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Volume 19, 2023

A clinical psychologist who studies alcohol.

In this article, I describe why I believe the study of alcohol use and its consequences is a rich and rewarding area of scholarly activity that touches on multiple disciplines in the life sciences, the behavioral sciences, and the humanities. I then detail the circuitous path I took to become an alcohol researcher and the various challenges I encountered when starting up my research program at the University of Missouri. A major theme of my journey has been my good fortune encountering generous, brilliant scholars who took an interest in me and my career and who helped guide and assist me over the course of my career. I also highlight selected, other professional activities I've been involved in, focusing on editorial work, quality assurance, and governance of professional societies. While the focus is on my training and work as a psychologist, the overarching theme is the interpersonal context that nurtures careers.

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Community Mental Health Services for American Indians and Alaska Natives: Reconciling Evidence-Based Practice and Alter-Native Psy-ence

This review updates and extends Gone & Trimble's (2012) prior review of American Indian (AI) and Alaska Native (AN) mental health. First, it defines AI/AN populations in the USA, with an explanation of the importance of political citizenship in semisovereign Tribal Nations as primary for categorizing this population. Second, it presents an updated summary of what is known about AI/AN mental health, with careful notation of recurrent findings concerning community inequities in addiction, trauma, and suicide. Third, this article reviews key literature about AI/AN community mental health services appearing since 2010, including six randomized controlled trials of recognizable mental health treatments. Finally, it reimagines the AI/AN mental health enterprise in response to an “alter-Native psy-ence,” which recasts prevalent mental health conditions as postcolonial pathologies and harnesses postcolonial meaning-making through Indigenized therapeutic interventions. Ultimately, AI/AN Tribal Nations must determine for themselves how to adopt, adapt, integrate, or refuse specific mental health treatments and services for wider community benefit.

Culturally Responsive Cognitive Behavioral Therapy for Ethnically Diverse Populations

Cognitive behavioral therapy (CBT) is often referred to as the “gold standard” treatment for mental health problems, given the large body of evidence supporting its efficacy. However, there are persistent questions about the generalizability of CBTs to culturally diverse populations and whether culturally sensitive approaches are warranted. In this review, we synthesize the literature on CBT for ethnic minorities, with an emphasis on randomized trials that address cultural sensitivity within the context of CBT. In general, we find that CBT is effective for ethnic minorities with diverse mental health problems, although nonsignificant trends suggest that CBT effects may be somewhat weaker for ethnic minorities compared to Whites. We find mixed support for the cultural adaptation of CBTs, but evidence for cultural sensitivity training of CBT clinicians is lacking, given a dearth of relevant trials. Based on the limited evidence thus far, we summarize three broad models for addressing cultural issues when providing CBT to diverse populations.

What Four Decades of Meta-Analysis Have Taught Us About Youth Psychotherapy and the Science of Research Synthesis

Intervention scientists have published more than 600 randomized controlled trials (RCTs) of youth psychotherapies. Four decades of meta-analyses have been used to synthesize the RCT findings and identify scientifically and clinically significant patterns. These meta-analyses have limitations, noted herein, but they have advanced our understanding of youth psychotherapy, revealing ( a ) mental health problems for which our interventions are more and less successful (e.g., anxiety and depression, respectively); ( b ) the beneficial effects of single-session interventions, interventions delivered remotely, and interventions tested in low- and middle-income countries; ( c ) the association of societal sexism and racism with reduced treatment benefit in majority-girl and majority-Black groups; and, importantly, ( d ) the finding that average youth treatment benefit has not increased across five decades of research, suggesting that new strategies may be needed. Opportunities for the future include boosting relevance to policy and practice and using meta-analysis to identify mechanisms of change and guide personalizing of treatment.

Evaluation of Pressing Issues in Ecological Momentary Assessment

The use of repeated, momentary, real-world assessment methods known as the Experience Sampling Method and Ecological Momentary Assessment (EMA) has been broadly embraced over the last few decades. These methods have extended our assessment reach beyond lengthy retrospective self-reports as they can capture everyday experiences in their immediate context, including affect, behavior, symptoms, and cognitions. In this review we evaluate nine conceptual, methodological, and psychometric issues about EMA with the goal of stimulating conversation and guiding future research on these matters: the extent to which participants are actually reporting momentary experiences, respondents’ interpretation of momentary questions, the use of comparison standards in responding, efforts to increase the EMA reporting period beyond the moment to longer periods within a day, training of EMA study participants, concerns about selection bias of respondents, the impact of missing EMA assessments, the reliability of momentary data, and for which purposes EMA might be considered a gold standard for assessment. Resolution of these issues should have far-reaching implications for advancing the field.

Machine Learning and the Digital Measurement of Psychological Health

Since its inception, the discipline of psychology has utilized empirical epistemology and mathematical methodologies to infer psychological functioning from direct observation. As new challenges and technological opportunities emerge, scientists are once again challenged to define measurement paradigms for psychological health and illness that solve novel problems and capitalize on new technological opportunities. In this review, we discuss the theoretical foundations of and scientific advances in remote sensor technology and machine learning models as they are applied to quantify psychological functioning, draw clinical inferences, and chart new directions in treatment.

The Questionable Practice of Partialing to Refine Scores on and Inferences About Measures of Psychological Constructs

Partialing is a statistical approach researchers use with the goal of removing extraneous variance from a variable before examining its association with other variables. Controlling for confounds through analysis of covariance or multiple regression analysis and residualizing variables for use in subsequent analyses are common approaches to partialing in clinical research. Despite its intuitive appeal, partialing is fraught with undesirable consequences when predictors are correlated. After describing effects of partialing on variables, we review analytic approaches commonly used in clinical research to make inferences about the nature and effects of partialed variables. We then use two simulations to show how partialing can distort variables and their relations with other variables. Having concluded that, with rare exception, partialing is ill-advised, we offer recommendations for reducing or eliminating problematic uses of partialing. We conclude that the best alternative to partialing is to define and measure constructs so that it is not needed.

Eating Disorders in Boys and Men

While boys and men have historically been underrepresented in eating disorder research, increasing interest and research during the twenty-first century have contributed important knowledge to the field. In this article, we review the epidemiology of eating disorders and muscle dysmorphia (the pathological pursuit of muscularity) in boys and men; specific groups of men at increased risk for eating disorders; sociocultural, psychological, and biological vulnerability factors; and male-specific assessment measures. We also provide an overview of current research on eating disorder and muscle dysmorphia prevention efforts, treatment outcomes, and mortality risk in samples of boys and men. Priorities for future research are including boys and men in epidemiological studies to track changes in incidence, identifying (neuro)biological factors contributing to risk, eliminating barriers to treatment access and utilization, and refining male-specific prevention and treatment efforts.

Mental Health of Transgender and Gender Diverse Youth

Transgender and gender diverse (TGD) children and adolescents are an increasingly visible yet highly stigmatized group. These youth experience more psychological distress than not only their cisgender, heterosexual peers but also their cisgender, sexual minority peers. In this review, we document these mental health disparities and discuss potential explanations for them using a minority stress framework. We also discuss factors that may increase and decrease TGD youth's vulnerability to psychological distress. Further, we review interventions, including gender-affirming medical care, that may improve mental health in TGD youth. We conclude by discussing limitations of current research and suggestions for the future.

Behavioral Interventions for Children and Adults with Tic Disorder

Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

The Garrett Lee Smith Memorial Act: A Description and Review of the Suicide Prevention Initiative

The Garrett Lee Smith (GLS) Memorial Act, continuously funded since 2004, has supported comprehensive, community-based youth suicide prevention efforts throughout the United States. Compared to matched communities, communities implementing GLS suicide prevention activities have lower population rates of suicide attempts and lower mortality among young people. Positive outcomes have been more pronounced with continuous years of implementation and in less densely populated communities. Cost analyses indicate that implementation of GLS suicide prevention activities more than pays for itself in reduced health care costs associated with fewer emergency department visits and hospitalizations. Although findings are encouraging, the heterogeneity of community suicide prevention programs and the lack of randomized trials preclude definitive determination of causal effects associated with GLS. The GLS initiative has never been brought fully to scale (e.g., simultaneously impacting all communities in the United States), so beneficial effects on nationwide suicide rates have not been realized.

Racism and Social Determinants of Psychosis

The Centers for Disease Control and Prevention has identified racism as a serious threat to public health. Structural racism is a fundamental cause of inequity within interconnected institutions and the social environments in which we live and develop. This review illustrates how these ethnoracial inequities impact risk for the extended psychosis phenotype. Black and Latinx populations are more likely than White populations to report psychotic experiences in the United States due to social determining factors such as racial discrimination, food insecurity, and police violence. Unless we dismantle these discriminatory structures, the chronic stress and biological consequences of this race-based stress and trauma will impact the next generation's risk for psychosis directly, and indirectly through Black and Latina pregnant mothers. Multidisciplinary early psychosis interventions show promise in improving prognosis, but coordinated care and other treatments still need to be more accessible and address the racism-specific adversities many Black and Latinx people face in their neighborhoods and social environments.

Developmental Consequences of Intimate Partner Violence on Children

Numerous studies associate childhood exposure to intimate partner violence (IPV) with adverse adjustment in the domains of mental health, social, and academic functioning. This review synthesizes this literature and highlights the critical role of child self-regulation in mediating children's adjustment outcomes. We discuss major methodological problems of the field, including failure to consider the effects of prenatal IPV exposure and the limitations of variable-oriented and cross-sectional approaches. Finally, we present a comprehensive theoretical model of the effects of IPV on children's development. This model includes three mechanistic pathways—one that is unique to IPV (maternal representations) and two that are consistent with the effects of other stressors (maternal mental health and physiological functioning). In our model, the effects of these three pathways on child adjustment outcomes are mediated through parenting and child self-regulation. Future research directions and clinical implications are discussed in the context of the model.

Psychoneuroimmunology: An Introduction to Immune-to-Brain Communication and Its Implications for Clinical Psychology

Research conducted over the past several decades has revolutionized our understanding of the role of the immune system in neural and psychological development and function across the life span. Our goal in this review is to introduce this dynamic area of research to a psychological audience and highlight its relevance for clinical psychology. We begin by introducing the basic physiology of immune-to-brain signaling and the neuroimmune network, focusing on inflammation. Drawing from preclinical and clinical research, we then examine effects of immune activation on key psychological domains, including positive and negative valence systems, social processes, cognition, and arousal (fatigue, sleep), as well as links with psychological disorders (depression, posttraumatic stress disorder, anxiety, schizophrenia). We also consider psychosocial stress as a critical modulator of neuroimmune activity and focus on early life adversity. Finally, we highlight psychosocial and mind–body interventions that influence the immune system and may promote neuroimmune resilience.

Racial, Ethnic, and Cultural Resilience Factors in African American Youth Mental Health

Racism constitutes a significant risk to the mental health of African American children, adolescents, and emerging adults. This review evaluates recent literature examining ethnic and racial identity, ethnic-racial socialization, religiosity and spirituality, and family and parenting as racial, ethnic, and cultural resilience factors that shape the impact of racism on youth mental health. Representative studies, purported mechanisms, and critiques of prior research are presented for each factor. Recent studies of racism and resilience revisit foundational resilience factors from prior research while reflecting new and important advances (e.g., consideration of gender, cultural context, structural racism), providing important insights for the development of prevention and intervention efforts and policy that can alleviate mental health suffering and promote health and mental health equity for African American youth.

Acculturation and Psychopathology

Acculturation and psychopathology are linked in integrated, interactional, intersectional, and dynamic ways that span different types of intercultural contact, levels of analysis, timescales, and contexts. A developmental psychopathology approach can be useful to explain why, how, and what about psychological acculturation results in later adaptation or maladaptation for acculturating youth and adults. This review applies a conceptual model of acculturation and developmental psychopathology to a widely used framework of acculturation variables producing an Integrated Process Framework of Acculturation Variables (IP-FAV). This new comprehensive framework depicts major predisposing acculturation conditions (why) as well as acculturation orientations and processes (how) that result in adaptation and maladaptation across the life span (what). The IP-FAV is unique in that it integrates both proximal and remote acculturation variables and explicates key acculturation processes to inform research, practice, and policy.

Posttraumatic Stress Disorder in Refugees

The number of refugees and internally displaced people in 2022 is the largest since World War II, and meta-analyses demonstrate that these people experience elevated rates of mental health problems. This review focuses on the role of posttraumatic stress disorder (PTSD) in refugee mental health and includes current knowledge of the prevalence of PTSD, risk factors, and apparent differences that exist between PTSD in refugee populations and PTSD in other populations. An emerging literature on understanding mechanisms of PTSD encompasses neural, cognitive, and social processes, which indicate that these factors may not function exactly as they have functioned previously in other PTSD populations. This review recognizes the numerous debates in the literature on PTSD in refugees, including those on such issues as the conceptualization of mental health and the applicability of the PTSD diagnosis across cultures, as well as the challenge of treating PTSD in low- and middle-income countries that lack mental health resources to offer standard PTSD treatments.

Risk and Resilience Among Children with Incarcerated Parents: A Review and Critical Reframing

Parental incarceration is a significant, inequitably distributed form of adversity that affects millions of US children and increases their risk for emotional and behavioral problems. An emerging body of research also indicates, however, that children exhibit resilience in the context of parental incarceration. In this article, we review evidence regarding the adverse implications of parental incarceration for children's adjustment and consider factors that account for these consequences with special attention to naturally occurring processes and interventions that may mitigate risk and contribute to positive youth development. We also offer a critical reframing of resilience research and argue that ( a ) scholars should adopt more contextualized approaches to the study of resilience that are sensitive to intersecting inequalities and ( b ) resilience research and practice should be conceptualized as important complements to, rather than substitutes for, social and institutional change. We conclude by offering social justice–informed recommendations for future research and practice.

Supernatural Attributions: Seeing God, the Devil, Demons, Spirits, Fate, and Karma as Causes of Events

For many people worldwide, supernatural beliefs and attributions—those focused on God, the devil, demons, spirits, an afterlife, karma, or fate—are part of everyday life. Although not widely studied in clinical psychology, these beliefs and attributions are a key part of human diversity. This article provides a broad overview of research on supernatural beliefs and attributions with special attention to their psychological relevance: They can serve as coping resources, sources of distress, psychopathology signals, moral guides, and decision-making tools. Although supernatural attributions sometimes involve dramatic experiences seen to violate natural laws, people more commonly think of supernatural entities working indirectly through natural events. A whole host of factors can lead people to make supernatural attributions, including contextual factors, specific beliefs, psychopathology, cognitive styles and personality, and social and cultural influences. Our aim is to provide clinical psychologists with an entry point into this rich, fascinating, and often overlooked literature.

17 Ahead of Print Articles

Volume 19 (2023)

Volume 18 (2022), volume 17 (2021), volume 16 (2020), volume 15 (2019), volume 14 (2018), volume 13 (2017), volume 12 (2016), volume 11 (2015), volume 10 (2014), volume 9 (2013), volume 8 (2012), volume 7 (2011), volume 6 (2010), volume 5 (2009), volume 4 (2008), volume 3 (2007), volume 2 (2006), volume 1 (2005), volume 0 (1932).

Clinical Psychological Science

Clinical Psychological Science  publishes advances in clinical science and provides a venue for cutting-edge research across a wide range of conceptual views, approaches, and topics. This bimonthly journal encompasses many core domains that have defined clinical psychology, but also boundary-crossing advances that integrate and make contact with diverse disciplines and that may not easily be found in traditional clinical psychology journals. Among the key topics are research on the underlying mechanisms and etiologies of psychological health and dysfunction; basic and applied work on the diagnosis, assessment, treatment, and prevention of mental illness; service delivery; and promotion of well-being. Articles are published OnlineFirst before they are assigned to an issue. This journal is a member of the Committee on Publication Ethics (COPE) .

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• Published: 09 June 2024

Psychological intervention improves quality of life in patients with early-stage cancer: a systematic review and meta-analysis of randomized clinical trials

• Sára Anna Bognár 1 , 2 ,
• Brigitta Teutsch 2 , 3 ,
• Stefania Bunduc 2 ,
• Dániel Sándor Veres 2 , 4 ,
• Bence Szabó 2 ,
• Beatrix Fogarasi 1 ,
• Olga Júlia Zahariev 1 , 2 ,
• Nóra Vörhendi 3 , 5 ,
• Omer Almog 2 ,
• Yael Hadani 2 ,
• Dorottya Gergő 2 , 6 ,
• Emese Mihály 7 ,
• Bálint Erőss 1 , 2 , 3 ,
• Stefania Bunduc 2 , 8 ,
• Katalin Márta 1 , 2 , 9   na1 &
• Péter Hegyi 1 , 2 , 3 , 9   na1  

Scientific Reports volume  14 , Article number:  13233 ( 2024 ) Cite this article

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The effectiveness of psychological interventions (PI) for malignant diseases is controversial. We aimed to investigate the effect of PI on survival and quality of life (QoL) in patients with cancer. We performed a systematic search of MEDLINE, Cochrane, and Embase databases to identify randomized controlled trials comparing PI to standard care (PROSPERO registration number CRD42021282327). Outcomes were overall survival (OS), recurrence-free survival (RFS), and different domains of QoL. Subgroup analysis was performed based on the provider-, type-, environment-, duration of intervention; cancer stage, and type. Pooled hazard ratios (HR) and standardized mean difference (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model. The OS and RFS did not differ significantly between the two groups (OS:HR = 0.97; CI 0.87–1.08; RFS:HR = 0.99; CI 0.84–1.16). However, there was significant improvement in the intervention group in all the analyzed domains of QoL; in the global (SMD = 0.65; CI 0.35–0.94), emotional (SMD = 0.64; CI 0.33–0.95), social (SMD = 0.32; CI 0.13–0.51) and physical (SMD = 0.33; CI 0.05–0.60) domains. The effect of PI on QoL was generally positive immediately, 12 and 24 weeks after intervention, but the effect decreased over time and was no longer found significant at 48 weeks. The results were better in the breast cancer group and early stages of cancer. PIs do not prolong survival, but they significantly improve the QoL of cancer patients. PI should be added as standard of care 3–4 times a year, at least for patients with early-stage cancer.

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Introduction.

