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Annu. Rev. Clin. Psychol. 2006. 2:21–49 doi: 10.1146/annurev.clinpsy.2.022305.

095245 Copyright c 2006 by Annual Reviews. All rights reserved First published online as a Review in Advance on January 16, 2006

Richard M. McFall
Department of Psychology, Indiana University, Bloomington, Indiana 47405; email:
Annu. Rev. Clin. Psychol. 2006.2:21-49. Downloaded from by University of Delaware on 11/29/07. For personal use only.

Key Words

Boulder model, Psy.D. training, clinical science, managed care

■ Abstract Competing models of doctoral training in clinical psychology are described and compared within their historical contexts. Trends in the field are examined critically with a focus on the impact of managed care on doctoral training and clinical practice. Implications for the future of doctoral training are considered, and a blueprint for the future of doctoral training in clinical psychology is presented.

OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Snapshot of Psychology and Clinical Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . Asking “Why” Before “What” and “How” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Boulder Model and “Why” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THEN VERSUS NOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Supply and Demand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State of the Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Specialization and Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Accreditation and Licensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Doctor of Psychology Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Science Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparisons Among Training Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THE CHANGING FACE OF CLINICAL PSYCHOLOGY . . . . . . . . . . . . . . . . . . . . Forces of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implications of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Positive Implications? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Implications of a Science-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BLUEPRINT FOR THE FUTURE OF CLINICAL TRAINING . . . . . . . . . . . . . . . . Scientific Clinical Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical Psychology as an Applied Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Goal of Doctoral Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 23 24 24 26 26 27 28 28 31 32 33 35 36 37 37 38 38 40 41 42 42 42 43




MCFALL Training Research Scientists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individualized, Integrative Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . What Not to Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sharpening Versus Leveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 44 45 46

The dual aims of this review are to examine the evolving state of doctoral training in clinical psychology and to offer a possible blueprint for its future. Reviews inevitably are influenced by the authors’ personal views. Because this review challenges the status quo, I want to assure the reader that I am not an interloper or gadfly; I am deeply committed to clinical training and clinical science. Nor am I a nihilist; I offer my review in the optimistic belief that clinical psychology potentially has the resources, integrity, and resolve to assess its present and future circumstances objectively, take the necessary steps to remain viable, and contribute to the future mental and physical well-being of our society. To gain a fresh, comprehensive overview of the field’s current challenges and future prospects, I examined more than 1000 articles on clinical training published over the past 15 years in the leading professional journals and newsletters. I also made good use of Web sites and sought advice on important developments from a network of colleagues. The broad scope of this material expanded my previous perspective on clinical training’s past, present, and future. Unfortunately, only a few of these articles and resources could be cited here. My intent is to offer an overview and synthesis of the themes, issues, and trends in the field, and to consider their implications for the future of clinical training. I begin with three general observations. First, I came across no reports of controlled studies of the effects of different models or methods of doctoral training in clinical psychology. Thus, my review is based largely on interpretations of descriptive data, correlational results, and qualitative evaluations. There is a dire need for solid research on doctoral training. Second, reviewing the literature convinced me that doctoral training in clinical psychology stands at a crossroads. The field must appraise its situation carefully and begin charting its future course with a sense of urgency. Below I discuss the forces that brought us to this juncture, describing how they are pushing us swiftly and inexorably toward a radical restructuring of both our educational system and our health-care system. The futures of education and health care are intertwined tightly. Our education and training ideally should be driven by the needs of the health-care system; the quality of our health-care system, in turn, depends on the validity of our education and training. Responding effectively to current challenges requires objective analysis, creative problem solving, and decisive action. Anything less will marginalize clinical psychology—along with the doctoral programs that

Annu. Rev. Clin. Psychol. 2006.2:21-49. Downloaded from by University of Delaware on 11/29/07. For personal use only.



Annu. Rev. Clin. Psychol. 2006.2:21-49. Downloaded from by University of Delaware on 11/29/07. For personal use only.

train clinical psychologists—in the rapidly evolving educational and behavioral health-care systems. Third, we cannot perpetuate the status quo in clinical training simply because it is familiar and comfortable; we cannot continue to train doctoral students the same old way simply because we’ve always done things this way. If evolving circumstances render past approaches no longer defensible or sustainable, then we must face this reality and deal with it forthrightly. This is a central theme of this review. When Astin (1961) wrote about the “functional autonomy of psychotherapy,” he was referring to the tendency for psychotherapeutic practices to take on lives of their own, to become independent of the clinical problems for which they were designed initially and the conceptual foundations on which they were based. This notion of functional autonomy is captured by the Berry’s World cartoon depicting two leather-clad motorcyclists astride their Harley hogs at a stoplight, both with outstretched arms, hands perched aloft on high-rise handlebars. Responding to a question from a pedestrian on the curb, one cyclist turns to his buddy and says, “I dunno. . . Hey, Moose! Why DO we have handlebars like this?” Many current approaches to doctoral training in clinical psychology show signs of functional autonomy. We rely on models and methods long after their original foundations have been forgotten or abandoned, without questioning their value, simply because we always have done things this way. The first step in developing a viable blueprint for the future of doctoral training in clinical psychology is to look critically at our current training. Like the motorcyclist, we should be asking, Why ARE we doing this?

Snapshot of Psychology and Clinical Training
This question assumes that we know what “this” refers to. We need a snapshot of clinical psychology, one of those signs with a red x that reads, “You are here.” Dry as statistics tend to be, the extensive data set compiled and published by the American Psychological Association (APA) Research Office (2005) provides the best, most up-to-date, wide-angle snapshot of contemporary psychology. I rely on this rich resource throughout the review. I do not have space to summarize these data in detail, but the following are some highlights. Currently there are about 100,000 psychologists with doctorates across all specialty areas, approximately 75% of whom are employed full time, primarily in for-profit or self-employed positions (40%) or in colleges, universities, or medical schools (35%). Surprisingly, over 40% are working in positions not directly related to psychology. Women and people of color have made significant gains in psychology over the last 30 years. Women now make up roughly 50% of the current workforce, 70% of the new graduates, and 75% of the current doctoral students. People of color make up approximately 10% of the workforce, 15% of the recent graduates, and 22% of the trainees. For recent doctorates, 77% of those in by University of Delaware on 11/29/07. one must look at the programs’ Web sites or brochures. The Boulder model’s history is relevant to us because it sheds light on . In particular. Comparative self-report data are published in the Insider’s Guide to Graduate Programs in Clinical and Counseling Psychology (Norcross et al. the specific content of core courses. we also need to ask related questions about specific program components. so-called ostrich behavior. We first need to know why we have training programs. Without a clear fix on the purposes of our training programs. Ignoring the “why” question amounts to functional autonomy. the health-service-provider subfields carry a training-related debt. doctoral training in clinical psychology has been dominated in the United States by the Boulder model of scientist-practitioner training. in extreme cases. 2006. and scholarly work varies considerably across programs. curriculum. For personal use only. but they do not address the more fundamental questions: What should training programs be doing. 2004b). students. On paper.755. as compared to 58% of those in research and other subfields. and what we are trying to achieve with them. how can we possibly evaluate whether they are sensible and successful.” Once we determine the overarching goal. one should examine the data programs submit to the Committee on Accreditation (CoA) in their annual self-study reports. the answers to these “what” and “how” questions depend on the answer to the “why” question.K. practicum training. we must ask “why” before we ask “what” and “how. or determine what changes. Downloaded from arjournals. What are the intended effects of this component? How would we know whether it is achieving these intended effects? Are these effects consistent with the superordinate goal? The Boulder Model and “Why” For over half a century now. Of course. carry a training-related debt in excess of $75. Asking “Why” Before “What” and “How” Such snapshots give us a static picture. the devil is in the detail. resources. Twenty-four percent of the health-service group. and training outcomes is submitted to CoA as part of the full accreditation application. these data are not as highly correlated with the CoA self-study data as one might expect. Blashfield. Psychol. However. and how should they be doing it? Logically.885.2:21-49. a resource used by many applicants. faculty. although this information may not be readily available to the public. as compared to only 5% of the research/other group. Rev. might be needed? Thus.24 MCFALL Annu. the content and structure of doctoral programs appear fairly standardized.000. On closer inspection. for the research/other group it is $33. A more detailed description of the programs’ philosophy. rearranging the deck chairs on the Titanic. To see what actually is happening in doctoral training programs. The mean debt for the health-service group is $58. Unfortunately. given that both come from the same source (R. there is little published data documenting some of the more important differences.annualreviews. primarily because of the constraints of accreditation and licensing requirements. personal communication). if any. or perhaps.

