The Psy.D. at 50: Theory to Practice
Though people have always puzzled over the intricacies of the mind, psychology is a young science. Histories frequently place the dawn of modern psychology at the beginning of the 20th century. The stakes of this new discipline were high because the subjects of study in this new field were the brains of living people seeking help. Early researchers with Ph.D. degrees came to understand that scientific research would have to be bolstered by an organized, ethical system of patient care. In 1973, the American Psychological Association (APA) established a professional degree to address a national shortage of practicing psychologists. In the ensuing 50 years, the Doctor of Psychology (Psy.D.) degree has reshaped how mental health care is taught, delivered, and understood.
How a Postwar Mental Health Crisis Created an Urgent Need for Clinicians
After World War II, demand for mental health care surged, but the research-oriented Ph.D. model produced too few clinicians to meet the need.
In 1949, 70 psychologists met in Boulder, Colorado, in part to address a widespread problem that was invisible to most Americans in the days after the end of World War II. Thousands of servicemen were returning from Europe and the Pacific demonstrating psychological symptoms of a condition that was commonly referred to “shell shock” or “combat fatigue,” that we now recognize as post-traumatic stress disorder (PTSD).
The Boulder Conference, as it came to be called, established the scientist-practitioner model of psychology in which members of this field would be trained in universities and, upon completing a dissertation, would be conferred a Ph.D. and the title of doctor. These psychologists would conduct scientific research, analyze data, and treat patients—often those who were diagnosed with the conditions the psychologists were researching.
This approach reflected a postwar attitude, buoyed by wartime experience, that science combined with organized action could offer rational solutions to systematic problems. The adoption of the Boulder model coincided with the adoption of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) by the American Psychiatric Association in 1952. With a standardized program of training, a definitive guide for a diagnosis, and a code professional and ethical standards, the American Psychological Association had established a system of mental health care. With these innovations, the professional structure of modern psychology study and practice, as we know it today, was in place.
How a New Degree Emerged to Expand Clinical Training and Access to Care
The Psy.D. expanded clinical training by shifting psychology education beyond universities and prioritizing practice over research.
In many ways, the success of the recommendations coming out of the Boulder conference and the implementation of the scientist-practitioner model revealed the need for an alternative approach as the public became increasingly aware of the value of—and urgent need for—expanded access to mental health care. In 1973, at a second conference in Colorado, this time in Vail, the attendees established a practitioner-scholar model, with the Psy.D. as a professional degree, on par with the J.D. lawyers earn and the physician’s MD. Students would receive an immersive education in the history and principles of psychology and hands-on training through internships in clinical settings.
One of the limiting factors of the scientist-practitioner model was that most psychologists were trained in large research universities where it was common practice that Ph.D. candidates would assist their professors in their research interests. While this tradition was effective in advancing scientific discovery, it did not necessarily address the needs of a far-flung populace.
A key determination of the Vail conference was that “the practice of psychology has progressed from a primary focus with diagnosis and assessment to primary focus with intervention.” As was the case with the scientist-practitioner model, the three focuses of professional psychology—research, practice, and education—would remain, but the emphasis would be on meeting the demand for clinicians to practice in their communities.
How Practice-Focused Education Became the Core of Psy.D. Training
Psy.D. programs emphasize immersive, applied training led by faculty who are active practitioners in community and public settings.
The opening of new clinical psychology programs across the country created an immediate need for faculty. Typically, these programs established a core faculty and augmented this with distinguished visiting professors, adjunct lecturers who were practicing psychologists with extensive field experience and armed with case studies that the newly minted professional psychologist would learn from and build upon. The Chicago School, which was founded in 1979 as The Chicago School of Professional Psychology, responded to the call of the Vail conference for new practitioners by teaching courses in rented classrooms and assembled a to address both the academic foundations of the field and principles of practice.
There were dramatic effects from the Vail conference recommendations on the growth of Psy.D. programs and the number of degrees conferred. It is difficult to track Psy.D. degrees conferred because reporting agencies typically report doctorate degrees, including Ph.D. and Ed.D.; however, the American Psychological Association Center for Workforce Studies conducted a survey that revealed that in 1978-79, the first year for which data is available, 62 Psy.D. degrees were conferred. In 2007-08, that number was 1,721. The National Council of Schools and Programs of Professional Psychology, founded in 1976, has seen its membership grow from 19 to 70 institutions. The true impact of the scholar-practitioner model, however, would be felt in the communities in which the clinicians practice.
How Graduates Entered Diverse Clinical and Institutional Roles
With terminal clinical degrees grounded in practice, Psy.D. graduates move into a wide range of clinical, administrative, and institutional roles.