Cancer is a leading cause of death and reduces life expectancy worldwide 1 . GLOBOCAN estimated that there were 19.3 million new cancer cases, and almost 10 million led to death in 2020, irrespective of the world region 2 . In Europe, the most common causes of cancer-related deaths are lung (380,000 deaths, one-fifth of the total), colorectal (250,000 deaths, 12.6%), breast (140,000, 7.3%; females only) and pancreatic (130,000, 6.8%) cancers. Altogether, these cancers account for 47% of all cancer-related mortality. The disease affects not only a large number of patients but also their families and the healthcare system, taking a psychological, physical, and financial toll 3 .

Survival used to be almost the only goal of cancer treatment; however, quality of life (QoL) is increasingly recognized as an essential outcome criterion for oncological treatments and has been linked to survival prediction 4 . Receiving a cancer diagnosis unquestionably has a negative impact on the QoL, which is related to the prognosis of the disease itself, the choice of treatment, and the duration of the disease. The need for frequent hospitalizations, negative emotions, and several symptoms significantly reduce the QoL of these patients 5 . For these reasons, the need for psychosocial interventions to treat and support these patients, as well as cancer survivors, has increased recently 6 .

The exact effect of how psychological interventions can improve QoL and prolong survival is inconclusive. Existing studies are based on small samples and are inconsistent regarding intervention provider, delivery methods, intervention type, duration and intensity, follow-up measurement periods, and methodological quality 7 , 8 , 9 , 10 .

Targeting this gap in existing literature, we aimed to investigate the impact of psychological interventions on the survival rate and QoL of patients with cancer and to present this information in a comprehensive study that breaks down this impact based on the provider, environment, type, and the duration of the psychological intervention, as well as on cancer type and stage.

In this study, we worked from independent primary studies that consisted of data that were further analyzed here. We gathered data and analyzed it with statistical methods to derive conclusions in this article. The recommendations of PRISMA 2020 11 and Cochrane Handbook guidelines were applied (PROSPERO registration number CRD42021282327) 12 .

Search strategy and eligibility criteria

We formulated our clinical question and defined the search strategy using the PICO-S (population—cancer patients; intervention—psychological intervention; comparison—no psychological intervention; outcome—OS, RFS and QoL, study type—RCTs) framework. The systematic search was performed in three databases: MEDLINE (via PubMed), Cochrane Library (CENTRAL), and EMBASE from inception until 18th October 2021, with the restrictions to include adult patients. The search was updated on the 1st of February 2024 during the revision process. The search key (Supplementary Material (referred to as S.) Table S1 ) with the following main concepts: psychotherapy AND cancer AND randomized—was used to identify the eligible articles according to predefined criteria. We also screened the reference lists of the identified articles for further eligible reports.

Only randomized controlled trials (RCTs) were considered eligible; adult patients diagnosed with any cancer receiving cancer or palliative treatment or who reported as 'cancer survivors' were eligible for our study. Patients who received psychological interventions were included in our analysis if data on their survival (overall (OS), recurrence-free (RFS)), or QoL were provided. Regarding the psychological interventions, various methods were eligible for the study: different types of psychotherapy, mindfulness, cognitive-behavioral therapy, relaxation, meditation, stress management, self-help, psychoeducation, and counseling carried out in a group, individual or guided self-help settings; face-to-face, on the telephone, or via the internet. Interventions carried out by psychologists, nurses, or any non-specified healthcare professional were also eligible. We included only full-text publications in peer-reviewed journals.

Data extraction

The duplication removal was performed using reference manager software (EndNote X9, Clarivate Analytics, Philadelphia, PA, USA). The titles, abstracts, and full texts were selected by two independent authors in pairs (DG and ASB). The possible disagreements were resolved by a third party (BF). To measure inter-rater reliability, Cohen's kappa coefficients (κ) were calculated. Studies with overlapping populations and ineligible study designs were excluded. Missing or insufficient data were included in the systematic review. From the eligible articles, data were collected manually by two authors (OA and YH) independently into a standardized data table (Microsoft Excel, Microsoft, Office 365, Redmond, WA, USA), and the disagreements were solved by a third reviewer (DG). The following data were extracted: publication characteristics: first author, year of publication, country of origin, number of centers, demographic characteristics of the study population, intervention characteristics: type, duration, provider, environment, outcomes—overall and progression-free survival, quality of life—measurement tool, time of the measurements in weeks, net minutes of intervention per patient, questionnaire scores (mean, SD)—as reported in each article. The outcomes of our analysis of the subgroups are summarized in Fig.  1 . A detailed explanation of the structure is given in Section S1 .

Structure of our analysis. Details of the investigated outcomes (survival and QoL), based on subgroups, and subcategories.

Statistical analysis

As we anticipated considerable between-study heterogeneity, a random-effects model was used to pool effect sizes. For OS and RFS, pooled hazard ratios (HR) with 95% confidence intervals were calculated using an inverse variance weighting method; heterogeneity was estimated using a restricted maximum-likelihood estimator, with the Q profile method for the confidence interval. For QoL, the standardized mean difference (SMD) with a 95% confidence interval (CI) was used as the effect size between the intervention and the control groups due to differences in the questionnaires measuring the outcomes. We used Hedges' g to calculate SMDs 13 . SMD values of 0.2–0.5 were considered small effects, 0.5–0.8 were considered medium effects, and values > 0.8 were considered large effects. As the articles reported QoL results at different follow-up time points, to make a prediction, we created a longitudinal model for predicting QoL at 0-, 12-, 24-, and 48-weeks post-intervention, using the time and the square of time as predictors of change in time. Forest plots illustrate the results at these specific time points (T0 = week 0, T12 = week 12, T24 = week 24, T48 = week 48). A separate longitudinal prediction-model was applied for different QoL domains and subcategories. The summary plots are used to visualize the calculated overall effects for a given outcome. Inverse variance weighting was used to calculate the pooled SMD in the longitudinal meta-analysis.

Publication bias and small study effects were assessed using funnel plots. All statistical analyses were made with R (v4.2.1) 14 using the following packages: metafor (v3.4.0) 15 and clubSandwich (v0.5.8) for model calculations, publication bias and influential assessment, meta (v5.5.0) 16 for forest plots, ggplot2 (v3.3.6) 17 for additional prediction plots. A detailed description of our statistical analysis is given in the Supplementary Material in Section S2 . We report the results as point estimates of the effect size (lower–upper limit of 95% CI) format.

Study risk of bias and certainty assessment

Two authors (ASB and NV) independently performed the risk of bias assessment using the Cochrane risk-of-bias tool for randomized trials Version 2 (RoB 2) 18 . Disagreements were resolved by a third party (BF). Five key domains were assessed: the randomisation process, deviation from the intended intervention, missing out-come data, outcome measurement, and selection of the reported results. Evaluations of these domains were categorized into: "low risk," "some concerns," or "high risk” of bias, as the guideline suggests.

Selection process

After duplicate removal and exclusion based on titles and abstracts, 11,374 articles were screened in more detail for eligibility. Subsequently, another 312 were excluded because of missing outcome parameters or ineligible study settings (e.g., wrong outcome measure, inappropriate control group, pre-existing psychological illnesses, etc.). This resulted in 129 articles analyzed in this study. In the updated search, 1431 articles were screened after duplication removal. Twenty-eight articles were searched in full length, which resulted in 14 articles analyzed in this study. The complete search and selection process is shown in the PRISMA flowchart Fig. S1 . The baseline characteristics of the enrolled studies are detailed in Table S2 .

Systematic review

Thirteen studies reported on global QoL, and nine studies 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 reported improved QoL in the intervention group compared to the control group. Five out of seven studies 19 , 20 , 21 , 28 , 29 reported improvement in the intervention group for emotional QoL. For physical QoL, two out of three studies 26 , 27 reported that scores in physical domains improved in the intervention group. For social QoL, three out of five studies 19 , 21 , 28 reported better QoL scores in the intervention group than in the control group. These studies were not included in the meta-analysis because of missing data.

Meta-analysis

Psychological interventions do not affect survival.

Fourteen studies reported on the OS, involving 2683 patients, and five reported on RFS, involving 900 patients. The OS of patients did not differ significantly between the intervention and the control groups (HR = 1.01; 95% CI = 0.95–1.07). Similarly, the two groups had no significant difference in RFS (HR = 0.99; 95% CI = 0.84–1.16) (Fig.  2 ).

The effect of psychological interventions on overall survival and recurrence-free survival. Psychological interventions did not result in significant differences in the improvement of overall survival (OS) ( a ) and recurrence-free survival (RFS) ( b ) between the intervention and control groups. Diamonds and horizontal lines represent the hazard ratio (HR) and confidence intervals (CI) for each comparison (OS: overall survival; RFS: recurrence free survival), cancer—various cancer subtypes .

Longitudinal meta-analysis: post-intervention (T0) results

Psychological interventions significantly improve quality of life in all measured domains.

Here, we present the results of model-based prediction values for the overall post-intervention effect sizes. In the intervention group, we found significant improvements compared to the control group in all analyzed domains of QoL: global (SMD = 0.65; 95% CI = 0.35–0.94), emotional (SMD = 0.64; 95% CI = 0.33–0.95), social (SMD = 0.32; 95% CI = 0.13–0.51) and physical (SMD = 0.33; 95% CI = 0.05–0.6) domains (Fig.  3 ). A forest plot of the pooled results for each domain at different time points is presented in Fig. S2 .

Forest plot of the pooled results in the different domains of Quality of Life. Psychological interventions significantly improve global, emotional, social and physical quality of life compared to the control group. Diamonds and horizontal lines represent standardized mean differences (SMS) and confidence intervals (CI) for each comparison.

Subgroup analysis of global QoL Based on the subgroup analysis structure mentioned earlier, we found significant improvement (T0) in the intervention group in all categories of providers: psychologist (SMD = 0.46; CI = 0.14–0.77; p = 0.006), healthcare professional (SMD = 0.77; CI = 0.38–1.16; p = 0.0004), and nurse (SMD = 0.74; CI = 0.25–1.23; p = 0.005). In the environment category, significant improvements were observed for face-to-face (SMD = 0.56; CI = − 0.22 to 0.91; p = 0.003) and online (SMD = 0.58; CI = 0.08–1.07; p = 0.029) intervention, but no improvement was seen when the intervention was delivered via telephone (SMD = 0.26; CI = − 0.63 to 1.15; p = 0.418). In the category of intervention type, we found that there was a significant improvement in the experimental group for individual (SMD = 0.68; CI = 0.37–0.99; p < 0.001), group therapy (SMD = 0.61; CI = 0.27–0.95; p = 0.0009), and the guided self-help therapy (SMD = 0.59; CI = 0.1–1.08; p = 0.026). Significant improvements in the cancer stage were only seen when patients were in the early stages of cancer (SMD = 0.66; CI = 0.14–1.17; p = 0.017) (Fig.  4 ). Regarding cancer type, we only found a significant difference in the breast cancer group (SMD = 0.53; CI = 0.18–0.87; p = 0.004). Individual study effects and other measured time points (T12, T24, and T48) are shown in Figs. S3 – S7 .

Forest plot of the subgroup analysis of Global Quality of Life (QoL). Summary plot showing results by provider, environment, type, and cancer stage for the global QoL. Diamonds and horizontal lines represent standardized mean differences (SMD) and confidence intervals (CI) for each comparison.

Subgroup analysis of emotional QoL Patients receiving the psychological intervention had significantly improved quality of life regardless of the provider: psychologist (SMD = 0.61; CI = 0.25–0.97; p = 0.0018), healthcare professional (SMD = 0.69; CI = 0.37–1.02, p = 0.0002), and nurse (SMD = 0.86; CI = 0.45–1.28, p = 0,0002). The results showed significant improvement in the environment subgroup in the experimental group when the intervention was delivered face-to-face (SMD = 0.77; CI = 0.35–1.19; p = 0.001), online (SMD = 0.94; CI = 0.57–1.3; p = 0.0004) or via telephone (SMD = 0.65; CI = 0.24–1.06; p = 0.005). There was a significant improvement in the type of intervention for the individual (SMD = 0.60; CI = 0.26–0.95; p = 0.001) and group-based interventions (SMD = 0.73; CI = 0.29–1.16; p = 0.0025). There was no difference when the type of intervention was guided-self-help (SMD = 0.68; CI = − 0.78 to 2.14; p = 0.212). Significant emotional QoL changes were only observed in the early-stage cancer group (SMD = 1.03; CI = 0.24–1.83; p = 0.016) (Fig.  5 ). Regarding cancer type, we found a significant difference in breast cancer (SMD = 0.77; CI = 0.4–1.15; p = 0.0006), gastrointestinal (SMD = 1.34; CI = 0.54–2.14; p = 0.014) and gynecological group (SMD = 0.62; CI = 0.13–1.11; p = 0.02) but no difference was seen in the prostate cancer group (SMD = 0.56; CI = − 0.04 to 1.16; p = 0.062). Individual study effects and the other time points are shown in Figs. S7 – S12 .

Forest plot of the subgroup analysis of Emotional Quality of Life (QoL). Forest plot showing the results of subgroup analysis of the emotional QoL domain by provider, environment, type and cancer stage. Diamonds and horizontal lines represent standardized mean differences (SMD) and confidence intervals (CI) for each comparison. mean difference, CI: confidence interval.

Subgroup analysis of social QoL Our analysis showed a significant improvement in social QoL in the subcategory of a psychologist (SMD = 0.32; CI = 0.06–0.58; p = 0.019) and nurse-delivered intervention (SMD = 0.43; CI = 0.19–0.68; p = 0.09) for the provider subgroup. The only significant environment was face-to-face intervention (SMD = 0.32; CI = 0.1–0.54; p = 0.006), and there was improvement only when the intervention was individual (SMD = 0.35; CI = 0.15–0.55; p = 0.001). Finally, there was no improvement in social QoL by the cancer stage (Fig.  6 ). Regarding cancer type, we only found a significant difference in the breast cancer group (SMD = 0.26; CI = 0.04–0.48; p = 0.021). Individual study effects and the other time points are shown in Figs. S13 – S17 .

Forest plot of the subgroup analysis of Social Quality of Life (QoL). Forest plot showing the results of subgroup analysis of the social QoL domain by provider, environment, type and cancer stage. Diamonds and horizontal lines represent standardized mean differences (SMD) and confidence intervals (CI) for each comparison.

Subgroup analysis of physical QoL Physical QoL improved significantly in the intervention group compared to the control group in all categories of providers: psychologist (SMD = 0.66; CI = 0.32–0.99; p = p < 0.001), healthcare professionals (SMD = 0.73; CI = 0.42–1.04; p < 0,001), and nurse (SMD = 0.58; CI = 0.33–0.82; p < 0.001). Significant differences were only found in the environment category when the intervention was delivered face-to-face (SMD = 0.32; CI = 0.0019–0.64; p = 0.049). In the type category, only the individual (SMD = 0.31; CI = 0.05–0.57; p = 0.022) intervention had a significantly better effect. There was no notable improvements in cancer stage (Fig.  7 ). Regarding cancer, we can observe significant improvement in two cancer groups: breast cancer (SMD = 0.55; CI = 0.2–0.89, p = 0.003) and gynecological cancer (SMD = 0.50; CI = 0.03–0.98; p = 0.042) The effects of individual study and data for the other time points are shown in Figs. S18 – S22 .

Forest plot of the subgroup analysis of Physical Quality of Life (QoL). Forest plot showing the results of subgroup analysis of the physical QoL by provider, environment, type, and cancer stage. SMD: standardized mean difference; CI: confidence interval. Diamonds and horizontal lines represent standardized mean differences (SMD) and confidence intervals (CI) for each comparison.

Impact of the interventions over time in the four domains of quality of life

The post-intervention intervention had a significant effect, but the follow-up time effect was not significant. However, the point estimate decreased slightly during the follow-up time, and the 95% CI for the 48-week effect was the 0 effect (Fig.  8 ). The significant baseline improvement measured at the estimated time 0 t did not decrease before week 48. By week 48, the improvement had disappeared in almost all domains except physical QoL.

Summary forest plot showing the effect of intervention at different follow-up times. We found that the effect of follow-up time was not significant (T0—immediately after the intervention; T12—at week 12; T24—at week 24; T48—at week 48) in the four measured QoL domains. SMD: standardized mean difference; CI: confidence interval.

Duration of intervention

Our analysis showed that, based on the duration of the intervention (net minutes/patient), QoL SMDs did not change significantly by each week in any domain (Fig.  9 ). (Global QoL: SMD = 0.06; CI = 0.01–1.2/min; p = 0.05; emotional QoL: SMD = 0.80; CI = 0.28–1.33/min; p = 0,006 social QoL: SMD = 0.29; CI = − 0.10 to 0.64 /min; p = 0.146; physical QoL: SMD = 0.23; CI = − 0.09 to 0.56/min; p = 0.159). Figure  9 .

Regression plot of the duration of the intervention in the four domains of QoL. Regression plot showing the estimated SMDs of the four QoL domains by follow-up times based on the duration of the intervention with no significant difference. The size of the point represents the precision (more accurately: the size is proportional to the inverse of the variance of the given study), predictor: net minutes of interventions.

Risk of bias assessment

The detailed results of the risk of bias assessment are presented in Table S23 . For survival and QoL, most of the studies had some concerns about the risk of overall bias, mainly due to the randomization process.

Publication bias and heterogeneity

For OS, we could observe a possible publication bias of small studies, but the effect of small studies does not change the conclusion to a relevant extent. In the case of RFS, the assessment of publication bias of small studies is limited as the number of studies is very low ( S24.1. – S24.2. ). For QoL, the funnel plots do not exclude the presence of potential publication bias, although the figure suggests a few outlier publications rather than systemic reporting bias (see S24.3. .– S24.2.6. ).

Statistical heterogeneity of survival data was considered moderate: OS: I 2  = 40% [0%, 68%]; and low: RFS: I 2  = 23% [0%, 68%].