which now is over 55 years old. The impetus for the new model came primarily from psychologists eager to expand the emphasis on practitioner training. At the same time. To put this into perspective. The Boulder model has enjoyed a remarkably long run. how well does the Boulder model fit the conditions and meet the needs of twentyfirst-century clinical psychology? It would be remarkable. the model declared that the first goal of doctoral training was to prepare all graduates for roles as scientists by emphasizing research training. Downloaded from arjournals. Clin. Thus. Little was known then about the etiology of psychological disorders. often interminably. DNA testing. and personal computers. It is unreasonable to expect anyone to predict conditions 50 years into the future with accuracy. as was the case in the rest of psychology and the other sciences. The model was designed at the dawn of the field. and scientific foundations of that time. there were no empirically supported behavioral treatments. 2006. but readers can find useful accounts elsewhere (Baker & Benjamin 2000. indeed. .annualreviews. Benjamin 2005. Similarly. For the academics who wanted the Ph. When the Boulder model was adopted in 1949.D. in clinical psychology to remain a research degree. The model’s genius was that it was sufficiently general and inclusive to offer something for everyone. economic conditions. Annu. jet by University of Delaware on 11/29/07. but perhaps it is time to consider adopting newer models to fit today’s realities. for those who wanted psychology to respond to the urgent need for clinical services following World War II and wanted to transform clinical psychology into a profession like medicine. and ethical. it represented a political compromise aimed at unifying the field. For personal use only. Benjamin & Baker 2000). space travel. many of the most important advances in contemporary clinical psychology could not possibly have been foreseen by the designers of the Boulder model. it is reasonable to ask. theoretical. A detailed history is beyond the scope of this review. microwave ovens. academic structures. the model also declared that a coequal goal of doctoral training was to prepare graduates for roles as professional service providers by emphasizing practitioner training.CLINICAL TRAINING 25 one answer to the “why” question. The Boulder model’s founders could not have anticipated the field’s evolution over the next fifty-plus years. it seems strange that clinical psychology training programs continue to rely on a training model based on outdated knowledge and designed to fit the circumstances and needs of a bygone era. consider the many developments in contemporary medicine and technology that persons living in 1947 could not have predicted accurately—developments such as antibiotics. birth control pills. cell phones. Science and practice were the model’s dual goals—the model’s hyphenated response to the “why” question. to fit the special conditions that existed around the time of 1945 to 1949: the aspirations and expectations. workforce needs. as we know it. there were no powerful pharmacological treatments for the major disorders. if not outright replacement. Therefore. Rev. Psychol. and patients with serious mental problems typically were institutionalized. The majority of contemporary clinical training programs still are based on the Boulder model. if the venerable model did not need extensive remodeling.2:21-49. plasma television.

barely keeping up with the demand. By the 1960s. Back then. By the 1980s. program than to get into medical school. however. The phenomenal growth in clinical psychology training programs was driven initially by the demand for mental health services following World War II. Pion (1991) and VandenBos et al. the number of programs offering doctoral training in clinical psychology grew in parallel. the demand for clinical psychologists started to lag behind the expanding supply. the disparity between supply and demand began to attract national attention. in which Robiner & Crew (2000) called for “rightsizing the workforce of psychologists in health care” by adjusting training-program Annu.D. Schneider (1991) warned that there were no magic workforce fixes in psychology’s future. counseling against overreacting. the number of doctorates awarded in all areas of psychology continued to grow steadily. For personal use only. Today. In 1949. . The need for psychologists to provide such services seemed so urgent that the United States Public Health Service and Veterans Administration offered grants and stipends in an effort to recruit psychology trainees. most likely social workers (Sleek 1994). It was projected. full of promise. Robiner (1991) dared to ask. psychologists in the United States was only about 4000. Recognizing that there no longer was a shortage of clinical psychologists. Despite these warning signs. As demand for clinical training grew. the Veterans Administration considered making a 50% cut in the number of doctoral-level psychology and support staff positions. it is well past middle age.2:21-49. the government stopped providing training grant support for the doctoral training of clinical practitioners. today. 2006. it seemed more difficult to get into a clinical psychology Ph.D. nearly doubling between 1970 and 2000 (APA Research Office 2005). Psychology became an exciting new professional field. more than 4000 doctoral degrees of various types are awarded in psychology each year.annualreviews. Psychologists in private practice began to have difficulty filling their appointment calendars. a special section of Professional Psychology: Research and Practice was devoted to the workforce issue.D. possibly replacing them with outside consultants. Clin. a far greater percentage than in by University of Delaware on 11/29/07. “How many psychologists are needed?” and called for a national psychology human-resource agenda. Professional Psychology: Research and Practice revisited the workforce issue in 2000 with another special section. Downloaded from arjournals. Rev. Clinical training now accounts for about half of these new psychology doctorates. and some experienced a downturn in income levels (Fyfe 1995). that if the growth rate in clinical training continued. everyone in the United States would have a Ph. (1991) took a more sanguine view. Psychol. the subspecialty of clinical psychology as we know it was in its infancy. in clinical psychology by the mid-twenty-first century. By the 1990s. In 1991. the total number of all Ph. As psychology approached the twenty-first century. in jest.26 MCFALL THEN VERSUS NOW Supply and Demand The circumstances and needs faced by graduate training programs today differ dramatically from those in 1949. for example.

describing the problem’s history and recommending funding for a full-scale workforce analysis focused not only on supply and demand. but it also was a disappointment. social workers were providing only about 5% of all mental health services in the United States. for example. Roles Another difference between 1949 and now is the change in clinical psychologists’ roles. Essentially. by University of Delaware on 11/29/07. by 1997 they were providing 56% of these services. Clin. (2000) countered that programs might retain their enrollments by expanding the scope and goals of their training. as all workforce analyses should begin with such an assessment. the report did not give specific questions that should be asked. this picture is changing once again: Social workers and mental health workers from other disciplines now are displacing psychologists as the primary providers of mental health services—doing to psychologists what psychologists did to psychiatrists earlier. unwilling to return to their limited test-giver role. 2006. The longer we delay facing these critical workforce issues. the deeper the hole we will have dug for ourselves. enrollments. an APA Task Force on Workforce Analysis (2004) issued its final report. The simple . Downloaded from arjournals.CLINICAL TRAINING 27 Annu. in that it merely recommended further study. Prior to World War II. fought back. Today. psychologists were allowed to function as independent psychotherapists to help meet the military’s urgent need for mental health services.K. personal communication). but also on needs. During the war. however. By 2004. we need to know the following: What are the specific needs that the workforce should be designed to serve? Is the current workforce training well matched to these needs. over time. there only were enough internship slots to accommodate 83% of the applicant pool in 2004– 2005 (Association of Psychology Postdoctoral and Internship Centers 2005. the APA Task Force report was an important first step. In November 2004. however. Psychol. Clinical psychologists. Once the genie had been let out of the bottle. For instance. At the war’s end. displacing psychiatrists as the primary providers of such services. and their market share was growing at an accelerating rate (Clay 1998). or might different training meet these needs more efficiently or effectively? For example. there was no putting it back.annualreviews. whereas Pion et al. This mismatch was due entirely to the growing applicant pool. the worst ratio yet. to plan for the future of clinical training. The pace of this shift has been dramatic. R. In 1991. Blashfield. winning the right to continue practicing as independent psychotherapists and. in that it acknowledged that the workforce problem required attention. workforce problems had become critical. For personal use only. The report’s call for including a needs assessment was important. are there more cost-effective ways to meet these needs than by training doctoral-level psychologists? Psychology no longer can afford to ignore such questions. the medical profession (largely at psychiatry’s behest) sought to restrict psychologists’ freedom to continue practicing as independent psychotherapists. For example. Rev.2:21-49. as the number of slots remained remarkably stable. clinical psychologists primarily administered psychological tests and rarely administered psychotherapy.

