30 Module 30: Clinical Psychology: The House that Psychology Built

Module 30: Clinical Psychology: The House That Psychology Built

Remember and Understand

By reading and studying Module 30, you should be able to remember and describe:

• The relationships among the various subfields and topics in psychology
• The scientist-practitioner gap
• Evidence-based practice
• The dangers of letting untested therapies proliferate
• Relevant research results
• Clinical judgment versus statistical prediction
• Alternative therapies
• Self-help books

Each of the six units in this book ends with special module like this one. Each of the ending modules uses one of the subfields of psychology to explain and illustrate some principles about the way science works. Specifically:

• Unit 1 (Module 4) uses discussions, arguments, and debates among psychologists to illustrate the essential role that tension and conflict play in a scientific discipline.
• Unit 2 (Module 9) uses the story of how cognitive psychology supplanted behaviorism to illustrate the way scientific revolutions often occur in a discipline.
• Unit 3 (Module 14) uses the subdiscipline of biopsychology to show that scientific progress is not a smooth, unceasing process, that technological and methodological advances may lead to very rapid progress or to dead-ends and wrong turns.
• Unit 4  (Module 18) uses the development of developmental psychology as an example of the process through which individual researchers carve out a niche, “dividing and conquering” small portions of larger, agenda-setting theories.
• Unit 5  (Module 24) uses social psychology and personality psychology to illustrate how even a “basic research” sub-discipline can take on real-life problems.

In a way, this Unit 6 concluding module is a little bit backwards, as one of our goals here is to explain something about the organization of psychology itself, rather than to use the organization of psychology to explain some fact about the way science works. Specifically, we want you to understand the unique role that clinical psychology plays in the discipline.

Clinical Psychology and the House That Psychology Built

The different subfields of psychology—cognitive psychology, biopsychology, developmental psychology, social and personality psychology, clinical psychology, and so on—are not randomly situated within the field. Rather, they are related to one another, and these relationships reveal the way that the overall discipline is organized. You can think of this organization as a little bit like building a house. We can build up a discipline of psychology brick by brick, floor by floor, subfield by subfield.

Suppose we are building a house of psychology. Let’s think of the research methods on which the whole discipline of scientific psychology rests (Modules 1 and 2) as the foundation and biopsychology (Modules 10 and 11) as the bricks with which we will build the rest of house. All of the other subfields are built upon the foundation of research and out of the bricks of biopsychology. The basic scientific information about the way neurons generate and transmit signals, the electrical activity throughout the brain, the rest of the nervous system, and the endocrine system underlie everything else in the discipline. For example, every single section of this book could include a short description of action potentials and neural communication, focusing on the specific brain areas, neural networks, and neurotransmitters involved (as well as hormonal and evolutionary considerations). These details constitute a large part of what you might study if you were to take a full course in biopsychology.

Now let’s think about the topics or subfields that would make up the first floor of the house of psychology. We would use the processes that function to get the outside world into the head, namely sensation and perception (Modules 12 and 13). These basic processes, similar to the biological underpinnings themselves, underlie nearly all of the rest of psychology.

The second floor, built on top of the first floor, incorporates most of the topics from the basic subfields, namely cognitive psychology, developmental psychology, social psychology, and personality psychology. To link the first floor and the second floor, we need some stairs, some processes that allow us to get from an inside-the-head representation of the outside world to higher-level processes that use that representation. The stairs are memory, learning, categorization, emotion, and motivation (Modules 5, 6, 7, and 20). These stairs are the basic units of thought and feeling. They provide the bridge between the straightforward reflection of the outside world in our heads and the complex ways that we manipulate, change, and use that reflection to plan, reason, solve problems, self-regulate, interact, and function in our world.

Our second floor, then, composed of the higher-order cognitive and social processes, builds on and uses the outputs of the “stairs.” Our second floor is filled with processes like problem solving, reasoning, critical thinking, attribution, and influence (nearly all of the topics not yet listed from Units 2 through 5). Think about problem solving, for example. A parent might be trying to solve the problem that his son is not enthusiastic about school. The son often complains about going and often exaggerates minor aches so that they seem like illnesses. The ideas contained in the problem (son, school, illness, enthusiasm, and so on) are concepts, the result of categorization and memory. The particular strategies that the parent might generate to solve the problem are manipulations or combinations of these and other concepts he has in memory. For example, he might try to take advantage of his son’s love of learning and try to persuade him that school can be fun. Because education is important to most parents, this problem is likely to lead to strong negative emotions, which are likely to influence the parent’s motivation to solve it.