The psychosocial difficulties experienced by cancer patients in the long term are broad and include a wide range of symptoms such as anxiety, uneasiness, mourning, helplessness, fatigue, concentration difficulties, sleep problems, mental and cognitive impairments, sexual dysfunction, psychological distress, and psychiatric illnesses 30 . These symptoms are even more common in patients with poor prognosis and advanced-stage cancer 31 . Therefore, the above-mentioned psychosocial symptom-free period and QoL have become the primary endpoints 32 . Firkinns et al. 33 found that QoL was significantly affected 2 to 26 years after cancer diagnosis. All these means that providing psychological support to cancer survivors in the long term is crucial.

Although our analysis concluded that psychological interventions do not prolong survival time, they can improve the quality of life of patients and the time that these patients and their families have left. Our analysis revealed significant improvements in all four measured QoL domains (global, emotional, social, and physical) in the intervention group compared to the control group, with the highest clinical effect in the emotional domains.

Moreover, our subgroup analysis showed significant improvements in QoL in the experimental group regardless of the intervention provider in most cases. This suggests that the rigorous research intervention and training have a strong influence on provider self-efficacy leaving less emphasis on the provider’s profession or personality itself 34 . The interventions used in the studies were mostly non-psychotherapies, where the role of a licensed psychologist would be essential.

The environment in which the interventions take place also influences the beneficial effect. Our analysis showed that face-to-face interventions were the most effective. This implies that personal interactions are important factors in delivering psychological interventions. The online form was only significant in global and emotional domains. This suggests that an online form can also be effective if a patient has difficulty going to hospital. A review article conducted on this topic found that even though online interventions may supplement traditional treatment setups for mental disorders, they could not provide consistent quality or replace face-to-face therapy 35 . Further research should evaluate how online therapies could be improved to be more effective in providing quality treatment for less mobile patients.

Regarding the type of interventions, there were significant improvements for individual therapies in all measured domains. Group-based therapies were significantly effective in the global and emotional domains. Cancer patients often express a preference for individual over group therapy for various fears despite their effectiveness 36 . Participating in group therapy where fellow patients are suffering from the same condition in a worse condition might be frightening to see. It is also possible that heterogeneous groups make it difficult to tailor the best possible treatment for each patient group. For this reason, individual therapies could be a better choice. Guided self-help was only statistically significant in the global domain, but we cannot draw conclusions due to the limited data.

It has been proposed that psychological interventions only affect the prognosis of patients with early-stage cancer, as the natural course of more advanced stages might obviate the possible effect of psychosocial factors 8 . Our results may support these findings as the point estimates were higher for early-stage patients but did not prove significant. The results for the cancer stage suggest that psychological interventions are most effective when provided in the early stages rather than in the advanced or survival phase. An interesting finding is that these interventions did not affect the survival category. These patients may have gone through post-traumatic growth, and these interventions are not strong enough for them to make a difference. A study conducted on post-traumatic self-growth among cancer survivors found that the positive effects of surviving cancer can last up to 4 years; however, after that, patients started to have lower scores 37 . We must highlight that we had limited data to analyze the effect of the cancer stage, but monitoring patients' needs, even for survival patients, should be a standard.

Regarding cancer type, we found that breast cancer patients benefited most from the psychological interventions. No improvement was seen in the prostate cancer group in any domains. This raises the question of whether gender plays a role in seeking and accepting psychological help. There is evidence in the literature to support the idea that gender is a predictor of attitudes toward seeking professional psychological help; however, other factors like cultural background and educational level are important factors, too 38 , 39 .

Interestingly, our results showed that the duration of the intervention is not an important factor for psychological interventions in improving the four analyzed QoL domains. This aligns with the results of a study where researchers found that the number of sessions, length, and treatment intensity were unrelated to therapeutic gains 40 . Due to the heterogeneity of interventions, we were not able to analyze data by duration, frequency, and occasion; therefore, further research is needed in this subgroup. This is, however, an important finding for future recommendations and funding, as we could standardize short but intensive interventions at least three or four times a year to be cost- and time-effective when treating these patients for their QoL. Figure  10 . shows the sum of the subgroup analysis of QoL domains.

Sum of the subgroup analysis of QoL domains. The figure shows the cumulative findings of subgroup analysis of all measured QoL domains. We indicated the significant differences between the intervention and the control groups with the bold *.

Our results suggest that psychological interventions are effective and should be introduced into the routine care of oncological patients. We have gained important information based on provider, type, environment, and duration of intervention efficacy, as well as on cancer stage and type, that can be used to improve the effectiveness of psychological interventions. At the same time, the significance varying across subgroups indicates that patients have different needs; therefore, we should strive to provide personalized patient care.

Strengths and limitation

One of the strengths of this work is its absolute objectivity, which was performed using meta-analyses and rigorous methodology. We were able to provide the highest level of evidence available by including only RCTs with a large number of enrolled patients. To our knowledge, this is the most comprehensive meta-analysis to report on the effectiveness of psychological intervention by provider, environment, type, and cancer stage subgroup. Although the results of this meta-analysis seem promising, the conclusions should be interpreted with caution. In terms of the limitations of this work, the first and most important thing to note is the heterogeneous study/clinical settings between the included studies, in particular, the different types of interventions, cancer types, and measurement tools. These differences made it necessary to use less sensitive statistical analysis. Criteria were developed to define psychological interventions; however, these terms and methods can often be used interchangeably, and the distinction may be subjective. This is further aggravated by insufficient details on interventions; therefore, decisions on inclusion or exclusion may also be superficial 7 . We could only rely on a small amount of data for the survival analysis, so conclusions should be drawn carefully. Lastly, a further limitation is the presence of moderate to high risk of bias in some areas.

Implications for practice and research

Implementing scientific results in everyday clinical practice is crucial and can improve disease management, diagnosis, and therapy 41 , 42 . Our results suggest that psychotherapy should be introduced as standard care for patients with cancer. Psychologists are not part of the patient care team in many countries, and psychotherapy is unavailable for oncological patients. However, psychological interventions should be provided, especially in the early stages of cancer, and should be repeated at least three or four times to maintain the beneficial effects. Further trials could make more personalized recommendations based on cancer types, stages, and psychological methods.

Another important aspect of this review is that our results highlight the need for randomized-controlled clinical trials with standardized methods and reporting on results to accurately assess the effect of psychological interventions. Psychological research is always challenging; however, more objective analyses could be obtained by standardizing intervention methods, questionnaires, intervention duration, frequency, and how data and results are reported.

Even though the survival analysis did not show significant differences between the two groups based on the limited amount of data, our results provide evidence for the beneficial effect of psychological interventions on several aspects of QoL in patients with cancer. While medical research emphasizes survival as the hardest outcome, QoL plays an important role in individuals' lives and should not be underestimated. A longer life in suffering is not necessarily better than a shorter one spent in a better well-being. For that reason, in clinical practice, the assessment of QoL should be an essential part of routine care to provide personalized psychological treatments.

Data availability

All data is shared as an additional file.

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Open access funding provided by Semmelweis University. Funding was provided by the New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund (to BT–ÚNKP-22-3-I-PTE-1693 and to KM–ÚNKP-22-4-II) and by an ITM NRDIF grant (TKP2021-EGA-23). Sponsors had no role in the design, data collection, analysis, interpretation, and manuscript preparation.

Author information

These authors contributed equally: Katalin Márta and Péter Hegyi

Authors and Affiliations

Institute of Pancreatic Diseases, Semmelweis University, 1083, Budapest, Hungary

Sára Anna Bognár, Beatrix Fogarasi, Olga Júlia Zahariev, Bálint Erőss, Katalin Márta & Péter Hegyi

Centre for Translational Medicine, Semmelweis University, 1085, Budapest, Hungary

Sára Anna Bognár, Brigitta Teutsch, Stefania Bunduc, Dániel Sándor Veres, Bence Szabó, Olga Júlia Zahariev, Omer Almog, Yael Hadani, Dorottya Gergő, Bálint Erőss, Stefania Bunduc, Katalin Márta & Péter Hegyi

Institute for Translational Medicine, Medical School, University of Pécs, 7623, Pecs, Hungary

Brigitta Teutsch, Nóra Vörhendi, Bálint Erőss & Péter Hegyi

Department of Biophysics and Radiation Biology, Semmelweis University, 1085, Budapest, Hungary

Dániel Sándor Veres

Department of Internal Medicine, Siófok City Hospital and Outpatient Clinic, 8601, Siófok, Hungary

Nóra Vörhendi

Department of Pharmacognosy, Semmelweis University, Üllői út 26, 1085, Budapest, Hungary

Dorottya Gergő

Department of Internal Medicine and Hematology, Medical School, Semmelweis University, 1088, Budapest, Hungary

Emese Mihály

Center for Digestive Diseases and Liver Transplant, Fundeni Clinical Institute, 022328, Bucharest, Romania

Stefania Bunduc

Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation University of Szeged, 6725, Szeged, Hungary

Katalin Márta & Péter Hegyi

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Bognár, S.A., Teutsch, B., Bunduc, S. et al. Psychological intervention improves quality of life in patients with early-stage cancer: a systematic review and meta-analysis of randomized clinical trials. Sci Rep 14 , 13233 (2024). https://doi.org/10.1038/s41598-024-63431-y

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Research Article

What should we call mental ill health? Historical shifts in the popularity of generic terms

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Visualization, Writing – original draft

* E-mail: [email protected]

Affiliation Melbourne School of Psychological Sciences University of Melbourne Parkville, Melbourne, Victoria, Australia

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Writing – review & editing

• Nick Haslam, 

• Published: June 4, 2024
• https://doi.org/10.1371/journal.pmen.0000032
• Reader Comments

Substantial attention has been paid to the language of mental ill health, but the generic terms used to refer to it–“mental illness”, “psychiatric condition”, “mental health problem” and so forth–have largely escaped empirical scrutiny. We examined changes in the prevalence of alternative terms in two large English language text corpora from 1940 to 2019. Twenty-four terms were studied, compounds of four adjectival expressions (“mental”, “mental health”, “psychiatric”, “psychological”) and six nouns (“condition”, “disease”, “disorder”, “disturbance”, “illness”, “problem”). Terms incorporating “condition”, “disease” and “disturbance” became less popular over time, whereas those involving “psychiatric”, “mental health” and “illness” became more popular. Although there were some trends away from terms with medical connotations and towards more normalizing expressions, “mental illness” consolidated its position as the dominant term over the study period.

Citation: Haslam N, Baes N (2024) What should we call mental ill health? Historical shifts in the popularity of generic terms. PLOS Ment Health 1(1): e0000032. https://doi.org/10.1371/journal.pmen.0000032

Editor: Vitalii Klymchuk, University of Luxembourg: Universite du Luxembourg, LUXEMBOURG

Received: January 17, 2024; Accepted: March 7, 2024; Published: June 4, 2024

Copyright: © 2024 Haslam, Baes. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data and all scripts are available at OSF: https://osf.io/6egsz/ .

Funding: This work was supported by Australian Research Council Discovery Project DP210103984 to NH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Terminology has long been a vexed issue in the domain of mental ill health. Blatantly stigmatizing colloquial expressions such as “crazy” and “lunatic” have been controversial for many years [ 1 ], and official diagnostic terms such as “schizophrenia” have also been denounced [ 2 ]. Some critics challenge the use of diagnostic terms in general, sometimes out of concern for the ill effects of labelling [ 3 , 4 ] and sometimes driven by a broader critique of medicalization [ 5 ]. Some writers who are comfortable with diagnostic terms criticize disease-first language (e.g., “schizophrenic person”) for reducing people to their illnesses, whereas others criticize person-first language (e.g., “person with schizophrenia”) because some people strongly identify with their diagnosis [ 6 , 7 ]. There is also lively disagreement about appropriate terminology for referring to users of mental health services, such as “patient”, “client”, or “consumer” [ 8 ].

Generic terms for mental ill health are one kind of terminology that has largely escaped systematic attention. These expressions serve as umbrella terms that refer to the class of specific conditions. Official psychiatric classifications such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Disease (ICD) employ the term “mental disorder,” but laypeople and professionals alike use a wide array of other expressions. These are typically compound, involving an adjectival expression followed by a noun, the former stipulating how the latter applies to the specific domain of mental ill health. Among the most common adjective expressions are “mental”, “psychological”, and “psychiatric”, with some writers now preferring “mental health” despite the occasional clumsiness of three-word terms such as “mental health disorder”. Some of the most common nouns include “condition”, “disease”, “disorder”, “disturbance”, “illness”, and “problem”. All combinations of these adjectives and nouns can be encountered in everyday use.

These adjectival and noun expressions have distinctive connotations. As a generic term, “mental” implies that the common element of the phenomena of interest relates to the mind. Thesauri list “physical” and “somatic” as antonyms of “mental”, arguably suggesting a dualistic contrast between “mental” and “physical” conditions. “Psychological” has a similar connotation (“of, relating to, or occurring in the mind” in the Merriam-Webster dictionary) but with a clearer connection to a specific profession and field of study (“of or relating to psychology” in the same dictionary). “Psychiatric” relates the phenomena of interest to a particular medical specialty. Like “psychiatric”, and unlike “mental” and “psychological,” “mental health”, used adjectivally (e.g., “mental health problem"), invokes a health context but without referring to a specific profession or discipline.

The noun components of generic terms also carry differing meanings, varying in the extent to which they implicate a medical framing of mental ill health. “Disease” and “illness” are arguably the most clearly medical. According to the ‘Small World of Words’ word association norms [ 9 ], the terms are strongly associated with one another and with “sickness”. Conceptually, “disease” refers to an objective organic malfunction, an entity prototypically caused by an external pathological agent such as a bacterium. “Illness,” by contrast, refers to the subjective experience of a state of ill health. “Disorder” and “disturbance” are sometimes used as near synonyms of “disease” and “illness” but imply a functional impairment or aberration rather than a structural pathology. According to the Compact Oxford dictionary [ 10 ], “disorder” is “usually a weaker term than disease, and not implying structural change” (p.449). “Disturbance” is less tied to the health domain than “disorder”, primarily linked to “problem” and “disruption” in Small World of Words. “Condition” is more neutral than most of the other terms, capable of referring to positive and negative states of health. “Problem,” finally, implies a negative state–associated in the word association norms with words such as “solve” and “issue”–without any direct reference to health. In short, the components of generic terms vary widely in their linkage to health and medicine and in their implied normalcy.

Terminology of this sort is one aspect of what Berrios [ 11 ] calls “psychopathological language”, the systematic language that at any point in history is deemed appropriate for referring to the psychopathological domain. Many generic terms have been widely used in recent history. Berrios notes that “insanity” and “madness” were popular terms in the 19 th century. “Mental disease” became a popular expression early in the late 19 th and early 20 th century, featuring in the title of the Journal of Nervous and Mental Disease , the world’s oldest scientific monthly devoted to human behavior. “Mental disorder” became the preferred generic term in organized psychiatry when formal psychiatric classifications were developed, such as DSM’s first edition, published in 1952. The emerging preference for this term may have arisen because it did not presume a biomedical causation and side-stepped debates over the legitimacy of “mental illness” or “mental disease” [ 12 , 13 ]. More recently, terms whose connotations are even less medical have become popular, such as those including “mental health” and “problems.” The emergence of these expressions reflects a desire to destigmatize and normalize mental ill health, akin to the “euphemism treadmill” [ 14 ], whereby new terms replace those that have come to be seen as offensive or pejorative to ameliorate them. As a result of these terminological shifts, many generic terms are now in widespread circulation.

The implications of alternative generic terms are unclear and have attracted little research. Despite having different connotations, several alternative terms (“mental disorder”, “mental illness”, “mental health problem”) do not differ substantially in the range of phenomena to which they refer [ 15 ]. There is also little clear evidence of differential impacts on judgments of people with mental ill health. Szeto, Luong, and Dobson [ 16 ] found that undergraduate participants did not differ in their attitudes towards and desire for social distance from a person labelled as having a “mental disease”, a “mental disorder”, a “mental health problem”, or a “mental illness”. Similarly, Fox et al. [ 17 ] found no effects on a range of stigma measures when the terms “mental illness”, “mental health problem” or “psychological disorder” were used in a large sample of people with a history of mental illness. However, Lawson [ 18 ] found a greater desire for distance from a hypothetical person when they were labelled as having a “mental disorder” rather than a “mental illness” or “mental health condition.” As yet, no studies have examined other dimensions along which alternative terms might have differential implications, such as effects on professionals’ clinical judgments or on laypeople’s beliefs about causes and appropriate treatments. Although there may have been a trend away from directly medical terms towards more normalizing alternatives, there is as yet no evidence to suggest such a trend has had beneficial effects.

The previous empirical work on generic terminology reviewed above has compared four terms at most, and theoretical work has typically addressed the strengths and weakness of single terms (e.g., “mental illness” [ 19 ]). Studies have also restricted their focus to current usage of terms rather than how that usage has evolved over time. The present study therefore investigated historical trends in the popularity of a comprehensive set of generic terms. We examined the frequency of 24 terms relative to all terms and to one another over a 80-year period using two large English language text corpora. The study was primarily descriptive, aiming to characterize shifts in preferred terminology within society at large. However, we expected to find evidence of diminished popularity of more medical terms (e.g., those including “disease”) and rising preference for more normalizing terms (e.g., those including “mental health” and/or “problem”).

Two corpora were used to track the rise and fall of generic terms from 1940 to 2019. These corpora were chosen for their wide historical span, their very large magnitude, and their differing text sources. The first was derived specifically from books published across the Anglophone world, whereas the second includes text from diverse sources in the USA. If historical trends in terminology are robust, they should replicate across these two distinct corpora. The open-access repository contains all preprocessing scripts: https://osf.io/6egsz/

The Google Books corpus contained “books predominantly in the English language published in any country”, incorporating 361 billion words that appear over 40 times across the corpus from the 1500s onwards [ 20 ]. Frequency counts for specific terms were extracted using the `ngramr`package in R Studio [ 21 ], which facilitates direct access to the corpus, and annual total frequencies were downloaded from Google Books Ngram Viewer Exports. This study used the most recently compiled general English version of the corpus (eng_2019), which excludes low optical character recognition quality and serials. The Google Books corpus contains numerals, did not require preprocessing, and contained 1,423,515,352,830 tokens in the 1940–2019 period.