Moritz et al. have opened exciting research and diagnostic frontiers and seem destined to supplant the use of neuropsychological tests for the diagnosis of brain lesions (Bigler 2005. in cognitive science (e. and anxiety disorders. Advances in computer technology. you probably would be hiring social workers. mastering this material requires more intensive and extensive training. For personal use only. specialization has become the focus of doctoral training in psychology. 2006. Ashby & Maddox 2005). and knew that you could hire nearly two social workers for the price of one psychologist. and neurobiological aspects of mental disorders. as well as our approaches to the prediction. such as schizophrenia. attention disorders. Today. Such drugs have led to a complete restructuring of the mental health system. Lang et al. too. along with developments at the intersections of such areas (e. But this also leaves less time for learning material outside of the specialty. were aware of research showing no significant differences between psychologists and social workers in their effectiveness at delivering essentially the same services. and in electrophysiological recording and electromagnetic imaging (e. from genome mapping to epidemiological mapping of disease transmission. 2004). Treat & Dirks 2006).g. New scanning technologies. for example. transforming many classic state mental hospitals into historical artifacts. promise to transform our grasp of the affective. have led to astounding developments throughout the sciences.annualreviews. unipolar and bipolar depression.. Clin. with areas becoming increasingly insular . Changes over the past fifty-plus years have been amazing. boldly going wherever the advances may take them. and treatment of such disorders. cognitive.g. specialization has tended to balkanize psychology. More recent advances in behavioral and molecular genetics (e. To ensure that students receive training at the rapidly expanding frontiers of this science. State of the Science A critical difference between 1949 and today is the state of science and technology.. from space exploration to weather prediction. for example. were struggling to control costs. from neural imaging to the creation of artificial language and virtual realities.g. Steinmetz 2006.28 MCFALL explanation for this shift is market economics: If you were the administrator of a mental-health-care system. Downloaded from arjournals. Specialization and Integration All doctoral students used to be trained first as psychologists.g.. Annu. Moffitt 2005). As a result. Perhaps the most significant development in mental health care in the last half of the twentieth century is the development of so-called wonder drugs for major mental and emotional problems. Mukamel et by University of Delaware on 11/29/07. 2005). 2006. only secondarily as specialists. They must be sufficiently flexible and dynamic to evolve along with the science and technology. Rev. Toga & Thompson 2005. prevention. Psychol. As knowledge and technology in a given area expands. doctoral programs in clinical psychology cannot be wedded to tradition or be hamstrung by out-of-date requirements dictated by accrediting agencies or licensing boards..

top-down approaches are being displaced by brashly egalitarian.” or leveled the playing field. to give individuals everywhere a freedom to connect. which almost certainly has impeded scientific progress. irreverently hybrid. and a power to compete successfully. Nor will it be assured by establishing standard lists of “foundation. thereby making it possible to train specialists who also are integrative. requirements too easily met by superficial survey courses. this new world is organized horizontally.2:21-49. an unprecedented access to information. new technological developments have brought to light a liberating new way of conceptualizing inquiry and training—a way that offers the potential of achieving both depth and breadth at a reasonable cost. Producing specialists. and specialty competencies” for education and credentialing in professional psychology. and collaborate on a global scale. 2006. but also in science. thus. making it more competitive and productive. with minimal capital outlay. Whereas the world previously was organized vertically. however. so that persons working in one area often are unaware of advances in neighboring areas—advances that potentially could help them solve their own core problems. communicate. for instance. In this past by University of Delaware on 11/29/07. categorically structured. . The traditional authority-based. The proposed lists of such competencies are based on consensus opinion and tradition. These new technological developments and their implications are the focus of Friedman’s (2005) best-selling book The World Is Flat: A Brief History of the Twenty-First Century. and innovation. Downloaded from arjournals. controlled hierarchically. Specialization and integration seemed to be competing goals. the answer seemed to be no.. all pedagogical choices were difficult because they inevitably required compromises and trade-offs. core.annualreviews. providing integrative training meant increasing the breadth of training at the expense of depth and specialization. technology. for instance. and driven by access to resources. This truly integrative training cannot be assured by any standardized. To understand and solve clinical problems. Clin. meant increasing the depth of training at the expense of breadth and integration. Friedman (2005) describes how this flattened world also is revolutionizing our knowledge structures and our approaches to learning and problem solving. Is there any good way to ensure that students receive specialized training that also is integrative? Until recently.g. flexible. For personal use only. Friedman provides a compelling account of how digital and fiber-optic technologies have “flattened the world. It is not assured. by the CoA’s list of breadth requirements for program accreditation (APA Office of Program Consultation and Accreditation 2005). Psychol. open and accessible. one-size-fitsall approach to training. and producing specialists who also were integrative meant increasing both the length and cost of training to unreasonable levels. Kaslow 2004). Rev. This balkanization has made psychological training more fragmented and less integrative. students need integrative training that enables them to draw upon the best theories and methods throughout all of psychology—and all other relevant sciences—to solve their specialized problems. not empirical evidence regarding training outcomes. as advocated recently (e.CLINICAL TRAINING 29 and narrow. bottom-up Annu. and driven by merit. not only in commerce and geopolitics.

Instead. For students to qualify as experts. to share their storehouse of prestructured knowledge with novices. The implications of this new paradigm for graduate education and training are just beginning to be appreciated. Psychol. such inquiry has become available to virtually anyone. almost overnight. Although formal core courses still may be a reasonable way to transmit the basic outlines of established knowledge structures. filter. This new technology—along with the diversity of players taking advantage of its flexible. multidimensional information in unique ways that fit one’s specific interests. anywhere in the world. hierarchical form. and typically were structured in a fixed. which empower individuals to access and manipulate an unprecedented amount and diversity of information on their own by University of Delaware on 11/29/07. In the past.30 MCFALL approaches. and to organize. Downloaded from arjournals. to generate new information.2:21-49. Our education and training systems were designed to allow these experts. invite independent. along with everyone else. it also will force us to rethink our education and training systems—the methods by which we seek to transform novices into experts. education. discussion. moreover. to rethink what it means to be an expert. . and flexibly by the new tools of digital technology. 2006. But Annu. Rev. Traditional courses still may be useful for fostering collegiality. Clin. information-processing capabilities—signals a paradigm shift that promises to revolutionize intellectual inquiry. Now. such as Google. as this function is performed more reliably. shaping ethical values and judgments. flexible. modeling critical thinking. high-level intellectual inquiry was reserved for the fortunate few with direct access to the special resources of elite institutions. who has access to a computer and an Internet connection. For personal use only. giving trainees a shared perspective. evaluate. The new resource tools simplify navigation. and tastes at that moment. or encouraging oral communication. the primary role of experts was to serve as the storehouses and caretakers of discipline-specific information and formal knowledge structures. and novel exploration and discovery. in a discipline. they probably are no longer the most efficient or effective way to impart factual information. or specialist. These new approaches ignore old rules and boundaries as they assemble large amounts of information from diverse sources in novel ways to create new solutions to old problems. the students. and disseminate information and knowledge structures. integrate. retrieve. and debate. organize.annualreviews. This shift will force psychologists. The freedom of intellectual inquiry unleashed by these new technologies is symbolized by Internet search engines. expertise is redefined in terms of the skillful and creative use of the new technological tools to access the broadest possible range of relevant information. and give individuals unprecedented freedom to search. and apply this information in innovative ways to the analysis and solution of specific problems within the discipline—and across disciplines. In contrast. and training. effectively. questions. under the new paradigm. the primary role of experts no longer is to store. just-in-time. hybrid. they had to demonstrate that they faithfully and accurately stored these knowledge structures and that they were capable of retrieving and applying such knowledge independently. goals. the teachers. In the old paradigm. such resources usually were difficult to navigate. and analyze the wealth of cross-linked.

