Haruhiko Shimoyama, Ph.D., The University of Tokyo, Japan

Note: This study was supported by the grant in aid for scientific research of the Ministry of Education and Science (The number of the grant is 14310053)

1. Introduction

Clinical psychology has developed rapidly as a profession in this decade in many countries. However, the way in which the developments have occurred varies from country to country and the changing processes are still ongoing. So it is very difficult for any clinical psychologist to make a definitive prognosis for the future and prescribe the right way for clinical psychology to grow.

Nevertheless, in response to rapid developments and social demands, clinical psychologists have to improve the training system for the future (Helmes & Wilmoth 2002, Shimoyama 2002, Kennedy & Llewelyn 2001, Drabick & Goldfried 2000). Therefore, developing training programmes is an urgent task of clinical psychology today and the programmes should be drawn up according to a future model based on its development. As a whole psychologists review different life histories and find the developmental tasks common to various processes in order to formulate a developmental model. So I try to extract some common rules of the development of clinical psychology as a profession in this paper. I will make use of a comparative study and the metaphor of an experimental design for the formulation. The comparison between developments in Britain and in Japan will be used because they fit well with the experimental design.

2. Method

2-1. Describing the Histories Comparatively to Produce a Research Design

We will begin by considering the histories of clinical psychology comparatively between Japan and Britain. The Japanese Association of Clinical Psychology (JAC) was established in 1964, while the Division of Clinical Psychology in BPS was formed 1966. It means both of Japanese and British Clinical Psychology (JCP and BCP) actually started almost at the same time after the Second World War.

Then, let us see what happened to each of them afterwards. Concerning JCP, the Foundation of the Japanese Certification Board for Clinical Psychologists was established in 1988 and a 2 year master course was set up as the training course for certificated clinical psychologists. In 1995 the Ministry of Education in Japan started to introduce a school counselling system and formally adopted clinical psychologists as the counsellors. As for BCP, the British government commissioned a special review of the function of clinical psychologists in 1988 and a 3 year doctoral course was formally established in 1995 as the training course for chartered clinical psychologists. These social events suggest that the social demands for clinical psychologists increased in the 1980s and 1990s in both countries.

Thus, the periods of developing are similar, but the ways might be different. So we need to examine the ways in which JCP and BCP have grown so far. To clarify the difference I would like to focus on the role of science in developing their disciples because being scientific is considered to be one of main issues to make psychology professional.

At first we will look over some historical topics for JCP. In the 1950s, client-centred counselling was introduced to the field of clinical psychology in Japan from the U.S. with enthusiasm. In the 1960s,JAC started to work towards developing a nationwide certification system for professional psychologists following the APA method. However, younger members joined together with young radicals to insist that such a system of qualification would side with a social authority that was oppressing weak people such as patients. In the 1970s, JAC was dissolved in 1973. Professor Kawai, who had qualified from Jungian institute, assumed the leadership in reviving JCP. He has led JCP into its present orientation based on the individual and intra-psychic psychotherapy model, which is hardly scientific. In 1980s, JAC was re-established on the basis of the model in 1982. The history confirms that being scientific has not been an agenda for JCP.

Next, we will review briefly some historical references and topics for BCP. Eysenck(1950) claimed clinical psychologists be scientist-diagnosticians to play an important role in psychiatric field. Pilgrim & Treacher (1992) showed that Eysenck’s works have been very influential in that they had lead BCP to the scientist-practitioner model and directed the way of its developing. Corrie & Callahan (2000) also indicated that the British scientist- practitioner model owed its status principally to Eysenck, who criticized psychoanalysis from scientific point of view (Eysenck 1952) and popularised behaviour therapy instead (Eysenck 1958). Behavioural therapy had been dominant in the 1950s-70s. It was converted into cognitive-behavioural therapy in late 1980s (Rachman 1997), but the scientific attitude is still very important in terms of evidence-based approach. The history and the writings confirm that being scientific has been an agenda of BCP.