The second corpus is a combination of two closely related corpora: the Corpus of Historical American English (CoHA [ 22 ]) and the Corpus of Contemporary American English (CoCA [ 23 ]). CoHA contains ~400 million words from 1810–2009, drawn from 115,000 texts distributed across everyday publications (fiction, magazines, newspapers, and non-fiction books). CoCA contains 560 million words from 1990–2019 drawn from ~500,000 texts (extracted from spoken language, TV shows, academic journals, fiction, magazines, newspapers, and blogs). A similar merged CoCA/CoHA corpus has been used in previous research [ 24 ].

After merging, the combined corpus spanning 1810–2019 was processed following recommendations from Alatrash et al. [ 25 ] to clean it without compromising the qualitative and distributional properties of the data. This process included first excluding the special token “@”, which appears in 5% of the COHA corpus (introduced for legal reasons), malformed tokens that are possible artifacts of the digitization process or the data processing, and clean-up performed using the web interface (“&c?;”, “q!”, “|p130”, “NUL”), and removing escaped HTML characters (“(STAR)”, “<p>”, “<>”). Other symbols were excluded after manual inspection of the corpus (e.g., “//”, “PHOTO”, “(COLOR)”, “ILLUSTRATION”). Blogs were also excluded (“web” = 89,054 articles; “blog” = 98,788 articles) for not containing associated year data. Forty-one lines were removed for missing text data (3 fiction, 11 news, 25 magazines, 2 spoken text). The cleaned corpus was then lower-cased and punctuation (commas, periods, question marks) was removed. Numerals and function words were retained to mirror the Google Books corpus. The final combined corpus contained 931,569,490 tokens from 370,091 texts from academic articles ( n = 25,418), fiction books ( n = 30,497), magazines ( n = 136,493), newspapers ( n = 113,440), non-fiction books ( n = 2,635), spoken language ( n = 43,210) and TV shows ( n = 18,398). The current study restricted the corpus period from 1940 to 2019 using 716,070,640 tokens from 330,970 articles. Although very large, the combined CoCA/CoHA corpus was therefore 0.05% the size of the Google Books corpus.

Generic terms

We examined 24 generic terms (bigrams and trigrams) by combining four adjectival terms (“mental”, “mental health”, “psychiatric”, “psychological”) with six nouns (“condition”, “disease”, “disorder”, “disturbance”, “illness”, “problem”). The popularity of each term in each time period was examined as its prevalence as a share of all terms in that period.

The relative frequency of generic terms for mental ill health as a proportion of all terms was extracted annually for the Google Books corpus but by decade (i.e., 1940–1949, 1950–1959 etc.) for the combined CoHA/CoCA corpus in view of its smaller size and the relative sparsity of the generic terms. Three sets of historical trends in the popularity of the generic terms were examined in parallel for the two corpora. First, we examined the frequency of the generic terms collectively to assess whether these terms have changed in their overall popularity. Second, we examined the frequency of the alternative adjectival and then noun terms relative to one another, to evaluate which terms have risen and fallen in relative popularity. In these analyses, the frequency of an adjectival expression is summed across all nouns it combines with (e.g., “mental” = “mental condition” + “mental disease” + “mental disorder” + “mental disturbance” + “mental illness” + “mental problem”) and vice versa. Finally, we examined trends in the relative popularity of the 24 compound generic terms to determine which have risen and fallen in dominance.

Figs 1 and 2 presents the combined relative frequency of the 24 generic terms in the Google Books and CoCA/CoHA corpora. Both corpora show strong upward trends, with the generic terms more than twice as prevalent in the most recent time period as at the beginning of the study period. This rise is consistent with the growing cultural salience of mental health and illness, and the rise of psychiatry, clinical psychology, and other mental health professions through the 20 th century and since.

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Figs 3 and 4 displays the relative popularity of the adjectival components of the generic terms, each expressed as a percentage of all such expressions in each time period. The two corpora yield very consistent patterns. “Mental” is clearly the most prominent expression throughout the 80-year study period, reducing its share of all expressions only slightly. “Psychiatric” and “psychological” both emerge as increasingly popular adjectival expressions in the 1960s but then remain relatively stable. “Mental health” emerges in the 2000s but is always less popular than its alternatives.

https://doi.org/10.1371/journal.pmen.0000032.g003

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Figs 5 and 6 show the corresponding trends for the noun expressions, which are again broadly consistent across corpora. Terms incorporating “disease” fell in popularity over time (especially in Google Books), those incorporating “problem” and “disturbance” were relatively unpopular but stable, and “illness” rapidly becomes the dominant noun term in the 1950s and steadily increased its popularity since then. The trajectories of the moderately popular “disorder” and “condition” terms are less clear, the former rising gradually in Google Books but falling across the first two decades in CoHA/CoCA, and the latter showing a general decline in recent decades.

https://doi.org/10.1371/journal.pmen.0000032.g005

https://doi.org/10.1371/journal.pmen.0000032.g006

Figs 7 and 8 , finally, present the 10 most popular complete terms in each corpus, calculated based on their average relative frequency over the eight decades. The terms are ordered from bottom to top in average relative frequency, with the summed relative frequency of the 14 least popular terms represented by the white “Remainder” band. The two corpora yield highly convergent rankings, sharing nine of the top 10 terms and with their top four (“mental illness”, “mental disorder”, “mental condition”, “mental disease”) in identical order. “Mental illness” steadily rises to be the dominant generic term, “mental disease” steadily falls, “mental disorder” becomes a stable distant second, and two terms with “psychiatric” gain some ground in recent decades. However, most of the terms are of very low prevalence and demonstrate few meaningful historical shifts in popularity. Normalizing or de-medicalizing terms incorporating “problem” appear low in the top 10 once (Google Books) or twice (CoHA/CoCA), but those incorporating “mental health” do not.

https://doi.org/10.1371/journal.pmen.0000032.g007

https://doi.org/10.1371/journal.pmen.0000032.g008

In two large English language text corpora, we found consistent patterns in the popularity of a comprehensive set of generic terms for mental ill health. These patterns can be divided into those that are relatively stable over time and those that represent historical shifts. With regard to stable patterns, “mental” was overwhelmingly the most prevalent adjectival expression within generic terms throughout the 1940–2019 study period, with “psychiatric” and “psychological” far behind and “mental health” a very infrequent alternative. “Illness” was almost equally dominant as a noun expression within generic terms, with “disorder”, “disease”, and “condition” in a second tier and “disturbance” and “problem” rare. The relative unpopularity of “mental disorder” is surprising given the term’s ratification by influential psychiatric classifications. With regard to generic terms rather than their components, “mental illness” is easily the most prevalent in the study period, representing half or more of all uses of the 24 generic terms since the 1960s. Along with “mental disorder”, “mental condition” and “mental disease” it consistently accounts for more than 80% of all uses of generic terms throughout the study period in both corpora.

Patterns of change are also evident. Terms beginning with “psychiatric” and “psychological” made modest gains in popularity over time, as did those ending with “disorder”, whereas “disease” and “condition” tended to decline. Terms commencing with “mental health” grew steeply but from a very low base, and therefore did not feature among the most common generic terms. “Illness” consolidated its high popularity over time and “mental illness” rapidly rose to prominence, increasing its share of usage at least three-fold from 1940 to 2019. “Mental illness” rose most steeply from the 1940s to the 1960s at the apparent expense of “mental disease”, which fell steeply out of fashion during this period.

These patterns present a complex picture of the role of medical framing within generic terminology. Critics of medicalization have opposed terms they see as embodying a medical or disease model and proposed new terms to replace them. Their critique is often motivated by philosophical objections as well as the belief that the replacement terms will reduce stigma. Our findings offer some encouragement to these critics. Terms referring to “disease” have fallen from favor and those that include “psychiatric”, identifying mental ill health with a medical specialty, have not established a strong foothold. Normalizing terms such as “mental health problem”, which has no medical connotation and implies that mental ill health is an everyday dilemma to be solved, have become more prevalent in recent years.

Several findings point in the opposite direction, however. “Illness” may be less wedded to organic pathology than “disease”, but it is medical nonetheless and remains the dominant noun when referring to mental ill health. Its dominance, especially in the expression “mental illness”, has only increased in recent years, despite decades of criticism surrounding its legitimacy [ 13 ]. Less medically saturated terms that incorporate “mental health” or “problem” remain unpopular, at least as indexed by appearance in diverse forms of text, calling into question claims that “mental health” is increasingly used as a euphemism for “mental illness” [ 26 ]. Efforts to overhaul generic terminology have thus far not been effective in bringing about substantial change, and the rising prevalence and historical durability of “mental illness” suggests that altering public preferences for generic terms may be difficult. It could be argued that “mental illness” foregrounds subjective experience in its adjectival and noun components and should therefore be embraced rather than dismissed as medicalizing [ 19 ].

There has been very little systematic research on generic terms for mental ill health, so many possible avenues for future work are open. The corpora examined in the present study primarily represent written language generated by people outside the mental health professions, and it would be informative to assess preferences within and between these professions (e.g., clinical psychology, psychiatry, mental health nursing, social work). It would be equally informative to evaluate how professionals, laypeople and service users construe the differences in connotation between generic terms as well as their preferences among them, just as studies have examined preferences for alternative ways of referring to service users [ 8 ]. One informal exploration found that “some people prefer the phrase ‘mental illness’ as it emphasizes the seriousness of the conditions experienced by people; others prefer ‘mental health problem’ because they see it as less stigmatizing; others prefer mental ‘disorder’ as potentially encompassing both ‘problems’ and ‘illnesses’ while also acknowledging the non-medical dimension” [ 27 ] (p.46)]. A more systematic empirical investigation of understandings and preferences for generic terms is overdue.

Equally important is to establish whether generic terms have differential effects on perceptions of and by people experiencing mental ill health. Although vignette studies find few effects on stigmatizing attitudes [ 16 , 18 ], they are limited in quantity, in realism, and in the range of terms examined. No studies have explored whether generic terms have implications for how people with mental ill health perceive themselves (aside from Fox et al.’s [ 17 ] examination of self-stigma) or for how clinicians view them, including possible effects on the perceived durability, causation, or appropriate treatment implied by different terms. Is a condition described as a “psychiatric disease” likely to be perceived as more serious, organic, and suitable for pharmacological treatment than one described as a “mental health problem”? Examining the possible implications of different terms for how the general public and affected persons perceive and evaluate mental ill health should be a research priority.

Our study has several limitations. First, it only examines terms in English and its findings are unlikely to generalize to other languages. It would be worthwhile exploring shifts in preferred terminology in other linguistic and cultural contexts. Second, the study’s datasets ended in 2019 and there may have been significant changes since that time, during a period of intense attention to mental ill health. Future studies should examine ongoing terminological shifts. Third, the two corpora are drawn entirely (Google Books) or primarily (CoHA/CoCA) from written texts drawn from specific regions and therefore cannot be presumed to correspond to spoken language use or equally to all relevant geographical communities. More colloquial spoken language might employ different terms from written texts, or the same terms with significantly differing frequencies. The corpora are entirely (CoCA/CoHA) or predominantly (Google Books) based on U.S.A. sources, for example, and the extent to which our findings generalize across the Anglosphere is uncertain. Regrettably, addressing these possibilities may be challenging because corpora of comparable size and historical depth that collect spoken language or text from other regions may not exist. Fourth and more generally, while corpus studies enable powerful, large-scale quantitative analyses of language use, they do not allow for more nuanced analyses of connotational meaning or detailed studies of how words are understood or used differently in specific communities or contexts and possibly even replaced. Qualitative studies that illuminate these complexities would be valuable to complement our findings.

Debates over diagnostic labels, person- versus identity-first language, and appropriate ways of referring to people using mental health services reflect a conviction that language use in the field of mental health is profoundly important. The present study points to intriguing shifts in the use of generic terms for mental ill health, but it remains to be seen whether the implications of these terms are equally consequential.

Acknowledgments

The research reported in this manuscript was supported by Australian Research Council Discovery Project DP210103984.

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10 Clinical Psychology Research Topics to Explore

Whether you’re working toward a PsyD or a PhD in Clinical Psychology , landing on a research paper that will sustain your interest throughout your doctoral program can be both thrilling and challenging.

Should you go with a niche you know well or branch out to another psychology specialization ? Should you choose a research topic you’re passionate about or opt for something more topical and needed in the broader realm of behavioral and mental health?

Only you can answer these questions—however, this blog may provide you with some inspiration and direction. Let’s walk through 10 of the most fascinating clinical psychology research topics and how they might bring you closer to your educational and professional objectives.

Explore Clinical Psychology Programs

10 Emerging Research Topics in Clinical Psychology

One of the benefits of clinical psychology is that it’s far from a static field.

With each passing year, we gain more and more insight into the brain and how it affects behavior. In the last few years alone, for example, we’ve obtained a clearer picture of the negative effects of digital media on mental health and behavior. But we’ve also seen how digital media (specifically, mobile apps) can enhance mental health when used correctly. 1

Put simply, clinical psychology is a dynamic, exhilarating realm with seemingly boundless possibilities for further research.

Nonetheless, it’s easy to feel overwhelmed when settling on a clinical psychology research paper topic, especially when it’s one that you may be intimate with for years. To that end, consider these top 10 psychology topics to get you started in your research area:

#1. Mental Health Technology and Digital Interventions

The pandemic dramatically altered how healthcare practitioners interact with their patients and clients. Whereas psychotherapy and other forms of counseling were once performed almost exclusively in person, COVID-19 turned mental telehealth into our new reality.

But what might the long-term effects of this be? And will it persist as we march into the future?

Exploring the impact of digital mental health interventions (such as apps, other digital tools, and teleconferences) on well-being may open up a world of possible clinical psychology research topics and questions. 2 For instance, it may compel you to ask and research thoughts like:

• How will AI alter mental health treatments, if at all?
• Will digital mental health interventions ultimately cause or worsen isolation?
• What are the downsides and perks of turning to social media for mental health information?
• What is the relevance and value of in-person counseling sessions, post-pandemic?
• Do clients feel safer in online sessions?
• How can technology be employed to monitor patients outside of sessions?
• How does mental telehealth affect the elderly?

Technology is rapidly and constantly changing. In other words, psychology and technology may be exciting subjects to explore as you work towards starting or completing your doctorate.

#2. Cross-Cultural and Global Mental Health 

Globalization has its pros and cons. Studies indicate that while it may have its advantages, it can also heighten: 4

• Discrimination

Each of these may have lasting effects, including increasing the risk of mental disorders like addiction, depression, and anxiety. In other words, it needs to be examined by experts from multiple standpoints.

As a doctoral student, you’re in an ideal spot to investigate this complex issue. It also emphasizes the need to gain cultural competency and a global mindset as a mental health practitioner, which is another possible research topic in and of itself.

#3. Neuropsychology and Cognitive Processes

The field of neuropsychology and cognitive processes continues to grow, particularly with the advent of digital tools and their ability to monitor cognition. 5 Exploring our advancing knowledge of how the brain affects behavior may allow you to look at a wide range of mental health disorders and the newest clinical interventions that are being made available, such as treating:

• Alcohol use disorder (AUD)
• Eating disorders
• Post-traumatic stress disorder (PTSD)

#4. Trauma and Resilience Studies

Psychologists and psychiatrists ranging from Bessel Van der Kolk to Peter Levine forever altered our understanding of trauma. What was once thought of as a purely psychological issue is now understood as a bodily ailment. 6

But how might this look as we move forward in time and gain an enhanced understanding of neuroplasticity? Will somatics continue to play a role in treating trauma, or will technological advances send practitioners and their clients in a completely different direction?

You may be in a position to dig deeper and find out.

#5. Behavioral Health and Chronic Conditions

The unique relationship between chronic conditions and behavioral health is also up for exploration. Growing research indicates that chronic conditions (such as diabetes) can trigger mental health complications like depression, which can then perpetuate the cycle of the chronic condition.

This topic may be especially timely and relevant as it emphasizes the need to bridge the gap between a patient’s full healthcare team and points out flaws in treating chronic conditions solely from a pharmaceutical stance.

#6. Psychotherapy Process and Outcome Research

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and other forms of traditional “talk therapy” have been mainstays in the field of clinical psychology for decades. But this, too, isn’t static, especially as clients continue to look more toward body-based therapies and technology-fueled solutions, like: 8

• Transcranial magnetic stimulation (TMS)
• Neurofeedback therapy 
• Brainspotting
• Somatic Experiencing (SE)

Is it too soon to know if these and other fresh forms of mental health treatments have the same staying power as, say, cognitive behavioral therapy? This might be optimal for exploration.

#7. Social Determinants of Mental Health 

Social determinants of mental health (SDOMH) refer to the external circumstances that may impact an individual’s mental well-being and make them more vulnerable to conditions ranging from depression to addiction. SDOMH includes: 9

• Unemployment 
• Social isolation
• Urban crowding

How will SDOMH change as we move forward? Will it? Additionally, what is a clinical psychologist’s role in addressing these issues? What are the most effective strategies for working with those who have been disadvantaged?

This is an important topic as we, as a society, continue to address long-buried issues of race and class.

#8. Addiction and Substance Use Disorders

Addiction remains a prevalent topic: Alcohol use disorder (AUD) affects roughly 10.5% of the population, while 46.8 million Americans wrestled with a substance abuse disorder in 2022 alone. 10

Analyzing the most recent treatments and the future of treatments might not only pave the way for your own work after completion of your PsyD or PhD but also do a tremendous service for those who suffer from addiction (and their loved ones and families).

#9. Child and Adolescent Mental Health

Numerous studies indicate that kids and teens now have unusually high rates of: 11

• Substance use

What plays into this? Is social media entirely to blame, or can social sites also be a resource for youngsters? And how can clinical psychologists tweak their methods to resonate with kids and teens?

These are just three of the many questions you might ask if you decide to adopt this topic for your clinical research.

#10. Ethics and Professional Issues in Clinical Psychology

Last but not least, consider the value of examining both the main and more subtle ethics and professional issues in clinical psychology at work today, such as:

• Privacy 
• Informed consent
• Cultural sensitivity 
• Termination of counseling

Shape the Future of Mental Health with Alliant International University 

From making a substantial difference in the lives of others to eradicating the stigmas that surround certain mental health conditions, clinical psychologists are in a prime position to fuel lasting change. Selecting a clinical research topic that ignites your spirit and works toward solving larger social issues takes this notion to the next level.