For personal use only. and slower growth (even declines) in enrollment. In this competitive environment. Accreditation and Licensing There also are important differences between 1949 and now in the degree of regulatory control over the training of clinical psychologists and over the practice of professional psychology.CLINICAL TRAINING 31 Annu. and finally choosing the most efficient. Downloaded from arjournals. Indeed. The first 29 doctoral training programs in clinical psychology were accredited by APA in 1948. genetics. It is time to drain the moat that has protected but isolated clinical training programs over the last half century. collaborative. Of course. No goal or method should be adopted uncritically. effective. As clinical psychology’s halcyon days recede into memory. This means providing clinical students with training at the cutting edges of psychological science—neuroscience. not just clinical programs. Clinical psychology was just getting organized as a profession in 1949. and developmental and social processes. then critically examining all available methods of achieving each goal. psychopharmacology. 2006. By 2005. 73 counseling programs were accredited. tighter budgets.2:21-49. The first doctoral program in school psychology was accredited in 1971. with another six programs accredited in 1949. by University of Delaware on 11/29/07.annualreviews. by 2005. productive. National Institute of Mental Health 2000) is a direct reflection of clinical psychology’s future hinging on its success in developing this bidirectional integration and cross-fertilization. Clin. quantitative modeling. . and workable options. first building a prioritized list of explicitly stated training goals. The first doctoral training programs in counseling psychology were accredited in 1952. clinical training programs no longer are assured of the favored status and resources they have enjoyed for so long. psychology departments are retrenching as they face increased costs. the new paradigm invites us to start with a blank sheet of paper and redesign our training programs. Rev. Psychol. clinical training programs must recognize that their long-term survival depends on their reintegration with the rest of the field. cognitive science. This means that nearly half of all currently accredited doctoral training programs in clinical psychology became accredited only after the demand for doctoral-level clinical psychologists had started to fade. the CoA accredits other types of practitioner training in psychology. the National Institute of Health’s translational research initiative (Cuthbert 2006. 227 doctoral training programs in clinical psychology were accredited by the CoA (APA Office of Program Consultation and Accreditation 2005). This paradigm shift could not have come at a more opportune time. 112 of which had been accredited for the first time since 1980. and integrative specialist. uniquely hybrid. The final design should be driven less by concerns about standardization and external requirements—concerns that tend to foster conventionality and squelch independence and innovation—than with empowering each student to flourish as an innovative. The programs should invite students from these other areas to apply their expertise in basic psychological processes to the investigation of important clinical problems.

the CoA currently accredits approximately 450 predoctoral internship training programs and 22 postdoctoral training programs. Thus. There now are 11 accredited doctoral programs in combined professional-scientific psychology. For personal use only. By June 2005. other proposals for system change have been floated by other sources. but licensing laws did not become common until the 1960s. This recent summit produced a proposal calling for significant modifications in the existing accreditation structure (Schilling & Packard 2005). although the specific details of the changes still are fuzzy. The specific provisions of these state laws vary. Dissatisfaction with CoA accreditation requirements. competing organization. today. including many clinical psychologists—broke away from APA to establish a new. Rev. Missouri. Downloaded from arjournals.annualreviews. Utah. however. APS is dedicated exclusively to advancing psychology as a science and is committed to reestablishing research training as the preeminent focus of all doctoral training. 2006. dissatisfaction with the revised CoA accreditation system led to another summit on accreditation in Snowbird. In 1945. Psychol. Meanwhile. so the alternative system never was implemented. These frustrations are reflected in the resentment expressed by members of the Council of University Directors of Clinical Psychology regarding the substantial portion of their annual midwinter meeting that is devoted to discussions of accreditation and licensing by University of Delaware on 11/29/07. and public relations. A steering committee was formed to draft plans for an alternative accreditation system. the CoA had revised its own guidelines and procedures in an effort to address the complaints. In 1988. all 50 states have such laws. Clin. In addition. practice. particularly their perceived infringement on academic prerogatives. training. rather than to more important substantive issues related to science and training. APS’s answer to . the American Psychological Society (APS).32 MCFALL Annu. including the CoA itself. with the last state. Organization From 1949 to 1988. led to a 1992 summit on accreditation in Chicago devoted to discussing the problems and considering alternatives. The current accreditation system is likely to be modified in the near future. 57 such programs are accredited. passing its law in 1977. APA’s monolithic control was challenged when a group of disaffected psychologists—mostly academics. Accreditation has become a big business—an essential part of doctoral training—that exerts a powerful constraining influence on the design of training programs. Many Boulder model programs regard the regulatory aspects of accreditation and licensing as unwelcome encroachments on their academic freedom and impediments to their ability to provide doctoral training of the highest quality. Connecticut was the first state to license the practice of psychology. the APA was the only major professional organization representing all facets of psychology—its science. but the laws impose another layer of regulation on the design of doctoral training programs. when these draft plans were completed.2:21-49. education. the first dating back to 1973. By January 1994. Now.

Yet. It also means that individuals and programs must make choices and assume responsibility for the consequences. They also worried that the philosophy of science taught in traditional Ph. The degree’s roots can be traced to the University of Illinois’ short-lived Psy. programs were accredited in the 1980s. and education to its particular vision.” Research training is minimized. programs are committed to the “scholar-practitioner” model of training (sometimes also referred to as the “practitioner-scholar” model).e. failing to provide genuine solutions to real-world clinical problems. Psy. Clin. programs was misguided. have choices today that did not exist 20 years ago. however.D. both APA and APS are thriving organizations. This 1988 split ran along fault lines that existed since before 1949— divisions that the Boulder model’s compromise had sought to patch and bridge. One option—which did not exist in 1949—is the training model associated with the doctor of psychology (Psy.D. complaining that the Boulder model’s research training requirements interfered with first-rate training for professional practice. Doctor of Psychology Training In addition to having a choice of organizations and visions. but that never had disappeared.2:21-49. the “why” question differs from APA’s answer. by the end of the 1970s. The existence of the two organizations means that individual psychologists. The Psy.D. Downloaded from arjournals. Psychol. all housed in universities.D.D. with the rapid growth of “freestanding” or “independent” Psy. In general. program.annualreviews. movement began to gather momentum in the 1980s.D.D. and another 17 from 2000 to 2005. 2006. programs. training model received a boost from the 1973 Vail Conference. The Psy. practice. the goal of training for APS is to train research scientists. practice-oriented psychologists were the first to defect.D. and each attempting to mold psychological research.D.CLINICAL TRAINING 33 Annu. had been accredited by the APA.. Psy. today’s clinical training programs also have choices of training models. 22 in the 1990s. degree became the first significant challenge to the Boulder model’s hegemony over clinical training.D. each representing overlapping yet distinct constituencies.D. students are taught to be consumers of science and “local clinical scientists” but not to be producers of .) degree. only four Psy. It is ironic that practice-oriented psychologists were the first to break away from the traditional scientist-practitioner training model. which began in 1969. Research-oriented academics seemed to be the most vocal critics of the Boulder model over the years. This model’s goal—its answer to the “why” question—is “to train professional practitioners. as well as doctoral training programs. complaining that the demands of practitioner training interfered with first-rate research training. Today. Fourteen Psy. For personal use only. each with its own vision of psychology’s by University of Delaware on 11/29/07. which was devoted to developing and promoting the model (Korman 1974). programs—i. The Psy. whereas the goal of training for APA is to train scientistpractitioners. programs not located in psychology departments of traditional universities. each with a different structure and emphasis. Yet. Rev.