That brings us to the third floor and the roof of the house, the helping side of psychology. Just as the second floor built on and used the outputs of the first floor, stairs, and foundation, the top of our house builds on and uses all of the underlying knowledge about psychology. For example, think about one of the most important topics in clinical psychology, the understanding and treatment of major depressive disorder. The discovery from biopsychology of the role of low levels of serotonin and faulty serotonin receptor sites in depression has led to the use of selective serotonin reuptake inhibitor antidepressants. The discovery that specific brain areas, such as the hippocampus and cingulate cortex, are especially important in depression sets the table for the development of drugs that are even more selective, ones that may someday be able to have pinpoint effects, increasing neural activity only in the faulty areas. Discoveries from cognition and learning (such as learned helplessness and negative thinking styles) have contributed immensely to our understanding of the psychological factors that contribute to depression, as well as to effective psychotherapeutic treatments for the disorders.

As you can probably tell, psychology needs all of its subfields and research methods. Just as you cannot remove any part of a real house without rendering it unrecognizable and unusable, you cannot get rid of any piece of our discipline and still have a recognizable and useful psychology.

The Scientist-Practitioner Gap

There is, unfortunately, a problem in the house of psychology, however, that we have not yet discussed. To borrow an idea from Module 4, there is tension in the discipline of psychology. Remember, some tension is useful; if there is too little, a discipline grows stale and uncreative. If there is too much, though, a discipline can suffer from avoidance of difficult issues or even, if things get bad enough, explosive conflict. We are at the point in psychology where there is definitely some avoidance going on. Observers have referred to the situation as the scientist-practitioner gap. Although there has always been tension between researchers and practitioners in psychology (similar to other fields where basic researchers and applied practitioners must co-exist), some worry that the current gap is substantial and getting larger (Patihis et al. 2015; Tavris, 2003).

On one side of the gap are some therapists who contend that academic, scientific psychology is of little use in their efforts to help people solve their psychological problems in the real world. These therapists reject the idea that the effectiveness of a psychotherapy should be demonstrated through research. They contend that the process of therapy is too variable and fluid to expect that its effects can be measured (Carey, 2004). Some therapists feel strongly that psychotherapy is more of an art than a science.

On the other side of the gap are many academic and scientific researchers in psychology as well as a significant number of therapists and clinical psychologists. They insist that scientific psychology is intimately related to clinical psychology and that research is the only reasonable way to judge whether psychotherapy is effective. Note that, because some clinical psychologists also favor what has become known as evidence-based practice, which is the use of therapies that have been justified by research, this is not exactly a “scientist-practitioner gap.”

We have to reveal a very strong bias in this controversy. We are firmly on the side of the academic, scientific, and clinical psychologists who favor the use of research as a foundation for therapy. We simply cannot understand why anyone would want to ignore everything we have learned from the basic science of behavior and mental processes in favor of a non-scientific version of psychological therapy. It seems to us that ignoring or rejecting the role of research and scientific psychology would be like disbanding the Food and Drug Administration, the government agency that is charged with ensuring that drugs are safe and effective treatments for disorders. To return to the house of psychology metaphor, it is as if some clinical psychologists believe that the roof and third floor should be floating in mid-air, completely separate from, unsupported by, and unrelated to the rest of the house.

scientist-practitioner gap: tension between researchers and practitioners in psychology

evidence-based practice: the use of therapies that have been justified by research

The Rallying Cry of the Scientific Side: How Do You Know?

We think of some psychotherapy techniques, the ones not based on research, as a lot like advice. Advice is very unpredictable. Sometimes it is very good; for example, if you are a psychology undergraduate interested in going to graduate school, you might be advised to get involved in research (this is excellent advice). Sometimes it is not so good; many guidance counselors (and unfortunately, some well-known politicians) advise high school students that a psychology degree is a waste of time and money (if we may be so bold, we would like to suggest that this is dreadful advice). Sometimes, the exact same advice that would be good for one person would be very poor for someone else. That is what many untested therapies can be like; think of them as hit or miss. Without independent evidence of the effectiveness of a therapy technique, “how do you know” whether it will be a hit or a miss? Even if the outcome is favorable, “how do you know” that it wouldn’t have turned out that way without the advice or that some other advice wouldn’t have made the outcome even more favorable? For example, maybe you can get into graduate school without getting involved in research, and perhaps there is some other activity that would have give you an even better chance.

The alternative to advice is knowledge based on research. Suppose you are depressed and someone tells you to eat five pieces of dark chocolate per day because “chocolate releases endorphins.” How do you know if that is good or poor advice? Well, basically, you need to take a couple of hundred depressed people and randomly assign half of them to eat chocolate and half to eat a placebo (fake chocolate, sounds delicious!). After six months, as long as both researchers and participants are not aware of whether they are in the experimental group (chocolate) or the control group (placebo), we could measure whether the chocolate group is less depressed than the placebo group. If the chocolate group is less depressed, we could have some confidence that eating chocolate is an effective treatment for depression.