Alliant International University may get you closer to becoming the type of clinical psychologist who can make an impact. Whether you’re exploring our PsyD in Clinical Psychology or have just started college, we’re proud to offer doctoral programs for psychology that can help you excel in your future profession. And with online and in-person classes and training, you might find the flexibility your life requires.

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Sources: 

• “Exploring the Latest Frontiers in Clinical Psychology Research.” The Clinic, March 25, 2024. https://theclinicca.org/exploring-the-latest-frontiers-in-clinical-psyc… .
•  Park, Susanna Y, Chloe Nicksic Sigmon, and Debra Boeldt. “A Framework for the Implementation of Digital Mental Health Interventions: The Importance of Feasibility and Acceptability Research.” Cureus, September 19, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9580609/.  
• Bond, Raymond R., Maurice D. Mulvenna, Courtney Potts, Siobhan O’Neill, Edel Ennis, and John Torous. “Digital Transformation of Mental Health Services.” Nature News, August 22, 2023. https://www.nature.com/articles/s44184-023-00033-y.  
• “Cross-Cultural Mental Health.” CMHA British Columbia, July 14, 2016. https://bc.cmha.ca/documents/cross-cultural-mental-health-and-substance-use-2/.  
• “New Research Looks at the Promise of ‘Digital Neuropsychology.’” McLean News | New Research Looks at the Promise of “Digital Neuropsychology,” January 7, 2019. https://www.mcleanhospital.org/news/new-research-looks-promise-digital-neuropsychology.  
• Kuhfuß, Marie, Tobias Maldei, Andreas Hetmanek, and Nicola Baumann. “Somatic Experiencing - Effectiveness and Key Factors of a Body-Oriented Trauma Therapy: A Scoping Literature Review.” European journal of psychotraumatology, July 12, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276649/.  
• “The Intersection of Mental Health and Chronic Disease.” Johns Hopkins Bloomberg School of Public Health. Accessed April 17, 2024. https://publichealth.jhu.edu/2021/the-intersection-of-mental-health-and-chronic-disease.  
• Theodora Blanchfield, AMFT. “What to Know about Brainspotting Therapy.” Verywell Mind, January 16, 2024. https://www.verywellmind.com/brainspotting-therapy-definition-techniques-and-efficacy-5213947.  
• Social Determinants of Health and Mental Health. Accessed April 17, 2024. https://www.ncsc.org/__data/assets/pdf_file/0025/70864/Social-Determinants-of-Health.pdf.  
• “Alcohol and Drug Abuse Statistics (Facts about Addiction).” American Addiction Centers, April 4, 2024. https://americanaddictioncenters.org/addiction-statistics#.  
• “Data and Statistics on Children’s Mental Health.” Centers for Disease Control and Prevention, March 8, 2023. https://www.cdc.gov/childrensmentalhealth/data.html.  

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• Open access
• Published: 18 June 2024

Psychological wellbeing with music therapy: the moderating role of health awareness, and strategic health management in post Covid-19 era

• Yang Liu 1 , 2  

BMC Psychology volume  12 , Article number:  355 ( 2024 ) Cite this article

Metrics details

Psychological problems are common among the people of every community. These psychological issues are leading people to mental health issues. Human well-being is required to be improved appropriately for the better health of the public. The objective of this research is to determine the influence of music therapy on the sustainable psychological well-being of the Chinese community. Furthermore, this research determines that moderating role of health awareness and strategic health management between music therapy and sustainable psychological well-being.

The research used a sample of 384 collected with a random sampling method. For data collection, a cross-sectional method was adopted to collect data on a Likert scale questionnaire. The Health Awareness Scale, Music Therapy Scale, Sustainable Health Management Scale and Sustainable Psychological Wellbeing Scale was used in this research.

The findings of the research highlighted that there is a significant and positive influence of music therapy on the sustainable psychological well-being of the Chinese community. This research also concluded that there is a significant and positive moderating role of health awareness and strategic health management between music therapy and sustainable psychological well-being. The findings of this research are new and novel in the literature on psychological well-being.

This research has some theoretical and practical implications to advance the literature and practice for sustainable psychological well-being respectively. In clinical practice, music therapy can be effectively used to improve the psychological well-being of individuals with sustainability. The information related to health awareness and practice for strategic health management is also necessary for the clinical patients to improve their psychological well-being.

Peer Review reports

Introduction

Mental issues are common in modern society because people are depressed and they have different concerns. Indeed, people in the past also faced mental health-related issues that were disturbing for them to improve their behavior and learning [ 16 ]. The better way to deal with people’s mental issues is to provide them with appropriate treatment on time. Mental health issues should be treated on time because when these issues would not treat on time, people may face significant problems in their life [ 37 ]. The behavior of mentally ill people is different from that of normal people, and this distinction is disturbing for people. The available resource for health improvement is required for people to get better treatment. Different kinds of clinical treatment are available for those people who are mentally not well [ 1 ]. However, they are required to take interesting initiatives to improve their health in a better way. The mental health of the public helps them to perform better in their routine life.

Indeed, there are different clinical treatments for people who are facing mental health issues [ 34 ]. However, music therapy is an emerging concept in Western countries regarding mental health issues. People who are facing mental health issues are required to get better clinical treatment to improve their health status [ 20 ]. However, many patients don’t rely on the significance and outcomes of mental health with clinical treatment. The stability of mental health issues for the public is required to be improved over time [ 3 ]. The success of people towards mental health stability helps them to enjoy life. The Chinese community is in large numbers in the world, and there are many mental health issues reported in this community. People who are facing mental health issues are required to get clinical treatment effectively. However, it is also noted that people have very limited information related to mental health issues.

[ 35 ] reported that physical therapy helps to improve the psychological well-being of people. Psychosocial well-being is defined as the state of mental, emotional, and social health of an individual. It is a broad concept that encompasses various aspects of human life, including personal growth, happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose in life. The study [ 19 ] highlighted that people who do not have effective treatment, face problems in the long term. However [ 7 ], reported that the mental health issues for the people should be maintained in time to ensure that their performance would be improved [ 12 ]. asserted that therapy with modern music can guarantee the successful mental treatment of people [ 5 ]. also highlighted that music therapy should be used appropriately to improve the health behavior of the people. In the meanwhile [ 25 ], asserted that music therapy has been less discussed from the perspective of sustainable psychological well-being, as earlier studies only focused on the role of music therapy in mental health improvement briefly. Furthermore, health awareness and strategic health management are critical factors but are not discussed widely in the existing body of literature.

Due to workload, social pressure, following the norms, and psychological illness, the Chinese community face problems related to psychological well-being. It is problematic for them to make good decision in bad psychological condition. On the other hand, health management is necessary for the public to improve their mental and physical health. The appropriate mental health is required for the individuals to perform their tasks in the better way. However, the individuals who are good in managing their health, it is appropriate for them to improve their health strategically. Hence, health management is considered as critical factor for improving mental health and psychological well-being. Therefore, the objective of this research is to determine the influence of music therapy on the sustainable psychological well-being of the Chinese community. Furthermore, this research determines that moderating role of health awareness and strategic health management between music therapy and sustainable psychological well-being. The research used a sample of 384 collected with a random sampling method. For data collection, the cross-sectional method was adopted to collect data on the Likert scale questionnaire. The findings of this research are new and novel in the literature on psychological well-being. This research has some theoretical and practical implications to advance the literature and practice for sustainable psychological well-being respectively. This research also has some limitations that are required to be addressed by future studies.

Review of literature

Theoretical underpinning.

Psychodynamics theory explains that the relationship between human behavior and emotions is influenced by their psychology [ 6 ]. It is necessary to influence human behavior for the right working, but this behavior is reported to be improved with psychological improvement. Human emotions are key to their performance and way of sustainability. The behavior studies highlight that human behavior is required to be improved. In this way, Psychodynamics theory significantly highlights that the underlying human emotions can be triggered with the psychological empowerment that is necessary for advancing their behavior in the right direction [ 40 ]. Access to human behavior and emotions for better psychological well-being is necessary for their emotional treatment. In modern times, different kinds of psychological treatments are recommended for human behavior to influence their understanding in the right way. Furthermore, Psychodynamics theory focuses on human emotions and other influencing drivers that are supporting to improve human behavior in a significant way. The right to work for human emotions can improve human being performance for better living standards. Access to human behavior and emotions by way of influencing drivers can improve human emotions in the right direction. By the underpinning of Psychodynamics theory, this research has considered music therapy as the influencing factor for sustainable psychological well-being as the dependent variable.

Hypotheses development

Music therapy is considered one of the critical ways to improve human behavior and emotions. Human emotions are positively and significantly influenced when human behavior is different [ 39 ]. The advancement of human behavior and psychology is helpful for them to perform well in different situations. There are different kinds of cases for people who are struggling with psychological well-being, and the people are required to improve their behavior and learning. The learning of cultural environment and cultural music can facilitate the people for their better psychological advancement [ 17 ]. Human emotions are related to their behavior, and people can improve their health when they have cultural associations. Music is considered the food of the soul, and it has relatable sentiments according to the living standards of the people that are motivating the people to deal with people better. Sometimes, there are negative and sometimes there are positive emotions influenced by music and culture. Human beings have different natures, and everyone has a different set of perceptions for their understanding [ 36 ]. However, every culture has a specific set of music, and the people belonging to this culture have a different set of mentality and culture. Access of people towards cultural information is possible through music. Indeed, people newly introduced to any culture also can get their critical information from their shared culture [ 23 ]. The accessibility to cultural understanding and information is improving the living standard of people concerning their cultural association. Music therapy is used almost in every culture for better human emotion development. The modern way of treatment is supported by music therapy, and based on this therapy people have relatable things to study [ 30 ]. The association of culture with music can’t be neglected, and it historically proved that every culture has a different set of music with relatable performances. Indeed, music performance and cultural awareness for music therapy are possible that can assist people to get a better understanding of their cultural values [ 21 ]. The relatable information to culture can promote cultural understanding for people and they can get a better approach towards sustainable psychology. Indeed, the role of music is critical in cultural awareness and promotion and people are required to focus on the cultural goals that are necessary for their better working approach. Music therapy is a widely used way of treatment in every culture, and people seem satisfied with this kind of treatment.

Hypothesis 1:

There is a positive relationship between music therapy and sustainable psychological well-being.

Health awareness is considered the fundamental way to improve the health status of the people. The people who are highly motivated to get health information, are seeking appropriate health opportunities in their life, and on the other hand, those who are not working to get better health facilities, are less motivated to get awareness [ 24 ]. The role of health awareness in the lives of people is critical because it can motivate them to get better treatment and work fairly. The relatable health information to the people and their cultural awareness can motivate them to get treatment for psychological well-being. People in every society have different sets of beliefs and opinions, and they are required to be motivated to a better standard of health and awareness [ 22 ]. The critical role of health awareness is necessary to improve the health standard of people, and people are required to have appropriate motivation to improve their psychological well-being. The role of music therapy is considered appropriate to improve human health, and people are required to get music therapy when they are not feeling well [ 10 ]. Almost, all people belonging to every set of age have a different set of opinions about their treatment. However, the better method to get emotional treatment is music therapy. By getting the entertainment of music, people can get into the catharsis that is necessary for their emotional improvement. The behavior of people for better achievement in health is possible when they have access to health awareness and better health standards [ 26 ]. The relatable health facilities are appropriately improved for the people when they are seeking any information. The awareness of the living standard of people is possible when they are highly motivated to get appropriate health standards. Reasonable health facilities are required for people to get better health opportunities, but music therapy should be used for both males and females to improve their health standards [ 8 ]. The way to improve public health can be a possible way to improve the standard of health in the right direction. People who are motivated to perform well, seek information that is appropriate to their better health standard. Reasonable working opportunities are required for people to get better health facilities when they are introduced to music therapy [ 19 ]. The influence of music therapy on public health is improved over time, and the awareness of the health facilities advanced people’s behavior for health awareness.

Hypothesis 2:

There is a positive moderating role of health awareness between music therapy and sustainable psychological well-being.

Maintaining health is a factor that is directly linked with people improving their work. Those individuals who are motivated to improve their health standards, are seeking relatable health awareness [ 18 ]. The advancement in health behavior can facilitate people to improve their health standards critically. Access to health is a significant factor that is improving public health facilities. Music therapy is considered one of the appropriate ways to promote public health. However, the people who are not motivated to get health facilities appropriately, are required to have health facilities in a significant way [ 9 ]. The relatable health facilities are appropriate for the public to improve their health standard accordingly. Awareness of health facilities can be a significant factor to improve the health behavior of the public. However, fewer people are motivated to get better health facilities, particularly music therapy in modern times. The awareness related to health facilities can promote the living standard of the public. In the meanwhile, those individuals who are less motivated to improve their health, are required to work appropriately for it [ 31 ]. Reasonable health facilities are appropriate for people, but they should have proper consciousness regarding their understanding and health facilities. The awareness to people of better health facilities can provide them with a way forward to improve their health reasonably. Furthermore, those people who have a systematic approach to improving their health, and they have rights plans for it, the health of these people is improved appropriately [ 33 ]. However, less focus on health improvement results in bad health conditions. Many people are highly motivated to improve the standard of their health, and they are required to improve their understanding and get treatment in new ways. The process of music therapy is simple in that people are motivated to improve the standard of their health with an effective approach. Access to public health can be a problem for people when they are motivated to improve their health standards [ 15 ]. Relatable health facilities are required for each disease, and for emotional disorders, therapy with music is highly recommended for the people. The advancement of modern treatment facilities is necessary for people to improve the standard of their health with effective performance and relatable opportunities. Music therapy is useful for people who are facing mental disorders or who are emotionally discouraged.

Hypothesis 3:

There is a positive moderating role of strategic health management between music therapy and sustainable psychological well-being.

The theoretical framework for this research is presented in Fig.  1 .

Theoretical model

Methodology

Questionnaire and pilot testing.

In the current research, the questionnaire was developed by the experts to measure the relationship between numerous variables and test the hypotheses as a matter of results. In such way, in view of past understandable literature, the arrangement of the questionnaire was developed furthermore with the help of the associated concerns. However, the experts had to get on table, and share their viewpoints on different theories. The questionnaire was developed ourself.

This is confirmatory research in which the relationship between different variables is tested with empirical data. In this way, the research is based on the primary data directly collected from the respondents. Since, this study is discussing music therapy for Chinese people in general; therefore, this research population is based on the Chinese community in Mainland China. The study has considered the sample size as 342 because according to Morgan’s Table when the population of any research is more than 1,00,000, then the data collection from 384 respondents would be appropriate for research findings. There was no inclusion and exclusion criteria for the respondents because the population was selected generally. However, the study has considered a Likert scale questionnaire for data collection because this kind of questionnaire is widely used when the behavior and perceptions of the people are required to be measured. Furthermore, this research has considered the reflective questionnaire that can be measured easily by the data collected on the Likert scale questionnaire. The scale items for this research are taken from the findings of existing studies in the literature. Before considering the scale items from these studies, the reliability and validity of the scale items were also tested. In this way, this research has tested the findings of composite reliability > 0.70 and Cronbach alpha > 0.70 for significant findings. The scale items for music therapy are adapted from the study [ 37 ], and it was determined that the scale items have validity and reliability. In the same way, the scale items for sustainable psychological well-being are adapted from the study [ 14 ], and it was determined that the scale items have validity and reliability. Furthermore, the scale items for strategic health management are adapted from the study [ 38 ], and it was determined that the scale items have validity and reliability. Finally, the scale items for health awareness are adapted from the study [ 16 ], and it was determined that the scale items have validity and reliability. According to scholars, when coefficient of reliability such as Cronbach’s alpha is above 0.70 for scale items, the researchers can use same scale in future research. Hence, the reliability of all scales were established based on the findings of source studies. The developed questionnaire is reported in Appendix 1 .

Data collection procedure

The face validity of the scale items was also confirmed by the expert researchers, and it was ensured that the items have appropriate validity. The research used a cross-sectional method of data collection because the scale items were reflective in nature, and many social sciences studies also used a cross-sectional method for data collection and analysis. The duration of data collection was two months because of response rate. However, the respondents were first informed about the purpose of study before the collection of data. Furthermore, the questionnaires were distributed to 500 respondents, and 401 responses were collected back. The respondents were targeted randomly to collect the data. Out of 401, 384 responses were selected back for the final findings of this research. The study has determined the findings with Smart PLS 3.0, and it has utilized the findings of measurement model assessment including convergent validity and discriminant validity, and the findings of structural model assessment including the path findings. These findings are significantly considered for the final empirical evidence of this research support.

Data analysis and findings

The collected data for this research is used to determine the missing values, skewness, and kurtosis. The findings of data normality are used to determine whether the data is useful or not. This research has considered the normality data test with skewness and kurtosis findings. The skewness values and the values of kurtosis for any research data are acceptable when lay between − 1 and + 1 [ 29 ]. The collected data for this research highlighted that the findings of this research have appropriate skewness and kurtosis values because no values were less than − 1 and more than + 1. In this way, the findings highlight that the study has the normality of data distribution. Furthermore, the analyzed data also showed the missing values, and there were no missing values in the data. Hence, the collected data for this research is appropriate and can be used for further tests. The findings are shown in Table  1 .

This research also tested the findings of convergent validity to determine the reliability and validity of research data. The findings of Cronbach alpha, composite reliability, and average variance extracted are checked for it. The composite reliability is tested to determine the reliability of data, the Cronbach alpha is used to test the validity of data, and the average variance extracted is used to test the variance between research data. The significant Cronbach alpha is achieved when the values are more than 0.70 [ 32 ], the significant composite reliability is achieved when the findings are more than 0.70 [ 28 ], and the significant average variance extracted is achieved when the values are more than 0.50 [ 2 ]. The results of these three reported that the study has significant composite reliability > 0.70, significant Cronbach alpha > 0.50, and significant average variance extracted > 0.50. However, the findings of factor loadings were also tested, and the significant factor loadings are achieved when the values are more than 0.60. The analyzed values show that the factor loadings for each item were more than 0.60, and this research has reliable items for data collection. The results are shown in Table  2 ; Fig.  2 .