2-2. Fixing the Design of the Experiment to Study the role of being Scientific

Consequently, we can say that the attitudes towards science are completely different between JCP and BCP. On the one hand, BCP has continued to assume that clinical psychology is itself scientific. On the other hand, JCP has turned out not to be scientific. I guess that the difference has made their developmental processes totally different. So what I wish to do here is to clarify how those attitudes towards science have influenced the developmental process in clinical psychology and consider the developmental task and model by using a comparative study with a metaphorically experimental design.

As the attitudes towards science might be an important factor to determine the ways of their development, we should introduce “being scientific” as the independent variable of the experimental design. “Becoming a profession” is a result of the development, so we should make it as the dependent variable. British clinical psychologists have intervened in the discipline with a view to being scientific, while Japanese clinical psychologists have been scarcely involved in the disciple in order to make it scientific. Therefore, we can define BCP as the experimental group and JCP as the control group. Finally we produce the design of the experiment shown as Table1 and formulate a hypothesis. That is being scientific would make a contribution towards clinical psychology’s growing into a profession.

3. Result

3-1. Examining the Changes of the Experimental Group

To confirm the hypothesis we need to investigate the effects of the intervention done by BCP with a view to being scientific. As the effects manifest themselves as the change of BCP that is the experimental group, we should examine it in comparison with that of JCP.

BCP has already established its distinction and consistency as a discipline and profession. Clinical psychologists in Britain tend to define the discipline in terms of (a) the basic science of psychology and (b) its application to the understanding and resolution of human problem. They claim that clinical psychologist is first and foremost “scientist-practitioner” (Marzillier & Hall 1999). Clinical psychology training involves a specialized knowledge of psychological functioning and psychological methods, which provides particular expertise in carrying out psychological assessments such as psychometric tests, formulating problems psychologically, psychological treatment, and psychological methods of research and evaluation. In basic training clinical psychologists specialize in behavioural and cognitive therapy.

In the course of becoming a profession, BCP has undergone a relatively recent evolution from an ancillary service to the medical profession, operating in very confined contexts, to the clinical psychologists of today, many of whom act as independent practitioners, contributing to virtually every aspect of health care, not only in patient-related activities, but also in environmental, organisational, planning and managerial aspects (MAS 1989. In the summary of “Review of clinical psychology services”).

3-2. Examining the changes of the Control Group

By contrast, JCP, far from becoming a profession, has been in the state of confusion and splits even as a discipline. First, as it contains ambiguous overlaps between clinical psychology, psychotherapy and counselling, it cannot even define itself as a discipline. Psychodynamic (especially Jungian) theory has maintained its influence so much that purely intra-psychic psychotherapy has continued to be an ideal model. However, the intra-psychic model is actually so specialized that most members are not able to master it. In addition, many problems that clinical psychologists are now expected to deal with are concerned with social behaviours in daily life. So such kinds of psychotherapy are of no practical use. As a result, the reality is that only a few leaders are psychodynamic (analytical) psychotherapists and the larger body are in effect counsellors. And very few are clinical psychologists as described by the British definition.

Second, JCP has been subject to theory-based sectionalism. Since psychotherapy adheres to its own theory it is inevitable that clinical psychology led by a group of psychotherapists is unable to go beyond sectionalism towards integration. As each school sees clinical psychology just from its own theoretical point of view it is very difficult to decide what should be taught as basic knowledge and skills and what training should be given. As a result, such theory-based sectionalism has caused a sort of paralysis as JCP struggles to establish a consistent discipline and develop the training system.

Third, JCP has had split between practice and research, which has resulted in alienation of research. Psychodynamic psychotherapy particularly tends to direct such exclusive attention on its own intra-psychic theory and aetiology that it cannot help being against evidence-based scientific thinking. In fact, JCP has not paid attention to psychological assessment and psychological research.

Fourth, JCP has also had spilt between training courses in universities and clinical fields in the community. Psychodynamic psychotherapy tends to focus on the training of skills such as dream analysis, transference analysis, sand play techniques for the individual and intra-psychic psychotherapy in the closed and fixed setting apart from clinical fields in the community. So JCP has not made efforts to develop training system in placements. In turn the practitioners in the field do not trust training courses in the university because such individual and intra-psychic psychotherapy is of no practical use in the community.

