Academic psychiatry – extinction or adaptation to a changing world: A view from clinical psychology

Henderson et al.’s Editorial contends that academic psychiatrists are now an endangered species, with potential impacts on undergraduate teaching, postgraduate training, research capacity and academic advice on health policy (Henderson et al., 2014). The Editorial identifies contributing factors, which include barriers to recruitment of trainee psychiatrists to academic careers due to demographic, financial and lifestyle factors, psychiatry’s ‘image problem’ within medicine (Lyons, 2013), the need for mentorship and the lack of career options offered by existing research fellowships. The Editorial predicts that, should the situation continue, psychiatrists will find their role in research replaced by ‘highly trained researchers from other professions’ and it urges far-reaching changes to avoid a looming extinction.

The situation in academic psychiatry is very different from that in clinical psychology, where demand for postgraduate training places far outstrips supply, students are fully engaged with research as part of their training, and there is no shortage of aspiring clinical academics. In this commentary, we consider why the situation has evolved so differently for the two professions and what lessons might be learned for the survival of academic psychiatry.

Psychologists are exposed to research at an early stage

As Henderson et al. note, embedding new professionals or trainees within an active research culture during formative stages in their careers is often the critical factor for generating the desire and tangible skills for a research-focused future. This is central in clinical psychology, which makes for an important contrast to the situation outlined in Henderson et al.’s Editorial. Psychiatric training adopts an apprentice model, which is grounded in direct clinical practice, embedded in mental health service delivery, and produces high clinical and profession skill. However, research is not necessarily a prominent component.

By contrast, the clinical psychology model is an academic one from the beginning. To enter into a clinical training program, a student must have completed a fourth year of study in psychology, following completion of a bachelor’s degree in psychology. In the fourth year, a major component (around 50%) is a research project. There is extreme competition to obtain postgraduate training places in clinical psychology because these are rare in comparison to those for the fourth year. So, by definition, those who obtain postgraduate training places must have performed very well in this research component.

The academic training model in clinical psychology

Professional training in psychology has undergone rapid change over the last decade, driven to a significant degree by mental health workforce reform, reform of Medicare rebating of psychological services, and strategic positioning by the Australian Psychological Society as the professional association. There has been a strong shift towards professional training of clinical psychologists relative to other specializations within psychology. This has seen a marked increase in the number of psychologists with clinical specialization, and these now dominate the profession and are the main training program in most Australian universities.

However, a common feature throughout this period of change has been an increasing emphasis on the research competency of psychology graduates. There has been considerable innovation in training models within the university system and this continues apace. There are now opportunities to combine professional and research training in models such as combined PhD/clinical Masters. The lesson here is embedding higher degree qualifications within professional training programs. The other major difference here is in terms of flexibility. Since psychology is broken down into numerous stages of professional qualification, it can be approached flexibly in a manner which fits with life stages, and reproductive and parenting responsibilities.

There are downsides of the clinical psychology academic training model. It could be seen as a system largely designed by academics to serve the interests of academics. Arguably the model comes at the cost of graduate clinical skill and substantive ‘real world’ experience. However, there can be no doubt that clinical psychologists obtain a comprehensive grounding in research and many remain interested in research across their careers. In effect, they really have no choice, since they will not be selected to move to advanced levels of training without demonstrable research skills and, increasingly, evidence of an emerging track record via publication.

Deakin University as a case example

Psychology uses a professional training model, which incorporates a substantial research project, and often within the framework of a professional doctorate, or clinical PhD program, and there is very strong demand for places in these programs. The DPsych program at Deakin, for example, annually attracts over 200 applicants to fill 20 places. This program contains a research component requiring a 50,000 word thesis and typically has the scope of three empirical studies. Students and supervisors are increasingly opting for a ‘thesis by publication’ where the student is required to publish at least three first-authored papers as a part of his or her final thesis submission.

Effectively there are two pathways to obtaining a research higher degree. DPsych places offer the dual clinical and higher degree qualification and it is highly competitive to obtain places in this postgraduate clinical training program. Some who are not successful, and a good number who have no practice aspirations, move directly into a PhD program upon completion of their fourth year of study in psychology. Psychology PhD students often supplement a scholarship or other source of income with casual academic work teaching in the psychology undergraduate program. Psychology academics are often inundated with supervision requirements for PhD and DPsych students. This generates ample opportunities to create research projects based around PhD projects – the challenge is to create meaningful clinical research by partnering with research-oriented clinical services and embedding such projects within the mental health system. A high proportion of graduates from both the PhD and DPsych programs go on to have continuing involvement in academia either as teachers or researchers.