rationale. respectively.D.D. these data are correlational. For personal use only. Norcross et al. 1997). the means are 41% and 33.D. (1997) found that when graduates from Psy. in Ph. Psychol. for instance. In recent years. Maher 1999.s has remained essentially level. the training council for the scholar-practitioner model.D. and as high as 80% in some cases. and philosophy of Psy. whereas the production of Psy. The aim is to free trainees from the rigors of research training—training that the model’s proponents say most of these students would be unlikely to use after graduation anyway—so that more time can be devoted to training them for professional practice. Clin.s has increased by 169% (APA Research Office 2005). students carry significantly heavier student-loan debts than Ph.2:21-49. programs are less selective in their admissions than university-based Ph.D. some may offer a Ph. training. In theory. Today.D.D. 2004a. training over the last 25 years has been startling. Peterson 2003. programs combined. programs. Yu et al. The National Council of Schools and Programs of Professional Psychology (2005). Downloaded from arjournals. programs account for nearly 30% of all doctorates awarded in psychology and 42% of the health-service doctorates in psychology. degree. the same means are 11% and 9.D.D. programs.D. nearly all in clinical psychology. From 1988 to 2001.D. suggests that they do. 57 of which were accredited by the CoA as doctoral programs. this growth has been almost entirely a result of the expansion of by University of Delaware on 11/29/07.D.D. programs.annualreviews. 2006. Students admitted to Psy. in research-oriented Ph. respectively. programs have lower mean GREs and undergraduate GPAs than those admitted to the Ph. Peterson & Trierweiler 1999. degree option to students who complete “scholarly” dissertations (not to be confused with empirical research dissertations).D. Yu et al. . they earn lower mean scores on the standardized test than graduates from Ph.D. so cause and effect are tangled hopelessly. respectively. programs sit for state licensing exams.D.D. Of course. The financial support levels are lower and the costs are higher in Psy. see Peterson 2003. In contrast. (For more detail on the history.D. Rev. however. the production of Ph. making inferences difficult. with a higher mean student/faculty ratio—nearly double that of university-based Ph. programs. programs with scientist-practitioner or practitioner orientations. programs with the least distinguished faculties produce a disproportionately higher percentage of all the doctorates.D. this additional training should produce superior practitioners. Although these programs usually award a Psy. programs is 50%. had 74 member programs in 2004. Do the orientations and degree distinctions associated with training models really matter or signify anything important? The following evidence.D.) The growth in Psy. Psy. the number of doctorates awarded in all areas of psychology has grown steadily. Psy. Nevertheless.D. training. with a mean class size of 48. Psy. distilled from several sources (APA Research Office 2005. the means are 17% and 10.D. As noted above. programs than in Ph. in all types of Psy. programs generally have a lower mean percentage of full-time faculty members. The Psy.D.34 MCFALL traditional research science. goals. 1997. these differences are so Annu. The mean acceptance rate in independent Psy. and Stricker & Trierweiler 1995. students. Psy. programs.D. Peterson et al.D. programs.

worrisome that Peterson (2003). which differs from the traditional vision. The Academy’s emphasis on the “science” underscores its commitment to empirical approaches to evaluating the validity and utility of testable hypotheses and to advancing knowledge by this method. .annualreviews. with 54 member programs—45 university-based Ph. an architect of the Psy. Thus.D.g. with the founding of the Academy of Psychological Clinical Science (also known as the Academy). Despite such evidence. has altered the landscape of doctoral training and practice in clinical psychology. another perspective on clinical training—a third major way of answering the “why” question—crystallized. In general. 2003). Although other reviewers less closely aligned with the Psy. training programs and nine predoctoral internship training programs. affect. cognition or health. programs has contributed to the growing disparity between supply and demand in the workforce. training model. Downloaded from arjournals. has expressed serious concerns about the quality of the training provided by many Psy. Peterson’s criticisms struck a nerve with proponents of Psy. For these Academy programs. with graduates from Psy..D. the preeminent goal of doctoral training in clinical and health psychology is to prepare students for careers as clinical scientists. it seems fair to conclude that the current evidence on Psy. Jaffe 2004. Kenkel et al.D. The Academy sees the development and application of clinical science as ongoing and dynamic processes. and is committed to facilitating the evolution of clinical science.CLINICAL TRAINING 35 Annu. Psy. prompting a rash of rebuttals and defenses (e. The Academy celebrated its tenth anniversary in May 2005. movement had raised similar concerns previously. seems to be gaining influence in some circles. Crossman et al. Their vision of clinical psychology’s future. Clin. . the primary emphasis in these programs is on research training.D. training. and at the application of knowledge in ways consistent with scientific evidence. Psychol. programs exerting a significant and growing political influence within APA and within clinical psychology.D. 2004. amelioration. their rules of evidence or ways of knowing truth—increasingly are presented as challenges to the traditional epistemological perspectives taught in most traditional training programs.. In 1995. an association of U. at the assessment. programs. as a competitor to the Boulder model.D. Clinical Science Training Today.2:21-49. and Canadian doctoral training programs in clinical and health psychology. although far from definitive. 2006. training. “Clinical science” is defined as a psychological science directed at the promotion of adaptive functioning. the Psy. For personal use only. According to the Academy’s mission statement (Academy of Psychological Clinical Science 2005).D.D.D. The Psy. does not paint a favorable picture. The sheer number of graduates from Psy. . training model is not the only challenger to the traditional Boulder model. Their epistemological perspectives—i.D.S. programs continue to attract large numbers of applicants and produce disproportionately large numbers of doctorates.e. Rev.D. . understanding. and prevention of human problems in behavior. by University of Delaware on 11/29/07.

however. and (e) “Dissemination: To foster the timely dissemination of clinical science to policy-making groups. who. Comparisons Among Training Models The sharp differences among clinical psychologists in terms of their visions. doctoral programs must choose from among three distinct training models (i. and consumers. scholar-practitioner.) Although the Academy is a relatively new organization. see McFall 2006.36 MCFALL Annu. funding. these have been simmering beneath the surface since before the Boulder conference. practitioners. many research-oriented psychologists believe that history has proven that these concerns were warranted (Sechrest 1992). research. the clinical science model. with its focus on training research scientists. who do more of these things than scholar-practitioner faculties. Comparisons of data for training programs identifying with the different training models show differences not only in stated philosophies and goals. Clin. Today. psychologists and other scientists. and access to.” (For more on the clinical science model. Today.2:21-49. it must demonstrate that its training content and outcomes are consistent with this model. (b) “Research and Theory: To advance the full range of clinical science research and theory and their integration with other relevant sciences”.. values. For personal use only. unified field. in turn. (2000) found that the faculties and students at clinical science programs are more actively involved in research than the faculties and students at scientist-practitioner programs. 2006. who skillfully will produce and apply scientific knowledge”. The CoA regards each model as a legitimate framework for accreditation but expects to find truth in the advertising: Once a program declares its model. and goals are not new. The Academy has established specific goals in five areas: (a) “Training: To foster the training of students for careers in clinical science research. and careers in clinical science”. Moreover. For by University of Delaware on 11/29/07. are more active than the faculties and students at scholar-practitioner programs. clinical scientist) when applying for accreditation. Downloaded from arjournals.e. they found that clinical science faculties publish more journal articles and give more presentations than scientist-practitioner faculties. The faculties at scholar-practitioner programs . resources and opportunities for training. is not new. Now that these differences are out in the open. it is difficult to maintain a public pretense that clinical psychology is a homogeneous. Woodworth (1937) had raised such concerns long before the Boulder conference. Cherry et al. The same pattern characterizes the students in the three models. (c) “Resources and Opportunities: To foster the development of. scientist-practitioner. (d ) “Application: To foster the broad application of clinical science to human problems in responsible and innovative ways”. Rev. A major faction at the Boulder conference had argued that science training should be the central goal of all doctoral training in psychology and had opposed the move toward professional practice training on grounds that this almost certainly would undermine the science training. but also in activities and outcomes. Psychol.