JCP has confronted social conflicts and limitation of social recognition as well. One of the conflicts is with academic psychology. JCP has kept itself apart from academic psychology, which has maintained a scientific paradigm, so that the two psychologies have no connection with each other. Moreover, since clinical psychology began to invade the territories that academic psychology used to occupy in the universities, serious conflicts between the two psychologies have occurred. A society of academic psychologies often expresses its formal objections to JCP.

Another conflict is with psychiatry. The Japanese association of psychiatrists declares that it strongly objects to legitimatising the qualifications of clinical psychologists as long as clinical psychology does not accept the condition of working only under the control of psychiatrists. As a result, the activities of clinical psychologists are greatly limited not only in the medical setting but also in mental health fields. Now the professional role of clinical psychologists is becoming confined to that of counsellors in the educational context.

4. Consideration

4-1. Confirming the Hypothesis

Since BPC established its distinction and consistency as a discipline and got its social role and independence officially recognised as a mental health profession, it has already achieved an identity and grown into a profession. On the contrary, JCP is not only suffering from confusion and internal splits, which makes it impossible for it to define itself as a definite discipline, but it is also involved in social conflicts, which limit social recognition. As JCP has had great difficulty in achieving an identity despite social demands, it finds itself marooned in an identity crisis. BCP has matured into adulthood without any serious identity crisis, while JCP is kept in adolescence. BCP even seems to have developed the shortest route to professional recognition for clinical psychology in the world, compared with the longer and more controversial route taken by clinical psychology in the United States over the 50 years since Boulder conference.

As a result we could say the hypothesis (being scientific would make a contribution towards clinical psychology’s growing into a profession) is verified by the comparison between the processes of BCP (the Experimental Group) and JCP (the Control Group). So Being Scientific (the independent variable) seems to cause Becoming a Profession (the dependent variable). However, the relationship between independent variable and dependent variable is not necessarily causal. To know what effects the intervention of the independent variable has had on the experiment group, we need to scrutinise what kinds of roles the being scientific has played for BCP to become a profession from a comparative point of view.

4-2. Investing the Role of the Independent Variable Comparatively

Then, we will investigate the role of being scientific and ascertain how it has worked to solve the problems shown above as factors preventing JCP from taking further steps towards becoming a profession.

Ambiguous overlaps between clinical psychology, psychotherapy and counselling

Being scientific demands that clinical psychology should define itself in terms of (a) the basic science of psychology and (b) its application to the understanding and resolution of human problems, which means that the clinical psychologist should be “an scientist- practitioner”. These definitions lead to a consistent distinction between clinical psychology and other professions such as psychotherapy and counselling.

Theory-based sectionalism

Being scientific demands the evidence-based approach, which overcomes theory-based practice and sectionalism (see, e.g. Miller 1997). Being scientific also demands behavioural therapy and cognitive behavioural therapy. That could lead to the integration of clinical psychology. On the one hand the aspect of behaviour is open to the objective and interpersonal world that could lead to a system theory model and a community care model. On the other hand the aspect of cognition is open to the subjective and narrative world that could lead to a phenomenological model and a psychodynamic model.

Split between practice and research (alienation of research)

Being scientific demands that clinical psychology should evaluate the effects of its clinical practice by psychological research. That brings creative interaction between practice and research, which refines the clinical assessment and intervention so that it is practically more effective with each psychological problem.

Spilt between training courses in universities and clinical fields in the community

Being scientific demands the result of research to be universally authorized. Cognitive behavioural therapy is actually effective in clinical fields and the evidence-based approach provides the social authority with its accountability by proposing scientifically evaluated data. Once the social authority acknowledges clinical psychologists as professionals, the society as a whole, not only the university but also the community, takes responsibility for training them. In that situation the clinical training in placements works well and facilitates the collaboration between them.

