Is There a Place for Clinical Thinking in a Hospital?

We risk becoming nurses rather than psychologists.

Posted Dec 01, 2016

Like clinical psychology, most of us were born in a hospital. Most of us spend our lives trying to stay out of the hospital, unlike clinical psychology, which has been trying to get back in. Presumably, it wants to be let in to work and not to die, but certain features of the hospital environment give me concern that the move could be fatal. I am old enough to remember when we were told that we could do only research and assessment. Then we were told that we could do clinical work only under a doctor’s supervision. With the advent of licensing laws that authorized us to practice independently, psychiatry threw in the towel on competing with psychology on clinical thinking and redefined psychopathology as a medical condition rather than a behavioral or emotional problem.

Medical patients are often ideally suited for psychotherapy. They have huge problems but plenty of psychological resources for addressing them. Mental patients, by contrast, are more likely to have compromised resources in the areas that are affected by problematic response tendencies, including social supports, relational strengths, and the capacity to observe themselves. In other words, all the preliminary work in therapy that you have to do to establish a working alliance with disturbed patients is not needed with typical medical patients.

The problem is not with the patients but with the setting when it comes to integrated care. Medical settings have a culture that impedes clinical thinking. This has been obvious in the effects on clinical psychology of the advent of pharmaceuticals and health insurers in setting a medical tone for care. Anxiety and depression are treated as illnesses themselves rather than as ways of coping with life problems (including physical illness). Categorical case formulations, in which it seems like diagnostic work is complete with the naming of the disorder, lead to categorical treatments, whether these be drugs or treatment manuals. Even if these approaches were effective, an assertion very much in doubt, they would be analogous to turning off the burglar alarm instead of finding the burglar.

In medicine, on the other hand, it is very often the case that treatments follow directly from categorizing the problem. You only have to watch a few episodes of House to see the glamor and efficacy of correctly naming the disease. Further, integrated care unfolds in a system in which the doctors have the highest status. I worry that we will try to imitate them or defer to them, that we will in effect become nurses rather than psychologists.

You know you’ve started practicing bad medicine rather than good psychology when you feel yourself losing status for knowing only clinical languages. I’ve seen health psychologists respond to medical patients by displaying their knowledge of the medical condition, and in some cases not even mentioning psychology. Mark my words: in the not too distant future, some psychology organization will forbid us from treating cancer victims unless we hold some cancer credential. That will be the death knoll of clinical thinking in a medical setting.

Meanwhile, if you are working in a medical setting and expressing yourself in clinical language (speaking, for example, systemically, psychoanalytically, behaviorally, existentially, or cognitive-behaviorally), you are probably on the right track. But we know enough about social psychology to appreciate how hard it will be to maintain a language that is discordant with the prevailing culture. Doctors can’t show on a diagnostic imaging screen such crucial “things” as the self organization, the family structure, a schema, or uncertainty.

It takes a special kind of psychologist not to try to gain status by translating these clinical concepts into areas of the brain, or into some other medical form. I’ve seen it done—my colleagues Lisa Solursh and Nicole Taylor are still practicing psychology and not medicine—but they seem to be in the minority. They (and, I’m sure, many others) have managed to avoid the pull to become mind physicians with a bag of tricks, which I assume has much to do with providing themselves ample opportunities to speak psychology throughout their weeks. Nicole also told me that certain subfields, like oncology, build in longer-term relationships with patients which then automatically protects a relational approach. But we must be humble in acknowledging that, without suitable supports, we are likely to emerge from integrated care as (poorly trained) medical professionals wondering what happened to our native tongues.

[This post was recently published in The Colorado Psychologist.]