For reasons good and bad, an important milestone in the evolution of mental health treatment in the United States was the passage of the Community Mental Health Centers Act (CMHA) in 1963. While the intention of this legislation to end the institutionalization of the chronically mentally ill in large hospitals where neglect and abuse were rampant, the intended effects of the law were not achieved, as the planned community mental health centers (CMHCs) were never adequately funded. The problem was made worse in 1981, when the Reagan administration shifted the burden of funding to the states through block grants.
The result was that many of the individuals who were released onto the streets from in-patient care ended up unhoused or incarcerated. Graduates from Psy.D. programs enter a workforce in which they meet patients and clients where they are, whether in private practice, hospitals, community mental health centers, schools, or prisons. As a doctorate-level or terminal degree, the Psy.D. degree provides those who hold it with the qualifications to serve in supervisory and administrative roles. By assuming executive positions, clinicians can not only shape practices within their organization but also can become stakeholders in broader conversations and initiatives surrounding theories of care.
50 Years On, the Psy.D. Remains Essential Amid Rising Challenges
The Psy.D. has broadened access to care and diversified practice even as persistent shortages and funding challenges keep demand high.
Looking back from a distance of five decades from the Vail conference, the Psy.D. degree has been a success, both on the fundamental level that the degree is widely accepted as equivalent to the Ph.D. in the field of psychology, and on the terms for which it was created, to expand access of the public to essential mental health services. Additionally, Psy.D. holders consistently stand out as leaders of organizations and as public experts.
However, challenges remain. Underfunding for mental health service providers is so persistent and widespread that navigating shortfalls must be seen as part of the role of administrators. Further, despite the concerted objective of recommendations coming out of the Boulder and Vail conferences to increase the number of clinicians in public-facing roles, a shortage of clinicians continues. The APA projects a shortfall by 2037 of 80,000 health service psychology professionals. This translates to a shortfall of 45%.
In pointing to the continuing shortage of providers, the A.P.A. is proposing a reimagining the roles mental health professionals with master’s degrees can play in bridging gaps of care. Should a major initiative arise from these recommendations, perhaps at a conference in Colorado, it will represent a continuation of the objectives of the Vail and Boulder conferences to deliver mental health services where they are needed most.
The Psy.D. at 50: Practicing the Psy.D.—Stories from The Chicago School
Part one of this article traced the history of the Psy.D. degree. What follows are brief portraits of The Chicago School professionals whose careers reflect that training in practice.
For Many Future Clinicians, the Psy.D. Path Is Best Suited for a Career of Practice
Traditionally, the Ph.D. has been the degree of choice for those seeking to pursue psychological research, often in academic settings.
As early as his undergraduate years, Robert Foltz, Psy.D., professor at The Chicago School, worked with severely mentally ill individuals in secure in-patient settings. Having chosen a Psy.D. degree as his entry point into a career as a mental health professional, he explains how pursuing a Ph.D. track would have altered his career path, “I would’ve become increasingly anchored in the biomedical research around schizophrenia, seeking to explain it through neurochemistry and neurophysiology,” he says. “But my pursuit enabled me to network with clinicians that were providing psychotherapy services to people diagnosed with schizophrenia.”
The majority of research related to psychosis and severe conditions is driven by the medical model, but there is a whole community of people doing effective psychotherapeutic work with schizophrenia.”
{Robert Foltz, Psy.D.}
Through his work in residential treatment with young people with severe mental and emotional conditions, he has also developed a private practice that specializes in treating clients who have been through the system but have not benefited from the typical delivery of services. His focus is on the intersection of drug therapy and psychotherapy, and he has come to believe through his research that our youth are being overmedicated. “The majority of research related to psychosis and severe conditions is driven by the medical model, but there is a whole community of people doing effective psychotherapeutic work with schizophrenia,” he explains.
While pursuing an B.A. at a Big Ten university, Melvin Hinton, Chief of the Office of Mental Health Management Services for the Illinois Department of Corrections, studied dream interpretation. He found the work fascinating and planned to continue as he pursued his doctorate in clinical psychology, but his advisor noted that from the way Dr. Hinton spoke of his interest in working with patients, he might be better suited for a Psy.D. degree. Shortly afterward, he recalls, “There was actually an evening seminar, where someone came to the university and talked about the Psy.D. degree, and I fell in love with it.”
Working within a correctional facility is not just about working with people who are incarcerated. It’s about impacting that environment, holistically, in a positive manner.”
{Melvin Hinton, Psy.D.}
While at The Chicago School, Dr. Hinton was selected for a competitive internship with the Cook County Department of Corrections and realized that working in corrections was his calling. He explains how the work of the clinician in a clinical setting affects the broader community. “Working within a correctional facility is not just about working with people who are incarcerated,” he explains, “It’s about impacting that environment, holistically, in a positive manner. It’s about impacting the criminal justice system in a positive manner. It’s about impacting the community outside of corrections in a positive manner.”