Conflict with academic psychology

Being scientific gives clinical psychology a chance to maintain its independence from psychiatry by the authority of science. On the ground that clinical psychology is not allied to medicine but allied to science, it keeps itself outside the remedial professions supplementary to psychiatry.

It is obvious that being scientific prevents clinical psychology from falling into splits and conflicts, and makes it possible for clinical psychology to be integrative and independent. Without being scientific, it would be difficult for clinical psychology to grow into a profession. In fact, although clinical psychologists and trainees in Britain might not believe it, clinical psychology in almost all countries except Britain is or has been experiencing such difficulties.

5. Discussion

5-1. Thinking about the Meaning of Being Scientific from the clinical viewpoint

Being scientific is obviously playing an important role in the growth of clinical psychology into a profession, but I still wonder if it is the cause of its growing into a profession. If it is the cause it would be a developmental task for clinical psychology to make the transit from adolescence to adulthood and JCP would have to assume being scientific like BCP to grow into a profession. Here we should examine whether being scientific is truly the only cause of the transition. So we will categorize the roles of being scientific and think about its meaning in the context. The roles shown above may be categorized into these 3 groups.

1. Giving clinical psychology a modern evaluation system and destroying pre-modern and dogmatic sectionalism so that some clinical work is refined.
2. Giving clinical psychology an academic authority as a superior system to give order to various models within it and to negotiate with different disciplines outside it.
3. Providing clinical psychology with some accountable data so as to convince the social authority to recognize the profession.

Being scientific implies an evidence-based approach and it refines some clinical work. Without evidence-based approach, clinical procedures derived from the specific therapeutic technique prescribed by the theory that the therapist believes in are applied to each and every problem. That is what I call theory-based approach, which leads to sectionalism. The evidence-based approach, by contrast, demands that the evaluation system be applied not only to outcome of the intervention but also the process of clinical work. Clinical psychologists are always required to check and evaluate how appropriate their procedures are from a critical point of view. It means that they need to adopt a hypothesis-testing method as a procedure to process their clinical works.

The hypothesis-testing method is a cyclical process, in which clinical psychologists objectively assess the problem, formulate a hypothesis about what the problem is and how to intervene in it, actually intervene in it according to the hypothesis, check the effectiveness of the intervention, correct the hypothesis to be more appropriate in solving the problem and intervene again etc. This cyclical process refines the clinical work. It has developed more elaborate assessment procedures like the functional analysis, case formulation methods and intervention skills designed to cope with each kind of mental problems and disorders.

Certainly the hypothesis-testing method has refined the clinical work, but we need to notice here that being scientific has not effect directly on clinical work. It has influenced clinical work only through the hypothesis-testing method. Therefore, none of the roles categorized above contributes directly to clinical work, but they each help clinical psychology to achieve a social identity as a discipline in modern society. Now we need to pay attention to the difference between clinical work and clinical psychology as a discipline. That is to say being scientific could help to achieve a professional identity, but does not always lead to improving clinical work. At least we may as well draw a distinction between developing clinical psychology and developing clinical psychologists.

Here we should consider the meaning of being scientific in terms of developing clinical psychologists. The scientist-practitioner model has been questioned in regard to training programmes as Kennedy and Llewelyn (2001) indicated. The reason why it is questioned lies in this point: being scientific is not always being practical, since a scientist is not always a good practitioner. However, “science” is needed for clinical psychology to become a profession in modern society. Ironically, the scientist-practitioner model, which has an internal split (Rice 1997), could help to unify various splits which clinical psychology might have. In the end, it could be said that being scientific or the scientist-practitioner model has played a tactical role in clinical psychology getting its position in the modern world.