Convergent validity

The findings of discriminant validity are also tested to determine discrimination between the research data [ 13 ]. This research has used two methods for the determination of discriminant validity. The findings are tested with Heteritrait-Monotrait (HTMT) method earlier. This method is used by the data analysis technique of the social science studies. However, the findings of HTMT < 0.90 are significantly acceptable [ 11 ]. The reported data in Table  3 ; Fig.  3 showed that the appropriate HTMT is achieved by the research findings.

However, the findings of cross-loadings are also used to determine the discriminant validity. This method is used to test the discriminant validity between the research data at the individual item level. The findings of discriminant validity with cross-loadings are significant when the values of items representing one variable are greater than the values of items that are correlated with it [ 4 ]. The output data of the cross-loadings displayed in Fig.  4 ; Table  4 highlighted that this research has appropriately considered discriminant validity. Thus, the data for this research has appropriate discriminant validity and can be used significantly in future studies.

Cross-loadings

Finally, the findings of the hypotheses were also tested, and this research has used structural equation modeling for path findings. The t-values were determined for the determination of the hypotheses’ status. The hypotheses of this research are directional, and the t > 1.64 is appropriate for significant hypotheses [ 27 ]. The analyzed data with the structural model reported that the first relationship of this research is significantly accepted, and there is a positive influence of music therapy on sustainable psychological well-being. The findings of the second hypothesis are also supported by the empirical data, and the study highlighted that there is a significant and positive moderating role of health awareness between music therapy and sustainable psychological well-being. This relationship is positive and strengthens the relationship between music therapy and sustainable psychological well-being, as shown in Fig.  5 . Finally, the findings of the third hypothesis are also supported by the empirical data, and the study emphasized that there is a significant and positive moderating role of strategic health management between music therapy and sustainable psychological well-being. This relationship is positive and strengthens the relationship between music therapy and sustainable psychological well-being, as shown in Fig.  6 . The results of structural equation modeling are highlighted in Fig.  7 ; Table  5 .

Moderation of health awareness

• Strategic health management

Path findings

The findings of this research are taken with measurement model assessment and structural model assessment. After the determination of data reliability, future tests are performed. The structural equation modeling approach is used to determine the findings of this research. The collected data significantly highlighted that the sustainable psychological well-being of the Chinese people is positively influenced by music therapy. Indeed, this relationship is newly developed in the literature, but the findings are in line with the conclusions of the existing studies in the literature. According to [ 10 ], music is regarded as the spirit’s nourishment since it evokes emotions that are relatable to people’s lifestyles and inspires them to interact with others more positively. The arts and entertainment may evoke negative emotions and other times good ones. People differ in nature, and each has a unique set of perceptions that they use to perceive things. According to [ 26 ], each culture has its distinct musical style and the individuals who make up that culture have their distinct mentalities and cultures. Music makes it feasible for people to access information about culture. A common language can indeed provide newcomers to any culture with essential knowledge. According to [ 15 ], one of the most important methods for enhancing human behavior and feelings is music therapy. While human behavior changes, it has a beneficial and important effect on the way people feel. Human behavior and psychology have advanced, which helps people function well in a variety of circumstances. People who struggle with their psychological well-being can experience a variety of cases, and they must work to improve their behavior and academic performance. According to [ 8 ], people’s improved psychological development can be aided by knowing about cultural environments and musical traditions. Human emotions and behavior are intertwined, and cultural associations help people enhance their overall well-being. Individual living standards are rising concerning their cultural affiliation thanks to the availability of cultural awareness and knowledge. Nearly every culture uses the use of music to promote the better development of feelings among individuals. According to [ 7 ], the application of music supports modern therapeutic methods, and patients can relate to the material studied as a result of this therapy. The public’s cultural awareness can be promoted by the knowledge that is relevant to them, and they can develop more effective strategies for practicing sustainability behavior. According to [ 9 ], music plays a crucial function in promoting understanding of cultures, and people must concentrate on the cultural objectives that are essential for their improved working methods. Every culture uses music therapy as a therapeutic method frequently, and people appear to enjoy it. According to [ 12 ], it is impossible to ignore how closely culture and music are related, and history has shown that each civilization has its distinctive musical repertoire and style of performance. It is feasible for people to learn more about their cultural values through performing musical pieces and cultural knowledge of music therapy. Hence, the role of music therapy should be considered practically to improve the psychological well-being of the public. It is important to advance the psychological well-being of the public which is helpful to improve. Therefore, the study rightly recommended the use of music therapy for improving psychological well-being of public.

Furthermore, this research has significantly reported that the empirical evidence supports that the moderating role of health awareness is significantly accepted between music therapy and sustainable psychological well-being. This relationship based on moderating effect is new in the literature on psychological well-being. However, the findings of this relationship are supported by the existing literature developed by the previous studies. According to [ 33 ], the primary means of enhancing people’s health status is thought to be raising their level of awareness of their health. On the contrary, people who have no opportunity to get superior medical care are less driven to get understanding. Individuals who are highly inspired to acquire health knowledge are looking for suitable healthcare possibilities throughout their lives. According to [ 36 ], the daily lives of individuals depend heavily on health knowledge since it can inspire them to receive better care and treat others decently. People may be encouraged to seek therapy for mental well-being if their medical data is relevant to them and they are aware of cultural differences. Individuals can enter the healing process that is required for psychological development by listening to interesting music. According to [ 17 ], whenever individuals have accessibility to improved health standards and health understanding, they are more likely to act in ways that will improve their health outcomes. When people are looking for information, the relevant healthcare facilities are upgraded appropriately. People can become conscious of their living standards when they are very motivated to achieve the right level of health. According to [ 22 ], while sufficient medical services are necessary for people to have better health opportunities, both men and women should use therapy in music to raise their standard of health. When someone is ill, they must take lessons in music therapy because music therapy is thought to be a useful tool for enhancing human health. According to [ 5 ], regardless of age, has a different set of thoughts about how they should be treated. However, music therapy is a more effective way to treat emotional issues. A potential strategy for raising the standard of health in the right direction is to enhance the health of the population. Individuals who are driven to succeed look to find knowledge that is compatible with their higher standard of health. According to [ 35 ], when people are introduced to music therapy, reasonable employment opportunities are necessary for them to have access to better healthcare. Each member of society holds a unique set of beliefs and perspectives, and it is necessary to inspire them to strive for a higher level of knowledge and health. Individuals must have the proper incentive to improve their mental happiness, and health knowledge plays a crucial part in raising people’s health standards. According to [ 23 ], the impact of music therapy on the general public has grown throughout time, and the public’s understanding of health resources has advanced their behavior in terms of health consciousness. The role of health awareness is reliable for the improvement in health standards of the public. Hence, the practitioners are motivated to use the music theory for psychological well-being of the public by ensuring the health awareness in public. The health awareness can provide better and reliable opportunities for the public to improve their standards of health.

Lastly, this research has significantly reported that the empirical evidence supports that the moderating role of strategic health management is significantly accepted between music therapy and sustainable psychological well-being. No doubt, this relationship based on moderating effect is new in the literature on psychological well-being. Nevertheless, the findings of this relationship are supported by the existing literature developed by the previous studies. According to [ 21 ], the component that is directly related to people’s ability to work better is the maintenance of their health. People who are motivated to raise their standard of health are looking for relatable health information. The development of healthy behaviors can help people significantly raise their level of health. The public’s medical facilities are being improved in large part due to increased access to healthcare. One of the relevant strategies for promoting public health is thought to be music therapy. According to [ 24 ], those who lack the necessary motivation to obtain medical treatment must be forced to do so in a significant manner. The required health facilities are available for the general public to raise their current level of health. Consumers can go forward to enhance their health practically by being more aware of improved medical resources. According to [ 31 ], the physical well-being of these individuals has enhanced appropriately if they have an organized method to doing so and the proper plans in place. However, failing to prioritize health improvement leads to poor health. Many people have a strong desire to raise their quality of health, but they must also learn more and receive care through novel methods. People who have the urge to better their health can do so through the straightforward process of therapeutic music listening. People’s knowledge about medical care can raise their level of living. According to [ 30 ], those people who are less driven to enhance their health must work appropriately for it in the interim. Individuals ought to possess proper awareness of their comprehension and medical facilities to benefit from reasonable healthcare resources. When someone is determined to raise their quality of health, getting access to healthcare services can be a challenge. According to [ 39 ], especially for each ailment, appropriate medical facilities are needed, and for persons with emotional disorders, music therapy is strongly advised. Health-related behavior can be significantly improved by raising awareness about medical resources. Nevertheless, fewer people today have the desire to access better healthcare, especially when it comes to the area of music therapy. For individuals to maintain their level of health with successful outcomes and relevant chances, cutting-edge medical services must advance. According to [ 18 ], people with mental illnesses or those who are emotionally depressed can benefit from learning about music therapy. Practically, this study also recommended that the health management should be in a strategic way by the people. It is important because strategic health management provides a way forward to the public for improving their psychological well-being. Hence, the findings of this research are critically important for advancement in health standards.

To sum up, the current study has some theoretical and practical implications to advance the literature and practice for sustainable psychological well-being respectively in post-covid 19 era. In clinical practice in post pandemic period, music therapy can be effectively used to improve the psychological well-being of individuals with sustainability. The information related to health awareness and practice for strategic health management is also necessary for the clinical patients to improve their psychological well-being. To conclude, the study asserted the importance of music therapy for improvement in psychological well-being of the Chinese community in post covid-19 era. The study recommends that the psychological well-being of the people was disturbed in post-covid-19 era which needs appropriate improvement for their better social life. The clinical practitioners are required to work in this direction to improve the level of their learning and performance.

Theoretical and practical implications

This research has developed a newly considered relationship based on theoretical underpinning. However, the empirical results supported the theoretically developed relationship of this research after post-covid era. The research advanced the literature of post covid-19 era on psychological well-being and reported that there is a significant and positive impact of music therapy on the sustainable psychological well-being of students. This relationship has introduced a new factor that is influencing sustainable psychological well-being. Furthermore, this study has contributed two moderating variables between the relationship between music therapy and sustainable psychological well-being, and the literature on psychological well-being is advanced by this research. The study has reported that health awareness is a significant moderator between music therapy and sustainable psychological well-being. This newly developed relationship also advanced the knowledge of psychological well-being with a significant moderating influence. Finally, the study has reported that strategic health management is a significant moderator between music therapy and sustainable psychological well-being. This newly developed relationship also advanced the knowledge of psychological well-being with a significant moderating influence. These findings also advanced the therapy of Psychodynamics as it is significantly accepted in the relationship between music therapy and sustainable psychological well-being. This research has novel findings as it has comprehensively introduced that the relationship between music therapy and psychological well-being can be strong when there is moderating influence of health awareness and strategic health management.

This research also has practical implications based on its significant findings. The study reported that music therapy should be considered the appropriate method to improve the psychological well-being of people. Indeed, people should go for music therapy when they are not appropriately treated for their emotional disorders or mental problems. Emotional health issues are critical, and these issues can damage the public who has a negative emotional state. However, the concerns for emotions are required to be improved with better psychological advancement. The required psychological improvement with music therapy can improve the health awareness and attitude of the public. The clinical treatment should add music therapy as a significant method of emotional treatment for those who are not in good mental health. This study also demonstrated that health awareness is necessary for people to get music therapy. The people have emotions and sentiments, but they can get better and more effective ways of health awareness when the government is creating awareness of health. The healthcare departments are required to promote health awareness in a critical way that should be acceptable for the public to improve their critical performance. However, strategic health management is also required to improve the health awareness of people which can be a significant factor in the advancement of health facilities for the public. The critical role of health awareness programs is to improve the health standard of the public with the newly introduced treatment of music therapy. The mental health of people can be improved significantly with music therapy. The clinical practitioners for psychological well-being can work on these practice-based recommendations to use music therapy for advancement in psychological well-being of the community. The role of music theory and health awareness is considered as critical in this research for advancement in psychological well-being of the community.

Future directions

No doubt, the findings of the study reported that there is a significant and positive influence of music therapy on the sustainable psychological well-being of the Chinese community. On the other hand, this study also concluded that there is a significant and positive moderating role of health awareness and strategic health management between music therapy and sustainable psychological well-being. The findings of this research are new and novel in the literature on psychological well-being. This research has some theoretical and practical implications to advance the literature and practice for sustainable psychological well-being respectively. Similar to the other studies, this research also has some limitations that are required to be addressed by future studies. This research has limitations as it has collected data from the Chinese population only, and the findings of this research can’t be generalized because data collection from backward countries may not support these results as people don’t have access to music therapy. Therefore, scholars are required to collect data from the population of another country to provide significant findings in the literature. Moreover, this research has collected data with a cross-sectional approach which is its limitation. In this way, the scholars are motivated to use the longitudinal data in future studies to understand the consequences of music therapy as well in post covid-19 era. Hence, it would be a significant addition to the body of knowledge.

Data availability

All the data within the manuscript.

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Liu, Y. Psychological wellbeing with music therapy: the moderating role of health awareness, and strategic health management in post Covid-19 era. BMC Psychol 12 , 355 (2024). https://doi.org/10.1186/s40359-024-01845-z

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Training the Next Generation of Clinical Psychological Scientists: A Data-Driven Call to Action

Dylan g. gee.

1 Department of Psychology, Yale University, New Haven, CT 06520

Kathryn A. DeYoung

2 Department of Psychology, Neuroscience and Cognitive Science Program, and Maryland Neuroimaging Center, University of Maryland, College Park, MD 20742

Katie A. McLaughlin

3 Department of Psychology, Harvard University, Cambridge, MA 02138

Rachael M. Tillman

Deanna m. barch.

4 Department of Psychological & Brain Sciences, Washington University, St. Louis, St. Louis, MO 63130

Erika E. Forbes

5 Departments of Psychiatry, Psychology, and Pediatrics, University of Pittsburgh, Pittsburgh, PA 15260

Robert F. Krueger

6 Department of Psychology, University of Minnesota, Minneapolis, MN 55455

Timothy J. Strauman

7 Department of Psychology & Neuroscience, Duke University, Durham, NC 27708

Mariann R. Weierich

8 Department of Psychology, University of Nevada Reno, Reno, NV 89557

Alexander J. Shackman

Author Contributions

Associated Data

The central goal of clinical psychology is to reduce the suffering caused by mental health conditions. Anxiety, depression, psychosis, substance use, personality, and other mental disorders impose an immense burden on global public health and the economy. Tackling this burden will require the development and dissemination of intervention strategies that are more effective, sustainable, and equitable. Clinical psychology is uniquely poised to serve as a transdisciplinary hub for this work. But rising to this challenge requires an honest reckoning with the strengths and weaknesses of current training practices. Building on new data, we identify the most important challenges to training the next generation of clinical scientists. We provide specific recommendations for the spectrum of stakeholders—from funders, accreditors, and universities to program directors, faculty, and students—with an emphasis on sustainable solutions that promote scientific rigor and discovery and enhance the mental health of clinical scientists and the public alike.

INTRODUCTION

The central goal of clinical psychology is to reduce the suffering caused by mental health conditions. Anxiety, depression, psychosis, substance use, personality, and other mental disorders impose a staggering burden on public health and the economy ( CDC 2020 , SAMHSA 2019 , Vos et al 2020 ). Addressing this burden will require the development and dissemination of intervention strategies that are more effective, sustainable, and equitable ( Mei et al 2020 , Uhlhaas et al 2021 ). Clinical psychology—a field anchored on the deep integration of basic science and clinical practice—is uniquely positioned to serve as a transdisciplinary hub for this research ( Baker et al 2008 , McFall et al 2015 ). But rising to this challenge requires an honest reckoning with the strengths and weaknesses of current training practices.

In this review, we marshal a range of new data to identify the most important challenges to training the next generation of clinical psychological scientists. We provide specific recommendations for a broad spectrum of stakeholders, with an emphasis on sustainable solutions that promote scientific rigor and discovery and enhance the mental health and wellbeing of clinical psychologists and the public alike.

How Did We Get Here?

The essayist James Baldwin wrote that “the great force of history comes from the fact that we carry it within us, [and] are unconsciously controlled by it” ( Baldwin 1998 , p. 722). Here we highlight the historical developments most relevant to understanding contemporary clinical psychology training practices and norms ( Benjamin 2005 , Levenson 2017 , McFall 2006 , Pickren 2007 ).

The Big Bang: 1945–1950

January 1945. World War II was raging and not a single American state licensed or certified clinical psychologists. There were no accredited doctoral training programs and no agreed-upon training models. By 1950, the war was over and these institutional fixtures were at least partially in place. Over half of all Ph.D.s awarded in psychology were clinical, with most students supported by the GI Bill or federal training and workforce development awards.

These rapid developments were galvanized by the Public Health Service and Veterans Administration (VA). In 1946, the VA anticipated the need to care for 20 million veterans, with tens of thousands requiring psychiatric or counseling services—a demand that far exceeded the existing clinical workforce ( Miller 1946 ). Addressing this looming crisis demanded the rapid training of thousands of clinicians, and spurred the American Psychological Association (APA)—an organization dominated by academic researchers—into action. The APA turned to David Shakow, who had spent the war years refining a training model for clinical psychology. Shakow’s vision of clinical psychologists as ‘scientist-practitioners’ was endorsed by the APA in 1947 and approved with minor modifications at a 1949 conference in Boulder, Colorado ( APA 1947 , Raimy 1950 ). In 1948, the APA began accrediting doctoral programs in clinical psychology, using the Shakow and Boulder reports as a model.

Sixty Years of Debate and a Pair of Breakaways: 1951–2007

Shakow envisioned training in clinical psychology as a doctoral-level program encompassing a heavy dose of general (‘breadth’) and technical (‘depth’) coursework, a year-long internship, and—unlike its closest competitor, psychiatry—an empirical dissertation ( APA 1947 ). No special allowance was made for the dissertation requirement: every competency in basic and applied science was to be mastered in just four short years, with graduates eligible for state certification following a year of supervised practice. Not surprisingly, concerns were soon raised about the feasibility of the compressed timeline and the adverse consequences of the “extra heavy requirement of courses and practicum work” for learning and rigor ( APA 1950 ).

