Psychologists reflect on changing
professional landscapes
(February 2009 Issue)

“Psychology is a combination of philosophy and biology and I think we’ve kind of forgotten our roots,” says Jack Plummer, Ph.D., a psychologist who practices in Meriden, Connecticut. (photo by Tom Croke)

By Ami Albernaz

Psychologists starting out in the late '60s and '70s encountered a landscape different from what it is today. Training might have been broader, some might say more eclectic. In the time before managed care, therapy was more of an open-ended journey than a short trip. The physiological underpinnings of behavior were even less understood than they are today.

Psychologists throughout New England who have been practicing for three or four decades recently reflected on the changes they've seen. While they embraced advances in neuroscience and its contributions to the field, some were wary of ever-thinner dissection of therapies and disorders, fearing these factors obscure a more complete understanding of patients. Some were gratified by what they called long-overdue recognition of the mind-body connection. All acknowledged that times have indeed changed.

David Barlow, Ph.D., founder and director of the Center for Anxiety and Related Disorders at Boston University, received his Ph.D. in 1969. "In those days, there was no evidence that psychological interventions were really effective. There was no evidence that anything we did had any effect," he says. "I think we were all extraordinarily cautious about our conduct in therapy, because we thought we could do irreparable harm by bringing up material that people weren't ready to hear."

Barlow says that learning to research the efficacy of interventions has been one of the most significant developments of his career. The DSM-III, which was published in 1980 and provided the most detailed classification of psychopathology to date, allowed for interventions to be more precisely focused.

"Over the years, more studies came out until we clearly had overwhelming evidence that the procedures and interventions we've been using are effective," Barlow says. "On the other hand, we're nowhere near where we should be. We've completed the first stage of developing effective treatments. But as we learn more about the treatments we develop, we now recognize that maybe we've sliced these disorders too thinly."

Barlow, who is working on DSM-V, due out in 2012, says the new handbook will likely be organized around higher-order principles of disorders. Treatments for anxiety and depression, for instance, might be more integrated and based on patterns common to emotional disorders.

Advances in neuroscience will continue to inform our understanding of disorders and the efficacy of treatment, Barlow says. In order to stay true to their profession and be able to meaningfully inform public policy, the next generation of psychologists should be well-trained in brain science, says Jack Plummer, Ph.D., who practices in Meriden, Conn. and serves on the APA's Council of Representatives.

"Psychology is a combination of philosophy and biology and I think we've kind of forgotten our roots," Plummer says. "Some people think psychologists don't belong in politics, but I think if our opinions are based on science, they can do a lot of good."

Plummer is quick to distinguish grounding in science from misplaced faith in pharmaceuticals.

"The medicalization of psychology hasn't served us well," he says. "I can appreciate the drive for prescription privileges, but what bothers me is that the whole world is pill-oriented and we don't want to be in the back pocket of pharmaceuticals. How about helping people find non-medication alternatives to changing their behavior? We still don't know how drugs work, but I think we've been taken in by them." Although research supports the efficacy of certain treatments such as cognitive-behavioral therapy, some psychologists fear that over reliance on these techniques means patients are no longer fully benefiting from the full range of methods psychologists have traditionally had at their disposal.

"It now appears psychologists have a more narrow range and specialization; their skills tend to be not as broad," says Leslie Feil, Ph.D., a psychologist in Barrington, R.I. and clinical assistant professor of psychiatry and human behavior at Brown University's Alpert Medical School. "I've been concerned that there tends to be a greater reliance on cookbook approaches to treatment, like CBT. I've often found they're very valuable… but I don't find it a substitute to learn how to do family therapy or for children, play therapy when appropriate. I think it's valuable to have different tools to deal with different cases."

Dannel Starbird, Ph.D., a psychologist in Dover-Foxcroft, Maine, says that technique-based training has risen as mental health professionals such as social workers and counselors have started administering therapy.

"As the amount of training has gone down, technique-based training has gone up," Starbird says. "CBT lends itself to a fairly easy, concrete description. It lends itself to easy teaching."

He agrees with Feil in that what's lost is a deeper reservoir of approaches to draw from - the mixture of psychoanalytic, psychodynamic and family models that he and his colleagues in the '70s were steeped in. Managed care demands psychologists be trained in empirically proven techniques and delineates approaches with which therapists can align themselves, he says.

"In the past, you would expect a psychologist to be able to take different approaches, to have a way to see a patient that would not require one single technique," he says.

Managed care has helped change therapy from a slow, open-ended journey to a short trip with a set destination, suggests Allan Lurvey, Th.D., who practices in Portsmouth, N.H., and is a past president of the New Hampshire Psychological Association.

"Managed care has been successful in teaching the public they can expect solutions from therapy - whether medicine or problem-focused therapy," Lurvey says. "It's an attempt to solve health expenses through letting the market determine what care is going to be given. I don't think there's a lot of thought given to what the better treatments are or what they might be."

Psychology students and patients today expect therapy to be more of an exact science than an art. "Students come in and they're not acquainted with inward ways of knowing human beings," Lurvey says. "Consumers of mental health don't understand when you teach about the internal life; it's all new to them. They expect that there will be a direct approach to fixing problems."

A fairly recent bright spot has been the recognition of the mind's influence on physical health. Starbird recalls that by the late '80s, he was incorporating principles from Herbert Benson's relaxation response into therapy; now, stress management is on par with CBT as a component of treatment.

Psychological factors of serious illnesses are now more discussed as well, which is gratifying for psychologists like Bernard Bandman, Ph.D., who has been facilitating communication between doctors and cancer patients for more than 20 years and in 2001 co-founded The Center for Communication in Medicine in Bennington, Vt.

"When you address the psychological needs of patients, you have better outcomes," Bandman says. "Sometimes patients don't understand what the doctors are saying because they feel overwhelmed and anxious; they don't really hear what the doctors say." Allowing patients to talk freely about their diagnosis and helping doctors better understand the impact of their words on patients both seem to lead to better compliance, Bandman says.

"In 2007, the Institute of Medicine [of the National Academies] identified the importance of addressing psychological care in cancer," Bandman says. "Over 20 years later, it gets legitimized, while we in the field have known it all along."

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