to short-term treatments? When should hospitalization be used and when are outpatient or partial care facilities more cost-effective?

Finally, clinical psychologists who practice psychotherapy have found themselves under attack by other professions that provide this service: psychiatrists, clinical social workers, marriage and family counselors, and even other psychologists (e.g., counseling psychologists). For example, those psychiatrists who are biologically oriented question whether psychosocial approaches to mental disorders are at all efficacious. And, because some disorders do tend to respond to approaches that have a biological orientation (e.g., medication for depression and schizophrenia), those practitioners oriented more toward a psycho-social approach often find themselves on the defensive.

On the other hand, some clinical social workers have argued that their education and training allows them to focus on the entire gestalt of the client rather than simply on individual psychological processes. And with that perspective, it is argued, they can better identify and treat more of the factors that facilitate or impede the treatment process. Further, it is argued that this holistic or systems approach leads to improvements that persist longer and pervade the client's life more deeply. Nevertheless, because they also adopt a psychosocial approach to treatment, it would seem that clinical social workers would be natural allies as psychologists respond to attacks from biological psychiatry.

There is no question that managed care represents a threat to the way clinicians have usually thought of themselves and to the way they are used to dealing with clients and patients. But who will set the standards by which assessments and treatments are evaluated? Clinical psychologists and other social scientists must take up this task. And in this way

Clinical psychology has an opportunity to shape managed care.

With respect to managed mental health care there indeed seems to be "more rhetoric than reason; more heat than light" (Feldman, 1992, p. 3). Charges of inefficiency and ineffectiveness are leveled at practitioners by the advocates of managed care. Many practitioners hurl their own charges and complaints at managed care organizations and at the proponents of managed care. In reviewing the problems that clinicians have with managed care, several themes tend to recur (Giles, 1993, p. 4).

Managed mental health care companies put dollars before patients.
 
Employees of managed mental health care companies merely feed the greed of the for-profit managed mental health care companies.
 
The quality and quantity of inpatient care is sacrificed to second-rate outpatient programs that rarely get the job done.
 
The quality of outpatient care suffers from managed care reliance on generic therapists with inadequate training and specialization.
 
Managed mental health care representatives are indifferent and hostile to provider opinions, preferring instead to make black and white decisions based on corporately derived cost containment rules.
 
In general, managed mental health care systems continuously place in jeopardy the lives of the very patients they are mandated to serve.

Feldman (1992) points outs that because managed mental health care has not been around very long, there has been little in the way of dispassionate analysis and research. Much of the professional literature is replete with anecdotes and observations that tend to reflect the optimism of those who are seek to manage mental health care and the unhappiness of those providers, both individuals and organizations, who find themselves being increasingly managed.

However, practitioners need not be passive victims of the managed care juggernaut. Rather, they have the opportunity to influence the way in which managed care organizations operate and managed mental health care is practiced in this country.

The way in which clinicians can influence managed care has been a part of clinical training from the beginning. Having been trained in a scientific discipline, clinical practitioners have the education and skills to design studies that can demonstrate that what takes place in practice is efficacious and cost effective. By designing (or working with others to design) studies that examine outcomes and the differential effectiveness of treatment, clinical psychologists can assume an important role in mental health services research. By demonstrating a willingness to study their own practices, clinicians have a unique opportunity to effect change rather than merely react to it.

The rush toward managed care in mental health has been inspired by the perceived (and real) increase in the cost of mental health and substance abuse services during the last decade (Feldman, 1992). However, it would be a mistake to assume that the debate about managed mental health care is just about economics. Cost and utilization are important, but access to and quality of care will be overriding issues in any future health care proposal. And it is especially around the issue of quality that practitioners have the opportunity to make important contributions -- by defining it at a conceptual level, constructing instruments by which to measure it, and conducting studies of quality, including consumer surveys and other assessments.

The debate over managed mental health care is also about professional status and autonomy. Many professionals fear that managed care threatens their autonomy. On the contrary, by responding positively to its demands, and making the case, through well-designed clinical studies, that specific mental health treatments are necessary, efficacious, and cost effective, clinical psychologists stand to gain status and autonomy--not lose it. On the other hand, if practitioners and clinical researchers refuse to conduct their own research on cost, quality, and access issues, managed mental health organizations will make these kinds of decisions with any information that is available -- information which may not adequately represent the true outcome of the therapeutic encounter. Thus, somewhat paradoxically, positive, constructive responses to managed care can actually benefit clinical psychology.