For personal use only. and capital. physical. Local politicians may act as though their decisions shape the future of their cities. with their differing answers to the “why” question. the outcome will be determined. humbling analysis. labor. by major forces operating outside of psychology. CMHC (15%). and medical center. and academic (11%). This is a thought provoking. other/multiple (23%). 2006. For clinical psychology to survive. and the unintended consequences of governmental programs. . These forces are reshaping the world in which clinical psychology and doctoral training are embedded. transportation systems.annualreviews. Rae offers a compelling account of the influence exerted by forces such as geography. hospital. technological developments. Clin. and postdoc (9%). but the outcomes actually are governed by other forces usually perceived clearly only in hindsight. access to energy. changing workforce demographics and skill requirements. using the city’s rise and fall to illustrate a general thesis that the fate of all cities is determined largely by economic. private practice (13% each). Training models do seem to make a difference. Psychologists may act as though they control their by University of Delaware on 11/29/07. A similar analysis of clinical psychology’s history would suggest that external forces are shaping the mental-health-care system and. postdoc (13%).2:21-49.CLINICAL TRAINING 37 engage in more service delivery than the faculties at scientist-practitioner programs. Interestingly. and freeway construction. Downloaded from arjournals. and social forces beyond the control of local governments. medical center. hospital. all designed to fix city problems. such as zoning. urban renewal. Rev. THE CHANGING FACE OF CLINICAL PSYCHOLOGY Forces of Change In an enlightening book. 3. subsidized housing. who provide more service than the faculties at clinical science programs. hospital (14%). 2. Annu. private practice (12% each). whereas scholar-practitioner students provide the least. Cherry et al. scientist-practitioner students provide the most service. the future of doctoral training in clinical psychology. Scientist-practitioners: medical center (18%). forces over which psychologists have little or no control. Psychol. consequently. Clinical scientists: academic (29%). although we must be cautious about drawing causal inferences from such correlational data. Scholar-practitioners: CMHC (25%). the tug-of-war among the different training models. will not be decided by debates or internal political struggles. instead. Yale political scientist Rae (2003) traces the history of New Haven. it must adapt to these forces and the new world they are creating. with clinical science students in the middle. but in the long run. (2000) reported that the five most common work settings for graduates from the three types of programs are as follows: 1. Connecticut.

with its shift from a fee-forservice model to a managed-care model of health-care delivery. especially the urgent need to control the skyrocketing costs of health care. conduct Internet therapy. train third-world providers. Cummings 1995. its insistence on accountability and evidence-based decisions.. One prominent example has been APA’s lobbying effort to persuade states to adopt laws granting prescription privileges to psychologists. 2006. Initially. This may be a slim reed. offer genetic counseling. two themes stood out. and psychology’s piece of that shrinking pie has decreased at an even faster rate (Bickman 1999). the managed-care movement is driven primarily by economic concerns.. and its focus on cost control. Seligman & Levant 1998). Indeed. alternative roles for psychologists (e. conduct physical exams. provide antiterrorism policy consultation and service. do risk evaluations for courts. and the public to adopt a more expansive conception of psychological education and practice. Implications of Managed Care In my review of professional practice literature from the past 15 years. 2001). as primary care physicians currently write over 80% . engage in political activism. provide telehealth services. even though they still are not sure what to do about this. act as trial consultants. however.annualreviews. mental health’s share of the total health-care budget has shrunk. Rupert & Baird 2004). For personal use only. The first theme is the widespread distress over managed care’s impact on traditional clinical practice. Downloaded from by University of Delaware on 11/29/07. 2001. Perrott 1998. engage in profiling/detective work. The same economic logic that helped social workers displace psychologists as the primary providers of traditional mental health services—the logic of cost-effectiveness analyses—has given life to psychologists’ hopes of displacing psychiatrists as the writers of prescriptions for psychoactive drugs. but these attacks soon gave way to articles offering advice on how to survive in a managedcare world (e.g. provide primary health care. Annu. Although mental health care accounted for less than 10% of all health-care costs and was not the primary target of the reforms.38 MCFALL Managed Care The most powerful force in the last 25 years—a 600-pound gorilla that cannot be ignored—has been the advent of managed care. provide infant care. the following is a small sample of the proposed new roles: write prescriptions. Under managed care. offer end-of-life care. Karon 1995. engage in medical crisis counseling. and provide psychological services to businesses. Rev. provide distributed or online education. practice in schools. Reed et al. The second theme is the search for new.. Psychol.g. APA has responded to the challenges of managed care by encouraging its members.2:21-49. Psychologists gradually seem to be absorbing that managed care is a major force not likely to disappear any time soon. this was expressed in articles attacking managed care (e. governmental officials. Clin. managed care’s impact on mental health care has been dramatic.g. offer entrepreneurial “niche” psychology. To illustrate the scope of envisioned possibilities. both reflecting practicing psychologists’ angst over uncertain professional futures. serve as psychologist-legislators. Levant et al.

.CLINICAL TRAINING 39 of all such prescriptions. Heiby et al. psychologists seem to be recognizing. and public health (Heiby 2002. Practitioners too often have disregarded the scientific evidence on assessment (Garb 2005). doctoral programs training large numbers of students should admit fewer students. there is less justification for continuing to train doctoral-level clinical psychologists for careers as practitioners. nor did the articles provide empirical evidence that (a) the new roles were in response to genuine needs. As noted above. Most research-oriented programs already admit small classes because research training is individualized and labor intensive. Robiner et al. Downloaded from arjournals. The demand for doctorallevel clinical psychologists trained primarily for careers as practitioners is declining.annualreviews. (b) psychologists were either qualified or the most logical choices to fill such roles. about which they know little. Given the imbalance between supply and demand. they also must change. The implications of managed care for doctoral training in clinical psychology are no less significant: Given the workforce changes wrought by managed care. and for which there is little empirical research support? The advent of managed care has profound implications for the future of professional practice in clinical psychology.2:21-49. Psychol. For personal use only. Unfortunately. the prospects seem dimmer. these lobbying efforts have made some headway. 2004. Just because someone can identify a need does not mean that the person can do anything effective to meet that need. Rev. it already has transformed the workforce. that as the world changes around them. the career prospects for practitioners currently employed may not look too bright. at some level. with little likelihood that this trend will be reversed or offset in the future. the field more generally. The articles encouraging psychologists to invent new roles for themselves were a bit disconcerting. Clin. with clinical psychologists being displaced as the primary providers of mental health services and with over 40% of currently employed psychologists working in positions not directly related to psychology. but for those not yet in the workforce who hope to become clinical practitioners. there also is less justification for continuing to train the same number of doctoral students as in the past. ignored clinical practice guidelines (Phillips & Brandon 2004). despite a heated debate within psychology about the merits of this gambit and its potential negative impact on doctoral training. Nevertheless. In general. However. or (c) psychologists actually had cost-effective services that they could deliver in such roles. 2006. Doctoral training programs and internships too often have failed to ensure that trainees are competent in empirically supported therapies (Crits-Christoph et al. So why should psychologists be entrusted to tackle new roles for which they were not trained. as Robiner & Crew (2000) Annu. none of the articles describing potential new roles for psychologists gave much consideration to how these roles might relate to doctoral training. and neglected to monitor their treatment outcomes (Lambert & Hawkins 2004). Consequently. the number of psychologists trained for these careers continues to increase. 2002. 2003). these programs have “rightsized” naturally. 1995). by University of Delaware on 11/29/07. Psychology’s track record for managing its traditional roles in clinical assessment and intervention has been spotty. leaving a small market share for psychologists to capture from psychiatrists.

which has led to some bad decisions and unhappy results. It has attempted to counter and co-opt the EST movement by reframing the issue in a less rigorous way. However. 1998. and quality control. too many doctoral programs in clinical psychology provide training for which there is less demand or need. If embraced by psychology. Amid the gloom over the impact of managed care. accountability. 1996. if the scale of doctoral training were adjusted to more appropriate levels and the training goals became more focused and realistic. this would lead to cascading changes in internship programs. under the label of evidence-based practice. managed care’s attention to data-driven. this could serve as a positive force behind clinical scientists’ push to improve the scientific foundations of mental health care and doctoral training in clinical psychology. The task force subsequently generated a series of reports and updates (Chambless et al. I have argued. Chambless & Ollendick 2001). and asked this group to review the empirical research literature on clinical interventions and identify those procedures supported by a reasonable body of evidence. Clin. All of these changes would be tough pills to swallow. A major by-product of the managed care movement has been its increased emphasis on cost-effectiveness.2:21-49. then president of Division 12 of APA. Admittedly. 2004. This effort to promote empirically supported treatment (EST) has met with growing opposition from some quarters of psychology. launched in the mid-1990s by David Barlow. He formed the Task Force on the Promotion and Dissemination of Psychological Procedures. Downloaded from arjournals. For personal use only. chaired by Chambless (1995). In general. In fact. A prime example of this push is the campaign to identify and promote empirically supported clinical practices. 2005. 1996. continuous quality improvement should be built into all mental health delivery systems. It is a lively debate that shows no sign of subsiding (see CritsChristoph et al. for an opposing view. Rotter 1971. Westen et al. Weisz et al. these concepts have not always been applied in principled ways. the leadership of APA recently added fuel to the fire. 2005.annualreviews. including the president of APA (Levant 2004). Of course. postdoctoral training programs. 2005). should be welcomed by psychological scientists. hence. and psychology departments. in principle these concepts are congruent with psychology’s traditional scientific values and. some psychologists—myself included—see a possible silver lining. Rev. science-based approaches represents a long-overdue development. and all doctoral training in clinical psychology should be guided by these principles (McFall 1991. which have provided a framework for promoting accountability in clinical practices and increasing attention to the scientific foundations of intervention training in doctoral programs. see Peterson 1996). APA president Levant formed the Presidential . 2006. Psychol. From my perspective.40 MCFALL advised. providers should be held accountable for delivering the most cost-effective services available. 2000. that mental-health-care decisions and practices should be based on the best scientific by University of Delaware on 11/29/07. Positive Implications? Annu. but they may be necessary medicine for the long-term health of the field. for example.