5-2. Rethinking about the Meaning of Science to Clinical Psychology

Now I would like to emphasize that the hypothesis-testing method is not scientific although it looks like as though it is being scientific. It is in the nature of science that it demands that we discover an abstract and universal rule that must be true beyond space and time. Science created the hypothesis-testing method in order to demonstrate and prove logically that the discovered rule is universally true. However, the hypothesis-testing method adopted by clinical psychologists does not aim at discovering such a truth. A clinical psychologist makes use of the method just to improve his clinical work to be more appropriate for the problem solving and more helpful to the client whom he is responsible for. So the validity of the process is tested according to its appropriateness to solve the problem, which is occurring within the real time and space framework. In effect, the clinical process is individually and concretely evaluated while the scientific process is universally and abstractly evaluated.

They look similar in terms of an evidence-based approach but in fact they are not the same. Nor is the clinical process an application of science to practice. If the clinical process is identified with a scientific process it would make the clinical work very partial or cause serious divisions within the clinical psychologist. The origin of the clinical process is different from that of science. So being scientific does not contribute directly to clinical work although it could contribute indirectly by bringing the evidence-based approach into clinical psychology. Considering the difference we should clarify the nature of the clinical process. At least we should reconstruct the definitions of evidence, hypothesis and criteria for evaluation in terms of the clinical process. For example, we should enlarge the concept of evidence to include qualitative data as well as quantitative data and the concept of criteria for evaluation should include the user’s point of view as well as the researcher’s point of view.

Here we should notice and take into consideration that being scientific is different from being a science. Then what is science? It is obvious that science has given birth to almost all modern disciplines including psychology and kept its powerful influence as an authority to modern society as well as the academic world. As a result, almost all disciplines have sought for some guaranty from science in the modern world.

However, We have begun to enter into the post-modern world. In this post-modern time some aspects of science have been criticised in terms of human welfare and the ecological environment, as everyone knows. I believe that the problems originate from the nature of science. Objectivism, reductionism and logical positivism are principles of science. Objectivism produces a split between object and subject. Reductionism, which explains complex data and phenomena in terms of something simpler, defined a person as an entity divided from relationships. Such notion of human being brought a split between the individual and the social environment. Logical positivism maintains the split between theory and real life.

As for clinical psychology, apart from academic psychology, it had other origins than science. For example, primitive spirituality was re-formed into psychoanalysis (Ellenberger 1970), which has been an important part of clinical psychology. However, to be admitted into the realm of science in the modern world, clinical psychology has had to shed some alien thoughts and works. So science has caused many splits in clinical psychology, such as between the object (behaviourism) and the subject (psychoanalysis, phenomenology), between the individual (individual therapy) and the social environment (system theory, community care) and between theory (research) and real life (practice).

If clinical psychology is to be strictly a science it must fragment. Therefore, being scientific – or using the scientist-practitioner model – is obviously a tactical and contradictory device to unify the divisions caused by science while still keeping in touch with science. I think it is mainly because science has been the authority of the modern world that clinical psychologists have needed such a contradictory concept to maintain themselves in this world. It is because being scientific or using the scientist-practitioner model is contradictory that it can play a tactical role in developing clinical psychology as a profession.

However, as psychologists go into training they may each experience serious mental conflict because it is difficult for a person to hold and keep the contradiction within himself or herself. That is why scientist-practitioner model has to be questionable way of training clinical psychologists. So, here, we have to examine again the meaning of being scientific from the training point of view.

6. Conclusion

6-1. Clarifying the Role of Being Scientific from the Training Point of View

In developing clinical psychologists we should create training programmes on the basis of the nature of the clinical process instead of that of a science because the main job of clinical psychologists is clinical work. And we should also provide scientific research training programmes in accord with clinical training because some clinical psychologists are expected to contribute to developing clinical psychology as a profession. Providing scientific research training programmes in accord with clinical training would not be so difficult if the clinical training were based on the evidence-based approach, which is close to scientific process. With regard to BCP, the clinical process was identified with the scientific process while it still clung to behaviourism, but after cognitive behavioural therapy was introduced it seems to have actually shifted its balance from a scientific process to a clinical process. By contrast, since JCP is still using a theory-based approach it is impossible to provide a research training programme.