No doubt, there are some excellent non-scientific therapists and some currently untested therapies that will turn out to be effective (Lilienfeld, Lynn, & Lohr, 2003). Again, however, without research, how do you know? Unfortunately, it is difficult to rely on the judgments of the effectiveness of therapy from the therapists themselves. They are as prone to reasoning errors, such as the availability heuristic and the confirmation bias, as any individual (Module 1). For example, because of the confirmation bias, therapists might be very likely to recall only the clients they treated successfully and forget about the clients who were not helped (the ones who came for two sessions and never returned). The availability heuristic might lead them to overestimate their rate of success. Paul Meehl (1993), a psychoanalyst who was perhaps the first to demonstrate the fallibility of clinical judgment, noted that earning a PhD does not automatically cure one of the misperceptions, memory distortions, and judgment biases that are common in all people. Similarly, you cannot use individual cases or testimonials. You cannot rely on clients’ memories and judgments, as they are just as prone to distortions and errors as anyone else. You cannot use “reasonableness.” Ideas that seem equally plausible can be on opposite ends of the “correctness spectrum.” What is it that makes the idea of judging one’s intelligence by the shape of the skull ridiculous and the idea of judging by one’s body-adjusted brain size a reasonable possibility? Research. We have research for psychotherapies so that we need not rely on the fallible memories or judgments of therapists or clients, on testimonials, or on plausibility arguments.

You have to realize that there is real risk in letting untested therapies proliferate unchecked. If a scientific researcher has no regard at all for how her research could be applied, it may put the discipline of psychology at risk; the discipline may be in danger of becoming obscure and irrelevant (more likely, though, it is the researcher that will become obscure and irrelevant). On the other hand, the applied practitioner who ignores research puts people at risk. When psychotherapists choose ineffective therapies, they forfeit the opportunity to use treatments that would be effective. And we have unfortunately discovered that some therapeutic techniques are worse than ineffective; they are actually damaging. For example, therapies that rely on hypnosis to help recover repressed memories may actually contribute to the development of false memories (Lilienfield, Lynn, & Lohr, 2003; Spanos, 1994). And there are still a significant number of practicing clinical psychologists who believe in the concept of repressed memories despite decades of research debunking the phenomenon (Patihis et al. 2015).

What Research Has Shown Us

Let us turn now to some of the results of research that speak to the effectiveness of specific therapies and diagnostic techniques. This small sample will work well to demonstrate how wrong we can be if we embrace a clinical psychology that rejects research.

Clinical Judgment. For many years, it has been known that, as we suggested above, the intuitive judgments of clinicians can be wrong. Clinical psychologists often are called upon to predict people’s behavior (is an individual at risk for suicide, is he a danger to society, and so on) or to make diagnoses or predict outcomes (for example, will an individual get better). When the judgments of clinicians are pitted against statistical predictions, the clinicians rarely come out on top. Even when very experienced clinicians are making the judgments, they often do not do well. And among the worst kinds of judgments are those that involve clinical interviews (Bonta, Law, & Hanson, 1998; Meehl, 1954; Grove et al. 2000; Swets, Dawes, & Monahan, 2000). Just talking to a client is not that good a way to figure out what is wrong or what is going to help the person.

As you might guess, different psychologists can disagree about the causes of a particular disorder. For example, a psychodynamic psychologist may believe that depression is caused by anger toward another person unconsciously directed toward the self, while a cognitively trained psychologist might believe that depression results from a pattern of self-defeating thinking. Whatever your preferred explanation is, it should not influence your decision about whether someone has the disorder, however. In other words, a therapist’s diagnosis should not be affected by his or her theoretical orientation. But at least some of the time, it does. For example, one study demonstrated that clinicians were more likely to decide that a hypothetical patient suffered from a particular disorder if the symptom list included symptoms that were important for their own preferred theory rather than other, equally diagnostic symptoms (Kim & Ahn, 2002).

