observer unhampered by institutional concerns, it would seem apparent that a knowledge of human behavior, thought, and emotion would be the logical and necessary foundation on which a professional practice dealing with disturbance of behavior, thought, and emotion would have to rest. Thus psychology—or, more generally, "behavioral science"-would seem, unquestionably, to be the basic academic discipline of choice. (That this should be considered a heretical statement when made by a psychiatrist is evidence of the almost incredible irrationality of the medical profession in this area; "a psychological background for dealing with psychological problems" would seem as obvious a choice as “a biological background for dealing with biological problems.") The relevance of personality theory, learning theory, communication theory, and the study of group interactions seems too obvious to need emphasis. Also relevant to the professional task would be some knowledge of sociology, to provide a broader perspective and to place the individual and the family in a social framework, and some knowledge of human biology, of the body in and through which man perceives his environment and expresses himself. A broad humanistic education and education in scientific method should be included to guard against what the French so aptly term déformation professionelle.

To approach the question from the other direction, the earlier discussion of the operational surface of the mental health professions may here be briefly recapitulated: The work of the mental health professional consists mainly of formulating, within some psychological theoretical framework and in psychological (or sociopsychological) terms, the problems presented to him by those who seek (or are brought into) his professional influence, and attempting to ameliorate these problems. The methods used in the formulating (or "diagnostic") aspect of the professional task are interviews of various sorts and. sometimes, psychological testing. The methods used in the therapeutic aspect of the taks are-again-interviews of various sorts (individual, family, group, etc.). environmental structuring (e.g., hospitalization), the prescribing of a limited number of "psychoactive" drugs, and (in a decreasing number of cases) electroshock therapy or referral for such therapy.

What are we to make of the fact--and I take it to be a fact-that good "diagnosticians" and therapists come from backgrounds which include nothing in common beyond training and experience in formulating and working with human problems by means of interviews? What are we to make of the discomforting fact that Margaret Rioch can train intelligent housewives to perform quite competently as therapists without the benefit of specific backgrounds in any of the usual "disciplines" (Pines, 1962)? What of the fact that psychiatrists with no training whatever in psychology other than psychoanalytic theory can be excellent therapists? The clear implication of these facts is that psychotherapy is still largely without true scientific underpinnings-is still, to use a cliché, as much art as science (perhaps, alas, more art than science).

Just as surely as this is the case today, however, the academic field to which we must look for elucidation of what we are already doing in diagnostic and therapeutic interviewing-and for scientific instruction in how we might do better-is psychology-whether it be the study of the intrapersonal psyche, the study of interpersonal behavior, or the study of the effects of hospital ward environments. If the practice in which we spend most of our time-namely, the psychological aspect of mental health work-has any scientific validity whatever, then our common basic discipline is psychology. If the important "answers" are really to be found in some other area-for example, neurophysiology or biochemistry-then we have been wrong all along-just as wrong as one would be in trying to treat a uremic delirium by psychotherapy. If, for example, certain cases of what we call "schizophrenia" were found to be caused by a chemical deficiency, those cases would at that point pass out of the realm of the mental health professional and into the realm of organic medicine (like delirium tremens, general paresis, and psychoses associated with brain tumors). The particular manifestations and emotional reverberations of the chemical aberration might be investigated psychologically, but the basic problem would be a medical one.

It may be objected that although the disturbances with which we deal are "psychological," physical methods can be and are being-found to take the place of that cumbersome and time-consuming activity known as psychotherapy. In this view, pragmatic therapeutic "answers" may come from such fields as biochemistry and neurophysiology even if the theory explaining the disturbances remains psychological. To the extent to which this view proves valid, the mental

health field as an area of phychological therapeutic effort will cease to exist. If it were learned, for example, that anxiety could be effectively and easily dealt with by inserting a needle into a specific area of the thalamus, then the relevant training would be that of the neurosurgeon. (We may leave aside the Orwellian questions raised by such an idea.) This sort of therapeutic activity could be labeled "psychiatry" only by a change in the meaning of the term. It is conceivable that a new medical specialty may evolve, based on neurosurgical, neurochemical, and neurophysiological methods; such a specialty, however, would be far removed from what we know today as "psychiatry," and the specialty training which today's psychiatrists receive would be almost as irrelevant to its practice as medical education is to most of the activities of today's psychiatrists. Among the pragmatic physical therapeutic modalities now in use, the "psychoactive" drugs, as indicated earlier, are by far the most widely used. For the practicing psychiatrist, the use of these drugs is an empirical activity based on knowledge of their psychic effects and not on knowledge of their chemistry or their loci of operation within the nervous system. Put in bald, practical terms, this means that the psychiatrist knows that 4 milligrams of a chemical known as Stelazine, for example, may-if taken two or three times a daymodify psychotic behavior in certain presumably desirable ways. He does not know-nor does he need to know-the chemistry of this drug; he does need to know what may happen if too much of it is ingested, what side effects it may produce, and that people with damaged livers should not take it.