Psy.D.-Trained Psychologists Deliver Mental Health Directly to the Public
Working in community-based settings, Psy.D. practitioners provide clinical services to clients and patients with a range of needs.
Joyce Nugent-Hirschbeck, Psy.D., enrolled at The Chicago School with the intention of focusing on schizophrenia, inspired by her experience with her brother who was diagnosed with the disorder. What she recognized from her personal experience was the strain that mental illness has on families. “My practicums and my internship were very focused on sites that did a lot of research in schizophrenia,” she says. “I carefully blended clinical training and research with the area of schizophrenia throughout all my training experience.”
The psychologist oversees the overall treatment process of underserved clients, advocating and ensuring they receive all of the resources and care that they need. ”
{Joyce Nugent-Hirschbeck, Psy.D.}
In addition to being a professor at The Chicago School for 30 years, Dr. Nugent-Hirschbeck has served as the chief in the juvenile justice system of Will County, Illinois, and served as chief psychologist for the Department of Human Services, specifically Tinley Park Mental Health Center, as well as well as working as clinical director for other-non-profit mental health agencies. Through these experiences, she has learned how psychologists can make a significant impact on behalf of their clients. “The psychologist oversees the overall treatment process of underserved clients, advocating and ensuring they receive all of the resources and care they need,” she says. “Psychologists are powerful gatekeepers within this system.”
Psychologists With a Psy.D. Serve an Expanding Role as Public Experts
In the media and as public advocates, Psy.D. practitioners bring psychological expertise to the public beyond journals and conferences.
As it is with many academic disciplines, much of the data or knowledge emanating from psychological research has traditionally been shared among academics and experts in the field through academic conferences and scientific journals. With the focus of the Psy.D. on practice within a broader community, clinicians become used to communicating in public settings. When these experts speak to the community to broaden public understanding, they create a multiplier effect in which the benefit extends beyond the clinical setting to the general public.
For Dr. Hinton, this advocacy takes the form of educating the public on the prevalence of trauma in prison populations and what forms of intervention are effective. “The overwhelming majority of people who are incarcerated will return to the community,” he explains. “Having them see that they can establish a rapport with a psychologist and remind them that when they go back out in the community, they can establish that same rapport with someone else, that’s powerful.”
Dr. Foltz’s extensive experience with adolescence has led him to rethink the prevailing approaches to pharmacological interventions for common conditions, such as ADHD and depression. He has written a book titled “No Method to the Madness” that assesses current practices and the uses of stimulants, antipsychotics, and antidepressants. The book is written for a wide audience from clinicians to parents. “It’s written at a level where parents can absorb the information and it would stimulate more questions with their prescribers,” Dr. Foltz explains. “So much of our decision-making is based on the research. Not everybody has the time to dive into the research, so I wanted to sum all that up for people. And much of the research doesn’t support common practices for these troubled youth.”
Experience in the Field Provides Clinicians With Insights for Improved Care
Through experience in real-world settings, clinical psychologists develop and improve treatment methods that make the most impact.
For psychologists in clinical practice, the ultimate measure of success is in improved patient outcomes. With this objective in mind, clinicians with years of experience in public health acquire a clear sense of what is working and where challenges remain. Dr. Nugent-Hirschbeck says that cuts to Medicaid have put additional pressure on an already stretched public health system. “Just maintaining where we are with treatment with people with severe psychiatric issues is that we need to make sure community and support systems are in place,” she says. “That’s the critical piece of ensuring stability and reducing re-hospitalization,” she says. An important piece, she suggests, is encouraging Psy.D. Students to expose themselves to community mental health training experiences. She says, “I have trained countless students to work with the severely mentally population and the staff, and once they’re exposed to this area of mental health, they realize just how amazing and rewarding it can be.”
As ongoing debate continues over medication versus cognitive behavioral therapy, certain disorders, including schizophrenia and major depression, remain stubbornly difficult to manage. Dr. Foltz sees a lack of training in trauma-informed practices and psychopharmacology. A survey he and his students conducted of APA-accredited doctoral programs reveal that only 5% require courses in trauma and 31% require training in psychopharmacology. For Dr. Hinton, as well, trauma is a key factor in treating incarcerated patients.
More broadly, Dr. Foltz suggests that clinical psychologists have focused, largely through necessity, on what he calls a very deficit-based model, meaning the focus is on identifying problems through symptoms and then working to reduce symptoms. “I’ve always argued that if we cultivate strengths, we, by default, will reduce the impact of the deficits or problems,” he says.
This reimagining of clinical approach reflects the essential work of the psychologist: testing theory through practice and modifying treatment according to outcomes. In this sense, it will always be the client or patient who drives the science.