Alternative Therapies. Perhaps you were unimpressed with our “chocolate cures depression” example. Perhaps it seems a bit far-fetched that someone would propose something so preposterous. Well, a Google search for “alternative psychotherapy” returns many directories containing unscientific therapeutic techniques, including:

• Music and gong therapy
• Sand tray therapy (playing in a miniature sandbox)
• Primal therapy (re-experiencing and expressing childhood problems)
• Acupuncture
• Aromatherapy
• Bowen technique (apparently, the therapist, ahem, touches the client, through clothes of course)
• Homeopathy

And although you have to search a bit more, you can find information on therapy techniques based on:

• Astrology
• Enneagram (an ancient method of determining personality)
• Transformative dreamwork (a technique that reveals hidden meaning in our dreams, some of which are “sent” to us)
• Color therapy (the use of colors or colored light to correct imbalances)
• Voice therapy (retraining of the vocal cords to produce empowerment, liberation, and pleasure)
• Toning and chanting (vocalization of pure sounds, sometimes repetitively, to enter a higher state of consciousness and heal oneself physically, spiritually, and emotionally)
• Past-life therapy (a technique in which the therapist guides you to visit your past lives to heal old wounds and disturbing memories)
• Light therapy (the use of bright lights for 30 minutes per day to relieve symptoms of winter depression)

Oh, by the way, that last one, light therapy, is a little different from the others. We know that  it works. Guess how we know. Right, research. Several experiments have demonstrated that people suffering from winter depression do indeed improve when exposed to light, compared to those given placebo treatments (Eastman, et al. 1998; Lewy, 1998; Terman et al. 1998; 2001). A recent meta-analysis even found that it is effective for both seasonal depression and non-seasonal depression (Geoffroy, et al. 2019).

The rest of the list, and dozens if not hundreds of additional alternative psychotherapy techniques, are available to cure nearly anything. At best they are untested; at worst, they have been demonstrated worthless by research. Occasionally, they are downright dangerous. In 2001, a 10-year old child in Colorado was suffocated by therapists during a rebirthing treatment, part of a larger therapy known as attachment therapy. Jean Mercer (2002) reported that there were no published studies using attachment therapy in a randomized, placebo-controlled design. Poor design and even statistical errors in the few studies that have been conducted have made for a very poor body of evidence in favor of attachment therapy. Mercer concluded from the evidence that the technique is not effective and is dangerous. The therapy is now illegal.

Oh, and about the depression-chocolate idea? It is suggested in the book Depression for Dummies (Smith & Elliot, 2003). There are exactly zero scientific journal articles in PsycInfo, the exhaustive listing of research in psychology, examining this link experimentally, although there was one study, a large survey, that showed a correlation between consumption of dark chocolate and reduced symptoms of depression (Jackson et al. 2019). We hope we do not have to remind you about correlation and causation. A second study, this time an experiment, did find that cocoa polyphenols (almost chocolate) did improve mood over a placebo in healthy individuals. But that is a far cry from treating clinically significant depressive symptoms. Incidentally, this study described itself as the first to provide experimental evidence of the ability of cocoa polyphenols to help regulate mood (Pase et al., 2013).

Self-Help Books. Many scientific psychologists lament the state of affairs in our local and online bookstores. One local store near us devotes more than three times the shelf space to self-help as to psychology. There are certainly excellent self-help books based on concepts and techniques that have been supported by research. Unfortunately, however, it seems that the very large majority are not based on psychological theory and research (Stanovich, 2004).

Making matters worse, very few research studies have examined the effectiveness of self-help books, even the ones that are based in psychological research and theory. For example, Gerald Rosen and his colleagues searched an entire decade and identified only fifteen such studies (Rosen, Glasgow, & Moore, 2003). That is a pretty frightening state of affairs when you consider that if you type “self-help” into the search box at internet bookseller Amazon.com, it returns more than 100,000 results.

Final Thoughts

Scott Lilienfeld of Emory University is one of the chief proponents of evidence-based practice. He is the editor-in-chief of the journal, Clinical Psychological Science, and co-editor of the book Science and Pseudoscience in Clinical Psychology. We recommend that you remember his name if you are intrigued by the small sampling of research results that we have outlined briefly here. Always remember, the goal of the evidenced-based movement is not to reject all clinical psychology as quackery. It is to help us sort through the hundreds of possible therapeutic techniques, allowing us to direct our attention to the ones that are most likely to be effective because they have a body of research supporting them.

Our goal is a more effective psychology, of course, one that integrates the myriad research discoveries about human behavior and mental processes with the goal to help people. We also believe that this close relationship between clinical practice and research will improve psychology’s reputation. Keith Stanovich (2019) has referred to psychology as the Rodney Dangerfield of the sciences. (Rodney Dangerfield is the late comic who was famous for his signature line: “I don’t get no respect.”) One of the key reasons that Stanovich cites for this lack of respect is that the non-scientific, even the fringe wing of psychology is often the most visible.

Several years ago (some, more years than others!), the three of us decided to devote our professional lives to psychology. Looking back over our lives up until now, we would each have to say that it was one of our top five all-time decisions. The house of psychology is something that we are proud to be a part of. The whole discipline, complete with all of the basic and applied subfields, is the psychology that we know, love, and respect. That is the psychology that we want you to know, remember, and use.