As Richard McFall noted, the ‘Shakow-Boulder’ model was a shrewd compromise, one that seemed to give everyone what they wanted: “For the academics…the model declared that the first goal of doctoral training was to prepare all graduates for roles as scientists…[And] for those who wanted…to transform clinical psychology into a profession like medicine, the model also declared that a coequal goal…was to prepare graduates for roles as professional service providers…” ( McFall 2006 , p. 25). But in this amorphous compact lay the seeds for decades of vociferous debate, two major breakaways, and many contemporary grievances.

Too much science! Over the years, some have argued that the Shakow-Boulder model shortchanges clinical training; that it devotes excess attention to scientific and statistical methods that will never be used in daily practice and that it exacerbates provider shortages ( Frank 1984 ). Ultimately, these criticisms led to another meeting and the establishment of the more clinically oriented ‘practitioner-scholar’ training model and Doctor of Psychology (Psy.D.) degree in 1973.

Too little science! Others have argued, with equal vehemence, that contemporary training practices have drifted from Shakow’s vision; that they devote far more hours than necessary to clinical training; that they stifle scientific innovation and rigor; and that they promote healthcare practices founded on clinical intuition rather than scientific evidence ( Baker et al 2008 , McFall et al 2015 ). More generally, members of the too-little science camp have argued that addressing the immense burden of mental disorders on global public health will require the development of more sustainable and scalable intervention strategies, not training a larger cadre of traditional providers. By the 1990s, frustrated by what they saw as an increasingly onerous and inflexible set of APA training requirements, the too-little science camp initiated a series of actions that culminated with the establishment of the Academy of Psychological Clinical Science (APCS), a formal alliance of science-centered training programs; the Psychological Clinical Science Accreditation System (PCSAS), a new accreditation framework independent of APA oversight; and the ‘clinical science’ training model, a “reaffirmation” of Shakow’s model ( McFall et al 2015 , p. 4).

Current State of Training

Today, the vast majority of Ph.D.-granting clinical psychology programs still subscribe to the scientist-practitioner model, at least in spirit. What was originally a 4-year program—and often described as such to applicants and students—now takes 6–7 years to complete ( CoA 2021a ). And, unlike the post-war ‘golden age,’ most students are now supported by work-contingent teaching and graduate assistantships, rather than training and workforce development awards.

Of the 175 programs currently accredited by APA—encompassing roughly 8,000 students and 2,000 faculty—one-quarter are now dual accredited by PCSAS. Of these, more than a dozen programs have publicly stated that they may let their APA accreditation lapse, and three—UC Berkeley, Stony Brook, and Washington University in St. Louis—have announced that they will not seek APA re-accreditation and, instead, rely exclusively on PCSAS accreditation. Graduates of PCSAS-accredited programs are now fully eligible for the nationwide internship match program, for VA internships, and for licensure in seven states, with licensure lobbying efforts ongoing in many other states.

Where Do We Go from Here?

Most mentors want their students to be happy, healthy, technically adept, scientifically rigorous—both in the laboratory and in the clinic—and professionally successful. Yet the actual degree of progress toward these shared goals is uncertain, more anchored in anecdote than evidence ( Levenson 2017 ). And it is clear that new challenges have emerged, from growing concerns about student mental health to hyper-competition for faculty positions and research dollars. Addressing these challenges and achieving our shared goals for the next generation of clinical psychologists demands a sober consideration of the relevant evidence. In this section, we highlight a range of new scholarship, best practices, and data, including the results of our own anonymous national survey of nearly 600 clinical psychology Ph.D. students and faculty at research-intensive programs. Data collection efforts focused on research-intensive (‘R1’) institutions and clinical science-oriented listservs. Key methodological details are detailed in the Supplement . For heuristic purposes, we have organized the data into 9 major challenges. Of course, reality is more nuanced, and it is clear that many of these challenges are deeply intertwined and causally interconnected. Addressing these challenges will require an ‘all-hands’ approach, and we provide specific recommendations aimed at the entire spectrum of stakeholders, from the institutional—funders, accreditors, professional organizations, and scientific societies—to the individual—program directors, investigators, and students.

CHALLENGE 1. AN INCREASINGLY TECHNICAL AND MULTIDISCIPLINARY FIELD

Clinical science has undergone a steady transformation over the past quarter century. Spurred by funders, inspired by new technologies, and motivated to better understand, predict, prevent, and treat mental disorders, the field has increasingly come to rely on complex multidisciplinary tools ( Teachman et al 2019 ); for instance, using smartphone technology and machine learning to predict suicide attempts and lapses in substance use ( Schultz et al in press , Wang et al 2021 ).

Data from our national survey underscore the ascendance of multidisciplinary approaches, with nearly half of respondents (43.2%) reporting a multidisciplinary professional identity. See the Supplement for survey details . Among multidisciplinary respondents, roughly half considered themselves clinical neuroscientists (47.6% of faculty, 55.1% of students), with the remainder split across a variety of blended identities. Regardless of professional identity, many respondents say they use conceptual frameworks and specialized tools drawn from other disciplines. More than one-third reported using specialized statistical techniques (e.g., growth curve modeling) in their work, and one in five mentioned neuroimaging approaches. Other popular approaches include psychophysiology, ecological momentary assessment, machine learning, network modeling, various developmental and genetic approaches, psychoneuroendocrinology, psychoneuroimmunology, data science, and computational modeling.

Cutting-edge multidisciplinary tools and concepts are challenging to master. Consider a student interested in applying neuroimaging techniques to psychopathology. They would need to learn a modicum of neuroanatomy, behavioral neuroscience, medical physics, digital signal processing, general linear modeling, programming, and practical expertise with neuroimaging-specific aspects of data acquisition, processing, and analysis. As the field continues to evolve, and today’s innovations become tomorrow’s norm, the training challenge becomes even more acute.

Students face several challenges in obtaining specialized training. First, technical training is difficult to obtain through existing coursework. One-quarter of survey respondents (24.5%) say that specialized technical coursework (e.g., neuroimaging) is not available at their institution. Nearly one-third of students (30.2%) say that existing classes are unhelpful or poorly suited to their needs. Students were nearly twice as likely as faculty to perceive existing classes as unhelpful (17.3%; d =.27), suggesting that faculty perceptions of course utility may be inflated relative to students’ perceptions, or that faculty could do more to communicate the practical significance of coursework to students. Second, more than one-third of students (39.7%) say it is not feasible for them to pursue relevant technical coursework, given their heavy load of APA-mandated coursework and practica. Students who self-identified as multidisciplinary were particularly pessimistic about the feasibility of completing coursework in programming and data science, with nearly two-thirds (68.2%) reporting low feasibility. As a result, many students report using ad hoc and unstructured training solutions, including one-on-one guidance from faculty and senior trainees (98.4%), internet-based self-study (91.3%), and bootcamps/workshops (71.1%). In short, insufficient availability of coursework and a lack of time and flexibility in training requirements make it unfeasible for many students to immerse themselves in the cutting-edge techniques that lie at the center of contemporary research.

Recommendation: Reimagine Multidisciplinary Technical Training

Many programs have failed to systematically address the pedagogical demands created by the field’s increasing reliance on complex, multidisciplinary tools and concepts, leading to inadequate access to relevant training opportunities. The problem is compounded by feasibility issues; many students simply lack the time and flexibility necessary to immerse themselves in cutting-edge techniques. Here we outline several recommendations for addressing these barriers. Granular suggestions are detailed in the Supplement . Recommendations targeting broader structural issues are described in a later section .

Increase Access

To develop the technical skills necessary to tackle the next generation of clinical science research, students need sufficient access to relevant training opportunities. Classes, workshops, and informal learning groups have the potential to provide greater efficiency than ad hoc one-on-one mentorship. A rapidly expanding catalog of online courses—many developed by leading methodologists—provide additional opportunities for learning specialized skills.

Increase Utility

Restructure courses..

Our survey respondents highlighted the value of student-driven, hands-on technical training, traditionally achieved via one-on-one laboratory mentorship. To achieve this at scale, existing courses could be retooled to increase the amount of learning-by-doing and on-demand teaching ( Lombardi et al 2021 , Millman et al 2018 ). In some cases, it will be helpful to integrate classroom instruction with hackathons, design sprints, or ongoing student research projects.

Develop tailored training platforms.

Training platforms (e.g., coursework, workshops) on relevant skills that are devised for other specialties—like a coding course offered in computer science or a neuroimaging course offered in medical physics—can be a poor fit for clinical psychology students. Overcoming this barrier requires the development of platforms tailored to the expertise and goals of clinical psychology students or, perhaps more feasibly, a spectrum of graduate students with similar goals and needs (e.g., Machine Learning for Social/Biomedical Scientists ).

Increase Efficiency

To allow sufficient time for mastering complex techniques, other aspects of training will need to become more efficient. In the long run, significant gains could be realized by enhancing the undergraduate curriculum (e.g., pre-clinical psychology track), as in medicine.

Consolidate.

APA-accredited programs are required to demonstrate that students achieve a doctoral-level understanding of key areas of ‘discipline-specific knowledge’ (DSKs), including the history of psychology, research design, statistics, psychometrics, and affective, biological, cognitive, developmental, and social aspects of behavior ( CoA 2021b ). Although this traditionally meant that students completed a separate class for each DSK, we encourage programs to eliminate ‘checklist’ coursework and, to the extent possible, develop integrative classes that satisfy multiple DSKs (e.g., Developmental Affective Neuroscience ).

Coordinate.

Absent intentional coordination, the likelihood of redundancy and overload across courses is high. Programs need to carefully monitor relevant courses and work with instructors to mitigate these barriers.

Create structured flexibility.

Inconsistent course availability is another barrier to efficient training. This challenge can be mitigated by proactively identifying multiple courses that can be used to satisfy particular DSKs. In some cases, there may be sufficient demand to warrant the development of specialty tracks (e.g., clinical neuroscience, developmental psychopathology). In other cases, individualized development plans (IDPs)—developed in partnership with a faculty mentorship committee—make more sense.

Collaborate

Reimagining and rebuilding the clinical psychology training model is a team, not an individual, event. It will require the creative development of new collaborations and training consortia that span programs, departments, and institutions. Technical workshops, for example, can be created or sponsored by faculty drawn from multiple areas of psychology or by campus units that serve multiple departments (e.g., neuroimaging centers, genomics centers, neuroscience or data science training programs). Some courses can be taught as a team, maximizing specialized expertise and reducing the burden on individual faculty. Faculty with expertise in a particular technique (e.g., neuroimaging) can form ad hoc work groups to devise new teaching materials or vet existing ones. To maximize rigor, efficiency, and ultimately feasibility, we urge the relevant professional organizations (e.g., APCS; Council of University Directors of Clinical Psychology, CUDCP) and scientific societies (e.g., APS) to actively foster the development of training platforms tailored to the needs of psychology graduate students, including clinical students. Even if modest fees are necessary—as with many existing bootcamps, workshops, and short courses—the efficiencies of scale are likely to make such a coordinated effort more feasible than individual efforts.

Successfully implementing these recommendations will require new institutional investments. Fortunately, the necessary degree of investment is relatively modest. Students need travel awards to attend workshops and bootcamps. Students and faculty need the resources necessary to create or host them. Preparing new instructional materials, devising new on- and offline training platforms, and retooling existing classes all require substantial time and energy. Ideally, instead of requiring students to identify and pursue these opportunities independently, training would be structured and organized by faculty to meet the needs of students interested in pursuing particular types of multidisciplinary research (e.g., neuroimaging, digital phenotyping). This would be more feasible with targeted support for protected time. Making new instructional materials and platforms open-source and freely sharing them would maximize returns.

CHALLENGE 2. DUAL TRAINING

Integrative training in basic and applied science is the hallmark of clinical psychology ( APA 1947 , McFall et al 2015 ). It is what distinguishes us from other areas of psychology (e.g., developmental affective neuroscience), which provide no training in clinical service and from other mental healthcare specialties (e.g., psychiatry), which do not expect doctoral students to discover new knowledge. Today, the APA, PCSAS, and most research-intensive programs continue to publicly tout the integrative nature of clinical psychology training. This is even true of programs that plan to drop APA accreditation. UC Berkeley, for instance, highlights their commitment to training “the field’s best clinical psychologists, fully prepared for positions at the forefront of modern clinical science and practice” and emphasizes that graduates will remain licensure-eligible in California ( UC-Berkeley 2021 ).

At its best, the integration of basic and applied clinical psychology provides a robust pipeline for discovery, translation, dissemination, and implementation. Clinical experience is a critical spark of therapeutic innovation ( Castonguay et al 2015 ). For example, Aaron Beck’s foundational work to develop cognitive-behavioral therapy (CBT) grew directly out of his clinical experiences ( Rosner 2014 ). As David Barlow and others have noted, in the absence of sufficient integration, we run the risk of focusing our scientific efforts on assays and models that are poor probes of the clinical symptoms and syndromes that we seek to understand and treat, leading to failures in translation ( Rubin 2021 ). Furthermore, if we really want providers to be scientifically sophisticated, data-driven, and nimble—ready to adopt new evidence-based approaches and to discard less helpful ones ( Baker et al 2008 )—then we need to ensure that both aspects of training—basic and applied—receive adequate attention, respect, and support.

In practice, the integration of basic and applied clinical psychology has proven exceedingly difficult ( McFall et al 2015 ). Data from our survey revealed that one-quarter of faculty and students (25.8%) perceive training in basic and applied clinical science as being in high conflict, with nearly three-quarters (73.9%) saying that students are forced to prioritize one aspect of their training at the expense of the other. More than half of students say that dual training promotes feelings of inadequacy (55.5%), frustration (68.6%), and anxiety (68.8%). As one wrote, “It’s frustrating to have to work towards this huge number [of practicum hours] when I don’t intend to pursue [service provision]… after graduating… Research is [my] priority and… it takes the backseat.” These challenges are significantly intensified for multidisciplinary students ( d s=.26–.38).

Although both faculty and students agree that training in basic and applied clinical science is challenging, our data revealed a notable discrepancy between their perceptions. More than half (53.3%) of students feel compelled to prioritize research at the expense of clinical training (24% feel compelled to prioritize clinical training over research; 22.6% do not feel compelled to prioritize one over the other). As one noted, “We receive the message that we should value clinical work as a tool to help inform our research, and research as a tool to help inform our clinical work…but student involvement in clinical work beyond the minimum is frowned upon.” Faculty perceptions were reversed, with nearly half (45.6%) believing that students feel compelled to prioritize clinical training at the expense of their research (19.5% of faculty believe that students are compelled to prioritize research over clinical training; 34.9% do not believe that students are compelled to prioritize one over the other).

What drives this discrepancy? Unlike medical schools and other provider-focused training programs, clinical psychology is deeply rooted in traditional academic incentives, which primarily reward faculty based on indicators of knowledge generation and dissemination, including papers published, citation metrics, and grant dollars. Accordingly, new tenure-track faculty are hired based on their outstanding technical skills, scholarly productivity, and passion for scientific discovery. This bias toward basic-science training and easily counted ‘products’ is amplified by hyper-competition for research dollars ( Alberts et al 2014 ). In many research-oriented programs, this leads to a bifurcation , where tenure-track faculty are minimally involved in clinical training and do not regularly assess or treat clients. Clinical training is instead overseen by a separate group of specialists, including clinical-track faculty, clinic directors, adjuncts, and outside practicum supervisors. As a consequence, the practical everyday realities and intrinsic value of clinical training are an afterthought for some science-oriented tenure-track faculty. As one student noted, “Faculty…forget that clinical work is an important and required part of our training that takes up time (and should take up time) and…I constantly feel…they would prefer that I neglect clinical work in favor of research.”

Recommendation: Integrate Basic and Applied Clinical Psychology

Our data reveal substantial conflict between the basic and applied aspects of training. Addressing this challenge requires a deeper integration of clinical science and practice. At minimum, we recommend that all programs foster regular opportunities for meaningful engagement between basic and applied trainers—including offsite supervisors—via program meetings, colloquia, workshops, and retreats. For additional suggestions, see Challenge 3 .

For some programs, it makes sense to go a step further, and establish a practice research network (PRN) ( Borkovec 2004 , Castonguay et al 2015 , Lucock et al 2017 ). PRNs are comprised of academic researchers and clinical practitioners who collaborate on joint research projects focused on assessment and treatment as it naturally occurs in the clinic. Aside from fostering integration, PRNs have a number of potential benefits, including

• Efficiency, because students are able to integrate clinical training, practice, and research
• Rigor, insofar as PRNs have the potential to provide larger and more diverse samples
• Strengthening the ‘bench-to-bedside’ pipeline by promoting the dissemination, refinement, and implementation of evidence-based treatments and creating new opportunities for collaboration ( Bickman 1999 )
• Promoting camaraderie among students, faculty, and community providers and creating novel opportunities for scientific collaboration

The Hierarchical Taxonomy of Psychopathology (HiTOP) consortium has pioneered a variant of the PRN approach, where standardized assessments are collected at multiple training sites and pooled for analysis. This has enabled the rapid development of new scales and novel digital platforms for using them ( Kotov et al 2021 , Simms et al in press ).

We recommend that professional organizations support the development of PRNs by serving as central clearinghouses for best practices and protocols. We urge funders to provide the modest resources necessary for PRNs and related clinical science collaborations to flourish.

CHALLENGE 3. MISALIGNMENT BETWEEN TRAINING AND JOBS

A key challenge for clinical psychology is the fundamental misalignment between the way in which we train students and the jobs that many of them will ultimately perform.

Service Provision

Most clinical psychologists are healthcare providers. Even among graduates of PCSAS programs, nearly three-quarters (73%) provide clinical services in their current job ( Kraut 2021 ). Yet students say that clinical training receives short shrift from their tenure-track mentors, many of whom dismiss provider careers as second-rate ( Benjamin 2005 , Castonguay et al 2015 ). As one noted, “It is extraordinarily frustrating that faculty do not seem to value clinical work, that only alum who are now prestigious researchers are ever mentioned…it’s like those who do any amount of clinical work failed.” These data raise serious concerns about whether doctoral training in clinical science—at least in its current form—can really be expected to elevate the scientific rigor of service provision ( Baker et al 2008 ). It seems farfetched to think that the current training environment will foster lasting attachments to clinical science values among alumni who work as providers ( Castonguay 2011 ).