Recently the emphasis on the clinical process has been true of developing clinical psychology as well as developing clinical psychologists. We are now moving to a post-modern world. In the modern world some authorities have kept their powers to control society, but in the post-modern world people are empowered and construct society themselves. In this post-modern society social professions should be accountable not only to the authorities but also to the users. Therefore, although clinical psychology could escape from the pre-modern world to the modern world through the authority of science, it might become stranded in a modern system in the post-modern world if it is determined to be scientific.

Today, being scientific is not as valuable as it was before for the development of clinical psychology. Instead being collaborative is becoming more valuable to the development of clinical psychology, especially in community care. Collaboration with the users as well as with other professions is essential for the reorganization of the health care system. Actually the NHS service is carried out by teamwork, which is not just a network of different professionals but collaboration (Marzillier & Hall 1999). By means of teamwork innovative community services have been organized and new clinical disciplines created. These new disciplines based on the biopsychosocial model – such as rehabilitation psychology, neuropsychology and clinical health psychology, are beyond the conventional framework supplied by medicine and science.

6-2. Formulating a Model for the Japanese Clinical Psychology

I conclude that being scientific is very important in the development of clinical psychology, but it is not a developmental task common to every development. It would be more correct to say that being scientific is very helpful only in getting clinical psychology out of the pre-modern sectionalism into integration and in proposing social accountability.

Clinical psychology in Japan is stuck with pre-modern sectionalism and cannot produce accountability to society. Introducing being scientific might be a strategy to destroy sectionalism, but it is almost impossible because we have very little scientific tradition and being scientific is strongly rejected by the psychotherapy model. So we need to get out of sectionalism into integration without being scientific.

I have tried in the past to develop a comprehensive model of clinical psychology, which could fit into the Japanese tradition and situation. As described above, psychoanalytic thoughts and skills are extremely popular. In reality that line of thought has been a big obstacle preventing Japanese clinical psychology from growing into a profession.

Therefore, at first I tried to avoid placing the psychotherapy model at the centre to creating a model for Japanese clinical psychology. I made counselling the basis, instead of psychotherapy. I thought making counselling the basis could be approved by almost all Japanese clinical psychologists. Counselling is obviously simple, but it is open-minded. In addition I thought counselling would fit into Japanese culture which is sensitive to relationship and familiar with narrative. So I made use of counselling to take clinical psychology out of pre-modern sectionalism, instead of going for being scientific. And I thought counselling skills are needed to collaborate with others and to listen to the user‘s narrative.

Second, I construct an integrative model of clinical skills and knowledge on this basis (see Figure 3). It consists of 3 functions, which are “communication” “case management” and “system organization”. The point is that it is open to community care and social every setting apart from the closed system of psychoanalytic psychotherapy, which confines everything to the individual and intrapsychic world. I placed psychotherapy as just one of the options of skills for “case management” and made it relative.

Third, I developed a comprehensive concept of clinical psychology. The comprehensive concept consists of 3 structures, which are practice, research, and profession (see the figure 4). I thought introducing research into Japanese clinical psychology could destroy the pre-modern theory-based practice. Of course we need to introduce the scientific and quantitative research. However, as it is difficult to introduce, I decided to emphasize qualitative research at first. And I thought qualitative research could match with post-modern social constructionism. Quantitative research, such as outcome study, can evaluate clinical practice, but it cannot create and develop it. It is qualitative research, such as process study, that can do it (Llewelyn & Hardy 2001). Qualitative research can improve and create clinical work as research through practice (e.g. Clegg 2000)

Qualitative research also can describe the process of “system organization” and evaluate it from the user’s point of view. Recently evidence-based practice has critically appraised itself in terms of lack of consumers perspectives (Trinder & Reynolds 2000). and introduced qualitative research into it (Stiles 1999). As I discussed above, making a contribution to system organization of community service provides accountability in post-modern society. Therefore, qualitative research is getting more important for the development of clinical psychology.

I am planning to emphasize the importance of research to get Japanese clinical psychology out of pre-modern theory-based practice. Thus I am aiming to develop Japanese clinical psychology into a profession with an integrative and comprehensive model.

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