Psychol. such as demands for cost-effectiveness. APA has taken the position that the EST movement’s definition of evidence is too narrow and restrictive. or ( f ) clinical supervision. If persons with master’s or bachelor’s degrees.s or Psy. let us consider the mythical belief that doctoral training increases the effectiveness of clinical service providers. The report was approved as official APA policy by the APA Council of Representatives in August 2005 (APA & Levant 2005). Bickman concluded that six common beliefs among clinical psychologists are myths. 2006. specialized. . (c) continuing education.annualreviews. the outcome of this ongoing EST–evidence-based practice battle is likely to be determined by outside forces. and integrative training in scientific research. (d ) licensing. psychologists do not agree on the definition of “best scientific evidence.CLINICAL TRAINING 41 Annu. Ultimately.D. or at least be consistent with this evidence? (As we have seen. If neither the quantity of clinical experience nor the amount of clinical supervision is correlated with effectiveness. should not the design of clinical psychology doctoral training programs be dictated by the best scientific evidence. which issued its final report in July 2005. Clin.) Are the designs of today’s training programs consistent with the scientific evidence? To explore this question. task force reports. After thoroughly reviewing the research evidence. Essentially. Second. Task Force on Evidence-Based Practice. With this action. he stated that it is a myth to believe that effective mental health services are assured by (a) clinical experience. For personal use only. redirecting these valuable and scarce resources to offering more extensive. perhaps doctoral programs should stop emphasizing the importance of accumulating a large number of supervised practicum training hours. Implications of a Science-Based Approach Most psychologists claim to be scientists. might do as well as those with Ph. Rev.s at delivering the same services. let us examine the degree to which today’s programs are consistent with the scientific evidence summarized by Bickman (1999). or at least claim to be “scientifically minded. or policy statements.D.2:21-49. what implications would this have for doctoral training and mental health practice? First. such as clinical experience or patient characteristics. (e) accreditation. giving too much weight to experimentally controlled randomized clinical trials while failing to give sufficient weight to other factors. (b) degree program training. and treatment specificity. let us consider the mythical belief that the amount of supervised clinical experience enhances the effectiveness of a provider’s clinical services.” but we set that problem aside for the moment. by University of Delaware on 11/29/07. admitting only those applicants interested in research training for careers as scientists. accountability. or perhaps with no degree at all. individualized. rather than by psychologists’ internal debates. If clinical psychologists were to take Bickman’s conclusions seriously and act accordingly. values. and context. perhaps doctoral programs should stop admitting applicants who are interested primarily in careers as practitioners. APA appears to have fired a shot across the bow of the EST movement. Downloaded from arjournals.” If these claims were true.

They should not be preoccupied with protecting their jobs as health-care providers. even if this requires a personal sacrifice. For personal use only. The welfare of those in need always must come first. to have achieved a state of functional autonomy. and continuing education requirements are additional ways to enhance clinical effectiveness. Clinical Psychology as an Applied Science Because it is an applied science. professional licensing. as well as with all other relevant sciences. not look for ways to soften scientific standards so that we can continue with business as usual. assessment. we should ask ourselves. committed to improving the human condition. respect for. we move from description to prescription. Anything less should be unacceptable. and contributions to scientific theory. Clinical psychology should be about pursuing knowledge and truth. Clinical psychologists should do whatever is required to promote the most efficient and cost-effective mental-health-care system possible. Here is a list of suggestions.42 MCFALL Third. In all respects. If these elements are nonessential. The level and integrity of the science in clinical psychology—i. Clinical psychology simply is the psychological science subarea concerned with advancing knowledge regarding the origins. knowledge. We should strive for increased rigor. and promotion of mental and behavioral health. it was a mistake from the outset of the field to equate scientific clinical psychology with professional practice careers. let us consider the mythical beliefs that program accreditation. and how should they do it? With these questions. if not derived from it directly. and methods—should be at least equal. Psychol. principles. perhaps they could be given less weight in doctoral training programs. to the high quality found in the rest of by University of Delaware on 11/29/07.annualreviews. but also to avoid acting in self-interest. and using this knowledge to solve problems. clinical psychology should be integrated fully with the rest of psychological science. Aside from its distinctive focus on clinical problems. Downloaded from arjournals. which brings us full circle. 2006. Imagine the resources that could be redirected to improving the science training. clinical psychology has an ethical responsibility not only to avoid doing harm. BLUEPRINT FOR THE FUTURE OF CLINICAL TRAINING What should clinical psychology doctoral training programs do. Like the motorcyclist. such as a loss in income or role. a great deal of our contemporary clinical training seems to be misguided. it should be indistinguishable from the rest of psychological science. Scientific Clinical Psychology Above all. Indeed. which I consider to be at least consistent with the above analysis. From this perspective. as determined by the best scientific evidence available—defined as rigorously as possible. Why ARE we still doing these things? Annu. reliance on. if not superior. it should not . clinical psychology should be a psychological science.2:21-49. prediction. Clin.e. Rev.

exploiting fully . Downloaded from arjournals. it also is most likely to remain a vital. and integrative as possible. methods. and flourishing field. Only one of the three leading doctoral training models—the clinical science model—seems to fit the needs and current realities in mental health under managed care. sensitivity to generalizability issues. 2006. increasingly. Training Research Scientists To design efficient and effective research training programs. etc. Programs should concentrate on what they do best—training research scientists. The clinical science model makes the most efficient use of scarce training resources and offers the best hope for clinical psychology’s future. or roles. flexible. recruitment and selection of trainees. the future does not look bright for doctoral-level clinical psychologists trained primarily for careers as mentalhealth-care providers. experience with clinical populations. both in terms of the integrity of the doctoral training provided and the likelihood that graduates will be prepared to make significant and enduring contributions to advancing mental and behavioral health. and methods. which offers the most solid foundation for clinical psychology’s future. focused. training components should be added to the design only when the logic and evidence are compelling. The Goal of Doctoral Training Annu. This is a principled course of action by which clinical psychology is most likely to make enduring contributions to the advancement of mental and behavioral health. written and oral communication.CLINICAL TRAINING 43 be about enhancing the professional guild. As scientists. The focus should be on ensuring that trainees acquire the necessary knowledge and skills to make important contributions to the advancement of our science and to the application of this science to the solution of mental and behavioral health problems. efficient. For personal use only. creativity and cross-fertilization. It is the only model in which training practitioners is not a goal. problems. the only one focused exclusively on training research scientists. technical competence. Doctoral programs should build on this special strength. we must be prepared to follow the scientific evidence wherever it takes us. The preeminent goal of all doctoral training in clinical psychology should be to train research scientists. research and grant support. content and curriculum. In each case. we need to start with a blank piece of paper. rather than clinging to past ideas. valid. in the process. For all the reasons I review in this chapter. performance evaluation. Rev. Research training has set clinical psychologists apart from all others in mental health. mentoring systems.2:21-49. investing in research training promises to yield the best returns over time. skeptically examining all aspects of training: the high school and undergraduate background. evolving along with the science. The aim should be to make the program as streamlined. Clin. this research expertise represents the most significant and distinctive value-added contribution clinical psychologists can make to mental health. ethics. Psychol. Moreover.annualreviews. pedagogical philosophy and training by University of Delaware on 11/29/07.