Clinicians should seize the opportunity to shape and control managed care, because:

Like it or not, managed care (or one of its close relatives) is here to stay.

Practitioners must accept the idea that managed care will not simply whither away. It is a burgeoning institution in its own right and its proponents are quite strong, vocal, and armed with studies that reflect short-term outcomes.

Part of the uncertainty about managed mental health care is that it is unregulated (Adelman, 1990, as cited by Giles, 1993). Amazingly enough, it appears that no one is responsible for keeping records on managed mental health care groups or even for knowing their names. Many state insurance commissioners have little or no authority to monitor such groups or organizations or intervene on behalf of consumers when problems occur. So part of accepting managed care must include a push toward its regulation. Alliances need to be formed between state psychological associations and other organizations, providers, and facilities to lobby aggressively for legislation to establish guidelines for managed care (Adelman, 1990, as cited by Giles, 1993).

A second course of action is less political in nature but requires active participation and commitment by practitioners. Those involved in mental health treatment services might examine how medicine has responded to managed care. A small but growing number of physicians are offering to sell their services directly to employers thereby bypassing the "middleman" -- the HMOs, insurance companies, etc. (Freudenheim, 1995, p. D1). In the last two years, physicians across the country organized many new medical groups (Freudenheim, 1995, p. D1) and have even begun their own HMOs.

This approach can only succeed if the practitioners can convince the employers that particular therapeutic interventions actually work. To that end, practitioners must establish clear, formal, standards and guidelines for practice through the research efforts that were discussed earlier in this paper.

The Institute of Medicine, a branch of the National Academy of Sciences, defines clinical practice guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" (Field & Lohr, 1990, p. 38). Most clinical psychologists in practice would be interested in the Guidelines on Depression in Primary Care that have been developed by the Agency for Health Care Policy and Research (AHCPR). These guidelines were discussed at length in a series of articles in the January, 1994 issue of the American Psychologist. The AHCPR guidelines are comprised of a review of the empirical literature on detection, diagnosis, and treatment of major depression (Munoz, Hollon, McGrath, Rehm, and VandenBos, 1994) and they end with primary care practice guidelines. Other guidelines such as the diagnosis and treatment of anxiety and panic disorder in the primary care setting are slated for development and release. Although formal guidelines may seem to represent an encroachment on the freedom of the individual practitioner, it is important to recognize that guideline development will continue. Clinical psychologists must actively participate in the formulation of these guidelines.

It may seem that these actions amount to capitulation to managed care. On the contrary, the key to survival is understanding the nature of mental disorders and their treatment better than the managed care companies do. That means having scientific data to support clinical practice. And, of course, data can only be obtained through carefully controlled study designs. Practitioners, together with researchers in clinical psychology and mental health services research, are in the best positions to design and conduct such studies because they have access to clients' presenting problems, ongoing treatment plans, and outcomes. The appropriate strategy, then, is to conduct such studies, gather clinical data into a reliable and valid database, and demonstrate that particular approaches are effective and efficient.

Some clinicians may turn to lobbying efforts to force the regulation of managed care. Such an approach will not address the fundamental issues that are clinical in nature. Other clinicians may seek to defeat managed care by simply resisting. That will not work either, for the simple reason that managed care will not go away. A more viable strategy is the formation of a strong, working alliance between science and practice.

In the final analysis, then, it is not enough to say that there is no conflict between science and practice and conclude that science and practice can go their separate ways. Science needs practice to maintain contact with the living material of the field, while practice needs science to survive. Science can provide the means by which practitioners can understand which treatment works the best under what circumstance, what constitutes quality of care, and which treatments are cost-effective. Armed with such information clinicians can assume a more powerful position with respect to managed care and can maintain the status and autonomy that the profession seeks. Without these tools, the argument is too often reduced to the moral equivalent of a "he-said/she-said" argument between practitioners and managed care organizations.

Clinicians who spend time and energy attempting to defeat managed care are wasting valuable resources. Their energy can best be focused on using the best scientific tools available to design studies, collect data, and draw valid conclusions that can contribute to the ongoing policy debate about what constitutes cost-effective and high quality mental health treatment. Managed care is not the enemy. The enemy is the reluctance to scientifically examine clinical practice and its outcome.

References

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John F. Kihlstrom, PhD and Lucy Canter Kihlstrom, PhD

Copyright 2000 Institute for the Study of Healthcare Organizations & Transactions

Last modified:   04.08.2010 02:58 PM