I would venture to say-again heretically-that all the factual material relevant for the effective and practical use of the psychoactive drugs could be learned in 2 weeks by the average intelligent student in the mental health field. Anyone who is inclined to dismiss this statement as absurd might well reflect on the fact that many practicing psychiatrists went through their entire training before the tranquilizers and antidepressants had even been heard of. These psychiatrists spent their weeks and months in pharmacology courses learning facts about drugs which, except for the sedatives and a small number of amphetamine preparations, they have never used and never will use in their work as psychiatrists. Thus, their knowledge of and experience with the newer drugs stems entirely from their own informal self-educative activities, while their formal training in pharmacology was largely devoted to material having no relevance to their later practice. It is not implied here that formal training in pharmacology is unnecessary, but simply that a brief, concentrated course in what has been termed "psychopharmacology" would be far more to the point than months spent in learning the intricacies of various digitalis preparations, antibiotics, and dozens of other drugs which are of vital importance to the work of the physician dealing with physical illnesses but of no importance to the work of the mental health specialist. Operationally, one certainly does not have to be able to prescribe all drugs in order to prescribe some drugs; institutional rules have already encompassed this fact in regulating the prescribing done by podiatrists, for example.

The important questions confronting any professional field serve as good indicators of the underpinnings of knowledge relevant to the field. In the mental health field, there are such questions as these:

1. Is anxiety generated and maintained in a purely reflex fashion (as the behavior therapist would say), as a result of cognitive processes (as the rationalemotive therapist would say), or as a result of conflict between instinctual drives and intrapsychic repressive forces (as the psychoanalyst would say), or by different mechanisms in different situations?

2. To what extent is behavior unalterably determined by infantile and early childhood experiences? How "free," in the existential sense, is man?

3. How much of what we observe in human behavior is attributable to intrapsychic forces and how much to interpersonal influences? What is the interrelationship between the intrapsychic and the interpersonal?

4. What really happens in the various forms of psychotherapy? 5. What is the role of values in the practice of psychotherapy?

The questions raised by the coexistence of such diverse practitioners as existential-experiential therapists on the one hand and behavior therapists on the other lead swiftly to questions about the very nature of man. Significantly, however, these-like the questions listed above are all questions for the psychologist or the philosopher, not for the anatomist or the physiologist. Even the most reductionistic of the therapeutic approaches, behavior therapy, comes straight from the laboratory of the experimental psychologist. Of the

really important questions confronting the mental health field today, only three are not basically questions in psychology, sociology, or ethics:

1. Are there biochemical and/or genetic abnormalities which play a causative role in schizophrenia?

2. Are endogenous depressions really manifestations of physiological malfunction?

3. To what extent does "subclinical" cerebral dysfunction play a part in childhood behavior disorders?

The investigation of these questions is properly in the hands of the biochemists. the geneticists, and other researchers; it is beyond the professional scope of the psychiatrist as we usually know him, despite his medical training. And, to repeat, if these conditions should be found to be, let us say, "metabolic diseases," they would cease to be primarily "mental health problems" in the same way that "psychosomatic headaches" cease to be a "mental health problem" when they are discovered to be caused by a brain tumor.

The mental health professional, then, is really working in the field of applied psychology in the best sense of that much-misused term-psychology applied to the task of alleviating psychological suffering-with some excursions into the realm of applied psychopharmacology. This is his true operational field no matter what is professional background has been. That jurisdiction over this field should be claimed by a profession whose basic education usually includes not a single course in psychology is, when viewed dispassionately, little short of fantastic.

My purpose in this paper is not to propose the details of a curriculum for future mental health professionals, but rather to evaluate the present education of the most influential of these professionals-the psychiatrists-and to suggest a direction for change. Such change must be in a psychological direction if our education is to make sense in terms of the realities of our professional work. When is some enterprising university going to formulate a curriculum for a School of Mental Health, based on the existing curriculum in clinical psychology and including appropriate additions from other fields (medicine, sociology, social work), and produce graduates whose work can then be compared with that of their more traditionally trained colleagues? It is a dream worth considering.

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Mr. SISK. We will also make your statement a part of the record at

this point.

(The prepared statement submitted by Dr. Brayfield reads in full as follows:)

STATEMENT BY DR. ARTHUR H. BRAYFIELD, EXECUTIVE OFFICER, AMERICAN

PSYCHOLOGICAL ASSOCIATION

Mr. Chairman, my name is Arthur H. Brayfield. I serve as Executive Officer of the American Psychological Association, which has its headquarters here in Washington at 1200 Seventeenth Street, N.W. The Association, with over 27,000 members, includes most of the qualified psychologists in the country. Affiliated with the Association are psychological associations in the District of Columbia, the Commonwealth of Puerto Rico, the Province of Ontario, and in all States except Alaska. Under our Bylaws, the territories and commonwealths of the United States, as well as the Provinces of Canada, are considered to be the equivalent of States.