Essentially. relying less on standardized checklists of formal courses. it clearly differs from the superficially broad and general training found in programs concerned with standardization and satisfying external requirements. All decisions about which skills and knowledge a trainee needs flow naturally from the trainee’s choice of research problems and theoretical approaches to investigating those problems. in the spirit of continuous quality improvement. an “as needed” approach to the acquisition of knowledge and skills. analyze the designs of successful clinical science programs. For personal use only.g. but they also will be encouraged to share the conceptual and methodological . mathematical modeler. the new paradigm growing out of recent developments in digital and fiber-optic technology. Although no two trainees in such mentorship programs may acquire exactly the same sets of skills and knowledge. in which trainees work closely with a research mentor. we need to ask how it can be done even better in the future. it is not concerned with coloring inside the lines. and integrative. ethicist. and study the methods of research mentors with exceptional records of training outstanding scientists over the years. but such anecdotal case-study methods are of limited value. and the inquisitive pursuit of answers to puzzles raised by unexpected results.44 MCFALL Annu. Another trainee might need to develop equally deep expertise in a different set of content and technical areas to pursue a different research problem. with the configuration dictated by the demands of the particular problems being investigated. article writer. Successful mentorship training ensures the acquisition of a broad range of specific knowledge and skills. It also tends to be highly individualized. study the training histories of outstanding clinical scientists (Levenson 2004). Unfortunately. These steps should help generate by University of Delaware on 11/29/07. We should not expect standardization in training.. systematically testing our hypotheses about effective research training. We must collect data. there undoubtedly are multiple ways to achieve similar positive outcomes. electrical engineer. Integrative Training Most successful research training programs rely on an apprenticeship model. and therapist for anxiety disorders. 2006. Rev. This type of training tends to be intensive. assessor. Clin. there inevitably are commonalities and overlap. psychophysiologist. Then. It is not a paint-by-the-numbers approach to training. conducting programmatic research on specific problems. for instance. One trainee. looking for factors that might have contributed to the desired outcomes: e. We first need to investigate how they have done this.2:21-49. there is little solid research on how to train research scientists (Klahr & Simon 1999). behavioral geneticist. might need to become an expert psychopathologist. Individualized. Nevertheless. computer programmer. Psychol. focused. Downloaded from arjournals. Trainees not only will take a limited number of foundation courses. developmentalist.annualreviews. grant writer. we need to “reverse engineer” exemplars of successful training. more on direct lab experience. a number of clinical science training programs can point to outcome data showing that they have been successful.

it might be achieved. Annu. these programs are designed to ensure that trainees learn more generally how to carry out independent programmatic research on specific cutting-edge problems. while recognizing that trainees should have reasonable prospects for employment following graduation. we should not take a cookie-cutter approach to doctoral training in clinical psychology.annualreviews. or allow the program’s content and structure to be driven by accreditation and licensing requirements that interfere with the program’s primary goals. they might spend their time more productively mastering skills more relevant to their research problem. Psychol.g. by University of Delaware on 11/29/07. The trainee’s competence in targeted areas should be assessed directly through performance samples. With this higher-order knowledge. However. and research supervision. such as the number of supervised clinical hours or the number of tests administered. For example. worry about students’ accumulation of supervised clinical hours. not always through clinical practicum experiences or formal coursework. surely must have first-hand knowledge of that disorder and a solid grounding in the best available assessments and interventions for that disorder.2:21-49. a clinical science trainee investigating a specific psychological disorder.CLINICAL TRAINING 45 details of their individual work through colloquia. roles as program evaluators or administrators in health-care settings. they should aim to train research scientists capable of filling a variety of roles—not only roles as faculty members in doctoral programs or medical schools. or involvement in research. This does not mean that clinical science programs should provide no training in clinical assessment and intervention. roles in health-policy research. independent study of training manuals. the design of such training (as with all the training) should be dictated entirely by its intended purposes. and shared problem solving. At the same time. such knowledge and grounding might be achieved in a variety of ways. Rev. through individual tutorials. tutoring. not indirect measures with questionable validity. What Not to Do We also can list things clinical science programs should not do. graduates will not be stuck in a narrow niche. posters. Clin. For example. education and training. but will be prepared to pursue a variety of research problems throughout their career. In short. such as schizophrenia. not by traditions and myths. Downloaded from arjournals. Rather. capable of pursuing only one problem. For personal use only. Trainees pursuing clinical research problems for which traditional therapy skills may be less relevant (e. doctoral programs should not be vocational schools. Clinical science programs should not emphasize practitioner training. or roles in any number of other areas that make good use of their research expertise. instead. instead.. but also roles as designers and evaluators of new assessments and interventions. molecular genetics studies of bipolar depression) should not necessarily be expected to demonstrate high competence in traditional skills. 2006. preparing students narrowly for specific jobs. Such programs are designed to ensure that every trainee emerges with the requisite qualifications and competencies to succeed as a scientific contributor in his or her problem area. seminars. .

html Am. and content. It is time to stop pretending. http://research. Levant RF.2:21-49. At the beginning. focused. it is time for clinical scientists to rid themselves of the burdensome balland-chain myth that clinical psychology is a homogeneous. Final report. flexible.46 MCFALL Sharpening Versus Leveling Finally. Once again. these students represent the future of our field. we must teach them to ask the critical questions. We cannot afford to be complacent. it is impossible to determine which differences. Washington. Rev. And I sketched a blueprint for the future. values. apa. It is time to declare that all ideas. DC: APA Annu. .org/ practice/ebpreport. Clin.pdf Am. faced with difficult choices for its future. Clin. Downloaded from arjournals. by University of Delaware on 11/29/07. analytical. 2005. emphasizing the key differences found in clinical psychology today rather than minimizing or ignoring them. Assoc. Assoc. Psychol. all epistemologies are not equally reasonable. Psychol. 2005.annualreviews. Psychol. that the graduates of various doctoral training programs have more commonalities than differences. theories. “Why ARE we doing this?” Surely we can do better. Am. and committed to excellence. psychclinicalscience. It is time to declare that the different training models. In the end. To ensure that clinical psychology is in good hands. org/ LITERATURE CITED Acad. The Annual Review of Clinical Psychology is online at http://clinpsy. Report of the 2005 Presidential Task Force on Evidence-Based Practice. Office of Program Consultation and Accreditation. creative. We must model this kind of thinking for our students by critically examining our doctoral training programs in clinical psychology. http://www. Program consultation and accreditation. I explained why we must become self-critical. all types of evidence are not equally valid and informative. Psychol. I stated that doctoral training in clinical psychology stands at a crossroads. Research Office.apa. and one’s choices among all the various options in clinical psychology are not simply a matter of personal taste. 2005. and methods are not created equal and do not deserve equal consideration. As long as potentially important differences are obscured through leveling. After all. actually are critical to the outcome. some differences may not matter. Task Force on Workforce Analysis.. Assoc. Psychol. for example. Assoc. This skeptical sharpening is at the heart of scientific thinking and research training.annualreviews. if any.apa. but the only way to find out is by starting with the assumption that they might be important and then empirically ruling out this possibility. 2005. 2006. are not equally defensible. http://www. with their discrepant goals. Research office index. Now it’s time to get to Am. 2004. to continue with business as usual. For personal use only. Psychol. Clinical scientists need to become sharpeners rather than levelers. unified field. Many such differences are described in this review.

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viii CONTENTS COGNITION AND AGING IN PSYCHOPATHOLOGY: FOCUS ON SCHIZOPHRENIA AND DEPRESSION.2:21-49. For personal use only. Smith and Justin MacKenzie RECOVERED MEMORIES. 2006. Clin. Philip D. Timothy W. Harvey. Rev. Abraham Reichenberg. Maxine Stitzer and Nancy Petry PERSONALITY AND RISK OF PHYSICAL by University of Delaware on 11/29/07. Elizabeth F. Loftus and Deborah Davis Annu. INDEX Subject Index 499 ERRATA An online log of corrections to Annual Review of Clinical Psychology chapters (if any) may be found at http://www. Bowie 389 411 435 469 CONTINGENCY MANAGEMENT FOR TREATMENT OF SUBSTANCE ABUSE. Downloaded from arjournals.annualreviews. and Christopher R. Psychol.