The need to adapt to a rapidly changing academic environment

Not examined in the Henderson Editorial, is the fact that working in a university setting has itself undergone very substantial change and this will have an impact on the choice to pursue one’s career in this setting. In Australia, these changes include considerable expansion of access, student fees, greater emphasis on industry partnership and links to professional bodies and internationalization – culminating in the impending deregulation of universities to become open to full-market competition across the sector. These major changes in the university sector may make undertaking a PhD more challenging in many disciplines and almost certainly more expensive. The disciplines which have benefited from these changes tend to be those who have adapted quickly to changes in funding models, linked niche postgraduate training opportunities to a solid base in often very large undergraduate programs, and have adopted innovative and flexible teaching delivery.

Competition among academic institutions is increasing and globalization means that competition is increasingly international. Universities strongly compete with each other for students and offer courses in the knowledge that dissatisfied students may go elsewhere. In this and many other ways, academic institutions have become more commercial and academics more engaged in media, marketing and promotion. One of the somewhat dystopian scenarios portrayed by Clark (2005) is worth considering as a thought experiment. In a fully deregulated tertiary education system, those who enrol in high-earning professions such as medicine will be expected to pay a significant contribution towards their education. In that context, research will be increasingly measured by the same metric; that is, it will be done only when there is a clear market potential for the product. High staff salaries and increased opportunities for academics will need to be financed by increases in student fees or greater involvement from private industry, who will also demand a greater say in curriculum. In such a deregulated market-driven environment, those who succeed will be those most able to meet the needs of their customers.

Solutions

The specific lesson from clinical psychology is that there is high demand from young people coming from high school to study mental health as a topic, with many aspiring to work in the area. It is also clear that research interests will naturally emerge in practitioners if research activity is built in at each step along the path to professional training. For psychiatrists of the future, this means a research component both in the medical degree and in fellowship training. In particular, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) needs to consider reintroducing a research project as a basic requirement for Fellowship.

Henderson et al. have called for ‘the investment of substantial sums over many years’, but this situation as a whole calls for a serious re-think to ensure additional resources are invested wisely. We offer the following reflections on what academic psychiatry needs to flourish:

Mentoring

Henderson et al. make much of mentorship within ‘an appropriate scientific environment’. We agree that mentoring is key, but it requires that medical schools recognize, evaluate and reward successful mentoring as a core academic responsibility (Bickel and Brown, 2005).

Students as consumers

Universities are in a global competition for students and disciplines are also competing with each other. To attract and retain students, academic psychiatry needs to see students as consumers of its services, who should be actively involved in decisions about teaching and research, and not simply the recipients of a top-down mentoring. PhD candidates in psychiatry cannot be left to make their own way, but must be provided with support, resources, encouragement, effective supervision and a vibrant research culture within their departments. This also requires that academic environments welcome a diversity of culture, lifestyle, ethnicity and gender, in keeping with the students it is seeking to attract. For example, attracting people who wish to combine academic, clinical and family roles requires that ‘departments add temporal flexibility and create and legitimize less-than-full-time appointments’ (Bickel and Brown, 2005).

Focus research on stakeholder needs

Given that the function of research is to provide new knowledge to those who can make good use of it, the role of stakeholders – the public, patients, practitioners, politicians, and policy-makers – requires greater emphasis (Clark, 2005). Research that is seen as relevant will be more attractive to potential students.

Funding

Research funding is dominated by late-career researchers. There needs to be a major change in Category One research funding and fellowship opportunities in order to foster the careers of younger researchers, and flexibility in this funding to permit the combination of clinical and research careers.

Broaden the disciplinary context

Academic psychiatry needs to find its raison d’etre beyond comparison with other medical specializations. It needs to contexualize mental health within wider questions about human development and health equity, and for academics to ‘champion human rights, economics, and the environment as key determinants of health’ (Clark, 2005). Universities, at their best, can be places where the exchange of such ideas occurs across disciplinary boundaries.