In this statement, prepared at the invitation of this Subcommittee, the American Psychological Association wishes strongly to support the aims and content of House Bill 10407. We gave similar support to its companion bill, Senate Bill 1864, in hearings before the Senate District Committee's Subcommittee on Public Health, Education, Welfare and Safety, on August 28, 1967. The amendments made to Senate Bill 1864 are entirely in accord with the Association's national policies with respect to regulatory legislation for psychologists. As you know, Senate Bill 1864 was passed unanimously by the Senate.

In 1955, the Association adopted a series of policy guidelines for state associations to use should they wish to develop legislation defining and regulating the practice of psychology. An up-dated policy statement, based upon experience with the laws in the intervening years, was adopted by our Council of Representatives in September 1967.

Let me summarize, if I may, what our policy statement suggests as basic provisions to be covered in a law regulating the practice of psychology. First, the qualifications of the psychologist should be set at a realistic level, high enough to assure competence, but not so high as to limit severely the number of eligible psychologists available. Our recommendation is the doctoral degree in psychology and two years of supervised experience. Second, the law should not restrict qualified members of other professional groups from doing work of a psychological nature consistent with their training and codes of ethics, nor should it place undue restrictions on the work of psychologists in institutional settings. Third, a code of ethics should be a part of the law or of its regulations. Fourth, adequate provision should be made for the licensing of psychologists already certified or licensed in other jurisdictions with standards no lower; this is frequently called reciprocal endorsement. Fifth, a provision should be included to protect the privileged nature of the psychologist-client relationship. House Bill 10407 meets all these criteria.

There are now laws in 37 States and six Canadian Provinces. The newest law is a licensing act approved in the State of South Carolina in March of this year. It is our earnest hope that Congress will act favorably on the bill before it, thereby giving public protection for the citizens of the District, and, in addition. providing a model for those states still without proper controls. The public has a right to expect help in locating competent psychologist services whenever they are needed; a legal definition of who may offer such services is a major contribution in providing necessary safeguards.

Finally, I should like to comment concerning questions that have been raised about the proposed legislation by the local associations of psychiatrists and psychoanalysts, questions concerned primarily with safeguards for the client requiring services outside the psychologist's area of competence. For the Committee's information, and for the record, I should like to point out that the proposed legislation contains a specific provision (Section 4) on this matter, and that it is in accord with the official policy adopted by the American Psychiatric Association in 1964, a policy agreeing with similar action by the American Medical Association in 1960. Further, Secton 4 is consistent with recommendations made jointly by what we call the "relations" committees of the two national associations-the American Psychological Association and the American Psychiatric Association.

Thank you for the opportunity to appear before you today.

Mr. SISK. If you want to comment on something in the article, you go right ahead, but we will make the entire contents a part of the record.

Dr. BRAYFIELD. I think that I also would like to comment on some comments that you made, Mr. Chairman, with reference to the state of California. I share with you a former residence in that state. I am familiar with many of the legislative practices, including the practice that the state of California has had which we, in the national office, consider as one of the strongest and most helpful pieces of legislation governing the practice of psychology as it exists in the state of California.

I wish also to comment, as one of the early witnesses did, that the Attorney General of the State of California has ruled recently with respect to the practice of psychotherapy in which he has ruled that it is not a medical practice nor limited to medical practitioners.

I would also like to comment as being relevant to earlier questioning that psychologists for perhaps the last 20 years have in many instances carried malpractice insurance, as do many other professions. I would point out for the record that in the history of the coverage of clinical psychologists by malpractice insurance there has never been a court award under the terms of malpractice insurance. I think this is an interesting bit of evidence, as the way in which psychologists have conducted their practices.

I do want to comment, but only very briefly, on the question of mental disease and mental illness. I will call to your attention that the most recent and leading text in psychiatry, authored by the Dean of the Medical School at Harvard University and by the Chairman of the Department of Psychiatry at Chicago, does not use the concept "mental disease," does not use the concept "mental illness," but use entirely in the 800 or 900 pages "misbehavior disorder." I think this is evidence of the shifting nature of the conceptualization of what is included in this field. I believe it is relevant to the earlier lineup questioning.

Thank you very much for the opportunity to appear here.

STANDARDS

Mr. SISK. Thank you, Dr. Brayfield.

You have heard the questions asked by my colleague from North Carolina, Mr. Whitener, with reference to Section 4. In view of the comments contained in your prepared statement, would you object to a rewriting of that section which spelled out that these things shall be a responsibility and shall be carried out, rather than it is now almost