Academic Research

“There is no more worrisome consequence of the hypercompetitive culture of biomedical science than the pall it is casting on [the] early careers of graduate students…” —Alberts et al. ( Alberts et al 2014 )

Tenure-track faculty are trained and incentivized to replicate and to create more academics. Yet it has become abundantly clear that the pipeline from doctoral degree to academic position is broken ( Alberts et al 2014 ). Dwindling government support for research and higher education has produced a hypercompetitive job market and a decline in the proportion of tenure-track positions ( AAUP 2020 , APA 2019 , Lin et al 2018 ). The number of degrees awarded each year far exceeds the number of open faculty positions. In 2019, 1,264 Ph.D. degrees in clinical psychology were conferred in the U.S. ( NSF 2019 ), but only 50 or so faculty positions were available at research-intensive institutions (25-to-1) ( Psychology Job Wiki 2019 ). Consequently, less than 1 in 8 (13%) clinical psychology Ph.D.s work in academia and, among those, less than half (48%) have traditional tenure-track positions ( APA 2019 , Christidis et al 2019 ). Among the small minority who obtain research-oriented faculty positions, it has become more challenging to secure research funding ( Alberts et al 2014 ). Adjusted for inflation, federal funding for psychological research decreased by nearly 5% over the past decade ( Lin et al 2018 ). Nearly 80% (77.8%) of NIMH grant proposals are rejected, and the average age of first-time NIH R01 grant recipients has risen to 43 years ( NIH 2016 , NIH 2021 ). In the face of such discouraging prospects, the field risks losing the most talented individuals.

Beyond the Clinic and Academia

Either by choice or due to poor academic job prospects, many clinical psychology Ph.D.s pursue careers in government and industry as administrators, analysts, data scientists, program officers, policy experts, regulators, and managers. Yet most programs do not invest significant effort in helping students navigate the transition to such jobs. As one student emphasized, “ model more career pathways than R1 academic jobs - it’s not realistic that all PCSAS graduates will get those positions…[and] our professors…don’t take steps to educate themselves or connect us with role models pursuing other career paths.” While there are efforts to provide such scaffolding, existing mechanisms are quite limited in scale and scope (e.g., AAAS/SRCD policy fellowships, NIH BEST program). As it stands, even with 6–7 years of success as a doctoral student, some graduates are compelled to pay for still more training to secure employment outside of academia.

In sum, the existing training model does a disservice to our students, most of whom will pursue careers in the clinic, government, and industry.

Recommendations

Addressing the misalignment between current training practices, students’ branching career paths, and the brutal reality of the academic labor market requires a multi-pronged strategy. Here we outline a few specific recommendations. Several recommendations outlined in Challenge 2 are also likely to be helpful. We reserve our reflections on systemic issues and hyper-competition for later in the Review .

Address Behaviors that Signal a Lack of Respect for Clinical Careers

The onus is on faculty to drive cultural change. We encourage programs and faculty to frankly acknowledge student perceptions of conflict, scorn, and perfunctory integration. We urge them to actively work to eliminate implicit and explicit signals of disrespect for clinical training and careers.

Create Staff Scientist Opportunities

We need more career opportunities for basic clinical scientists, opportunities that would benefit from our students’ rigorous training and scientific passion. Creating untenured staff scientist positions and research professorships is a feasible means of doing so, with underappreciated benefits for productivity and institutional knowledge ( Alberts et al 2014 ). We recommend that faculty increase the ratio of staff scientists to graduate and postdoctoral trainees, that programs cultivate inclusive environments and recognize the contributions of staff scientists, and that universities create appropriately attractive employment policies (e.g., opportunities for promotion).

Provide More Vocational Scaffolding

Programs should not radically revise their values or training to accommodate careers in government, public policy, and industry. Our job is to train scientifically sophisticated clinical psychologists, not administrators, data scientists, congressional staffers, or healthcare managers. Nevertheless, we urge departments, graduate schools, and universities to invest the effort and resources that will be required to nurture partnerships with non-academic/non-clinical employers and build substantive bridges for graduates. In some cases, it will be useful for programs to create the kinds of alumni networks, panel discussions, and pre-doctoral internships that are the hallmark of vocationally oriented graduate programs (e.g., MBA) ( Berenbaum et al 2021 ). With appropriate partnerships, internships can facilitate training in cutting-edge technical skills (e.g., summer internship at Google or SAMHSA), enable access to unique datasets (e.g., electronic healthcare records), create new partnerships with traditionally understudied and underserved communities, and provide students with experience working as part of multidisciplinary teams. A relatively modest investment at the campus level, for instance, has the potential to provide a substantial return in wellbeing and occupational success for trainees in multiple disciplines. We encourage accreditors and professional organizations to intellectually foster and materially support the development of such scaffolding.

CHALLENGE 4. STUDENT FINANCIAL STRAINS

Today’s students are more likely to carry substantial educational debt and experience financial strains than their predecessors (e.g., Peterson Foundation 2021 ). Among clinical psychology students, median educational debt is now $80,000 ( APPIC 2021 ). Pay is typically low, making it difficult to cover basic expenses and achieve other age-appropriate financial milestones ($16,035; Sampson et al 2018 ). In a 2019 Nature survey, two-thirds of graduate students (67%) agreed that financial worries were a top stressor ( Nature Research 2019 ). Other evidence points to financial strain as a key determinant of psychiatric distress and a barrier to healthcare utilization ( El-Ghoroury et al 2012 , Sverdlik et al 2018 ).

Recommendation: Increase Student Compensation

We urge programs and other stakeholders to create need-based mechanisms to help defray the cost of internship applications and relocation, other out-of-pocket professional expenses, and financial emergencies. We are encouraged by the recent expansion of the NIH student Loan Repayment Program and urge professional organizations, societies, and accreditors to advocate for more sustainable compensation packages, either in the form of increased salary or greater support for living expenses (e.g., housing subsidies). At minimum, we call on universities to provide compensation packages tied to the level of federal training awards (e.g., NIH F31: $25,863). Ideally, assistantships and fellowships would be tied to the local cost of living, which often varies tremendously across institutions (e.g., Boston vs. Bloomington; PayScale 2021 ). The bottom line is that it will be impossible to attract and retain the most talented students and to address urgent challenges to student mental health, wellbeing, and diversity without increasing student compensation ( El-Ghoroury et al 2012 , Sverdlik et al 2018 , Tilghman et al 2021 ). While we recognize that increasing student compensation creates a host of challenges for research and instruction (e.g., fewer teaching assistants), it is an ethical means of ‘right-sizing’ the field and creating a more sustainable and equitable training pipeline ( Alberts et al 2014 ). Given vested interests in keeping student compensation low, addressing this challenge may require students to employ collective bargaining tactics.

CHALLENGE 5. SYSTEMIC INEQUITIES AND INADEQUATE TRAINING

Reducing the immense burden of mental disorders requires that trainees are equipped with both the research and clinical skills to target health disparities and provide culturally responsive care. Systemic inequities in academia—including clinical psychological science—have an adverse impact on trainees who identify as Black, Indigenous, or People of Color (BIPOC); lesbian, gay, bisexual, transgender, queer (LGBTQ+); women; and individuals with disabilities and disproportionally affect those who hold multiple oppressed identities ( Freeman 2018 , Gruber et al in press , Ledgerwood et al in press ). Trainees from marginalized backgrounds face unique barriers at every career stage ( Galán et al 2021 ) and experience elevated mental health difficulties (e.g., Lipson et al 2018 ). Ultimately, systemic barriers contribute to limited representation in the broader field in both research and clinical care. BIPOC researchers are underrepresented in psychological science ( Roberts et al 2020 ), and there is a dearth of BIPOC clinicians: 40% of the US population, but only 17% of the psychology workforce, identified as BIPOC in 2019 ( APA 2020 ). Clinical science and the public suffer when the mental health workforce does not reflect the diversity of the broader population and fails to include the most talented clinical scientists.

In addition to the systematic exclusion of trainees from marginalized backgrounds in clinical science, current training in the provision of culturally responsive clinical care and research practices is inadequate. Despite the profound impact of discrimination and racism on mental health ( Pascoe & Smart Richman 2009 , Williams & Mohammed 2009 ), few programs have allocated sufficient attention to training in assessing and treating the consequences of structural stigma and racial trauma ( Galán et al 2021 , Williams et al 2018a , Williams et al 2018b ). While there is growing recognition of inequities in mental health and access to care (Finkelhor, Turner, LaSelva, 2021; Marrast, Himmelstein, Woolhandler, 2016; AHRQ, 2019), additional research on disparities, barriers to service use, and potential variation in clinical presentations and treatment efficacy is essential to optimally train the next generation of clinical scientists. As one example, though many programs emphasize training in evidence-based assessment and treatment, BIPOC individuals are underrepresented in treatment research ( Polo et al 2019 ). Thus, current approaches are, in fact, often only evidence-based for White clients ( Galán et al 2021 ). Simply put, doing the best clinical science possible requires us to undertake a radical re-examination of what we know, how we develop knowledge, and how we disseminate it.

Recommendation: Diversify the Workforce and Target Mental Health Inequities

Existing accreditation policies mandate training in diversity and multiculturalism. Yet it is clear that we must do more. While the scope of the present Review precludes detailed recommendations, recent reports provide comprehensive guides to promoting diversity and inclusion and implementing anti-racist practices in the context of clinical psychology training and service provision ( Cénat 2020 , Galán et al 2021 , Jordan et al 2021 , Mote & Fulford 2021 ). Here, we briefly highlight some of the most important components.

Increase Support for Trainees from Underrepresented Backgrounds

In order to diversify the workforce in clinical science and create an environment in which marginalized individuals can thrive, we need to reimagine the systems that govern recruitment, inclusion, retention, and success ( De Los Reyes & Uddin 2021 , Galán et al 2021 , Tilghman et al 2021 ). Evaluation criteria must change to reduce the bias inherent in current admission practices ( De Los Reyes & Uddin 2021 , Dougherty et al 2019 ). As one example, many doctoral programs have discontinued the use of the GRE for admissions or stopped requiring this exam ( Sealy et al 2019 ). Coordinated grassroots efforts to provide guidance at various stages of the graduate application process (e.g., Project SHORT, Application Statement Feedback Program, and informational events) and to debunk the ‘hidden curriculum’ in academia have the potential to increase applicant diversity. But admissions is only the first step. Once admitted, programs and universities must do more to cultivate environments that support trainees from diverse backgrounds and promote inclusion and belonging ( Galán et al 2021 , Singleton et al in press ). Formal funding opportunities designed to enhance and retain BIPOC trainees at every stage of training would also have a meaningful impact and could follow the longstanding and successful example of NINDS-funded programs designed to increase and support BIPOC trainees in neuroscience ( Jones-London 2020 ).

Enhance Training in Culturally Responsive Care and Responsible Research Practices

Curricular reforms will be critical in areas such as clinical training and research methods. Clinical training must prepare students to practice cultural humility and to identify and treat the consequences of systemic racism and structural stigma ( Galán et al 2021 , Hatzenbuehler 2016 , Williams et al 2018a , Williams et al 2018b ). Education and training in research methods must prepare students to conduct research that is socially just ( Galán et al 2021 ). Students must learn to ‘decenter’ Whiteness (i.e., recognizing and changing Whiteness as the ‘default’ in research) and to appropriately conceptualize and contextualize variables related to race and racism ( Shim 2021 , Simmons et al 2021 ). For example, it is crucial that all trainees, and especially trainees pursuing biomedical research questions and methods, understand that race is not a biological variable, but rather a proxy for the biopsychosocial impacts of systemic racism.

Increase Institutional Investment

We urge funders and other institutional partners to invest in workforce diversity and to support training that equips clinical scientists to tackle mental health inequities. We are encouraged by funders’ recent commitments to address structural racism and call on them to prioritize research on mental health disparities ( Galán et al 2021 , Taffe & Gilpin 2021 ). Departments and universities should engage funding agencies on these issues, and provide local support and incentives for training in socially just research and culturally responsive service provision, as well as educating faculty in best practices for mentoring students from marginalized backgrounds ( Galán et al 2021 ). Professional organizations and institutional partners also have an important role to play in translating new knowledge on variation in clinical presentation, diagnosis, and treatment efficacy back into the clinical science training curriculum and disseminating refined training materials.

CHALLENGE 6. STUDENT HEALTH AND WELLBEING

“Routinely, students in the “clinical training years”…of our program have mental health breakdowns, divorces, and academic difficulties due to the stress of trying to balance everything. Something needs to change if we are going to build a healthy and sustainable workforce.” —Survey respondent

Graduate students are at risk for developing internalizing disorders ( CGS & Jed Foundation 2021 , Hazell et al 2020 , Satinsky et al 2021 ). In a recent national survey of clinical and counseling students, nearly half (49%) reported significant anxiety, and more one-third (39%) reported significant depression ( Rummell 2015 ). In our survey, over half of students say they feel overwhelmed (61%) and exhausted/burned out (53.8%), significantly higher rates than faculty (26.8% and 15.5%; d s=.65–.75). Against this backdrop, it is concerning that over one-third (35.7%) of student respondents say they rarely have enough time for self-care, family, and other non-work activities—over twice the faculty rate (16.7%; d =.49). Among those who do manage to make time for self-care, many experience a degree of conflict, shame, or guilt. As one student emphasized, “although I do engage in self-care, I often feel like I am doing something wrong, not working hard enough, or doing things contrary to what my program would dictate.” In some cases, these problems are exacerbated by a culture that is dismissive of mental health concerns. As another student wrote, “the mental health of [students]…is often…waved off as a necessary evil of graduate school.” Aside from the negative impact on learning and scientific discovery, these data raise ethical concerns, given students’ integral role in service provision ( Campoli & Cummings 2019 ).

Recommendation: Promote Student Health and Wellbeing

The current training climate is neither healthy nor sustainable. This crisis is not specific to clinical psychology. It cuts across disciplines and degrees; has attracted the attention of journalists, policy makers, and university leaders; and threatens to undermine our shared values and goals, both for students and for public health ( CGS & Jed Foundation 2021 , Duffy et al in press , Evans et al 2018 , Forrester 2021 , Hazell et al 2020 , NASEM 2021 , Rummell 2015 , Woolston 2019 ).

While the roots of graduate student distress are complex, a landmark 2021 report from the Council of Graduate Schools (CGS) highlights the role of pervasive hyper-competition, poor work-life balance, maladaptive relationships with supervisors, and financial strains ( CGS & Jed Foundation 2021 ). The CGS report emphasizes that these and other stressors are often exacerbated for students from underrepresented and non-traditional groups, including BIPOC, LGBTQ+, and international students. Although efforts to enhance other aspects of graduate training—like carving out more time, creating more flexibility, or increasing student compensation—are likely to have positive ‘trickle down’ effects for student mental health, they are not enough. We need targeted wellbeing interventions ( CGS & Jed Foundation 2021 ), with appropriate tailoring for clinical psychology students ( Campoli & Cummings 2019 ).

Take Institutional Responsibility

We urge universities, departments, and programs to take greater responsibility for graduate student mental health and wellbeing. Institutional responsibility involves two mutually reinforcing elements: plans and leadership. We recommend the development of strategic plans and the institutionalization of task forces or officials explicitly tasked with helping graduate students thrive. We urge departments and programs to develop formal mental health policies ( Victor et al 2021b ). Although committees and policies can be performative, with appropriate power and recognition, they can foster novel partnerships, increase the flow of relevant resources, reduce stigma and other barriers to care, and raise awareness ( CGS & Jed Foundation 2021 ).

Devise and Implement Evidence-Based Interventions

We encourage the development and implementation of evidence-based interventions, including procedures for supporting students as they progress through stressful program transitions and milestones. Intervention needs to encompass both prevention and treatment and be scaled to the needs of individual students, most of whom do not require intensive care ( Victor et al 2021a ). To ensure diversity, equity, and inclusion, institutional stakeholders must remain mindful of the distinct needs of students from underrepresented and non-traditional groups ( Galán et al 2021 , Satinsky et al 2021 ). Education, awareness, and engagement are all crucial elements of this multi-layered strategy.

Student-mentor relations are a key determinant of graduate student wellbeing ( Duffy et al in press , Evans et al 2018 , Sverdlik et al 2018 ). Yet some faculty lack the necessary ‘soft’ skills. Providing faculty with mentorship training and incentivizing engagement would help address this concern. Of course, faculty training is necessary but not sufficient. While abuse is relatively rare, conflict and other negative experiences are not ( Evans et al 2018 , Woolston 2019 ). We encourage universities and programs to train faculty to identify potentially problematic relationships early, devise and enforce policies for overcoming different kinds of friction, and provide structured assistance (e.g., faculty mediators).

Self-care is increasingly recognized as a core clinical competency and a buffer against stress ( Miller in press ). To ensure a healthier culture in the future, we urge programs to incorporate structured training in self-care into their curricula. As Campoli and Cummings note, “stress and burnout clearly put psychologists at risk of violating ethics principles…self-care is not just an indulgence…but…essential [for] preserv[ing] the integrity of professional and ethical practice .”

Ensure Access to Care

Clinical psychology students’ professional and academic ties represent a critical barrier to care ( Victor et al 2021b ). It is imperative that programs provide students with confidential access to free or low-cost providers who are independent of the training ecosystem.

CHALLENGE 7. HEAVY STUDENT WORKLOAD

Expectations for clinical students have become increasingly unrealistic. Typically, students are expected to complete their coursework, first-year project or master’s thesis, qualifying examinations, dissertation, and externship in just 4–5 years. We expect them to master complex multidisciplinary techniques, cultivate outstanding clinical skills and cultural competency, comprehend hundreds of pages of assigned reading, mentor undergraduates, present their work at seminars and conferences, teach, and work on sponsored projects ( Fernandes et al 2019 , Fried 2017 , McMinn et al 2009 ). And, more than ever, we expect them to produce. Fueled by hyper-competition for dwindling faculty jobs and research dollars, we expect them to produce more and more papers, grant applications, and conference presentations ( Alberts et al 2014 , Barrett 2019 , CACTUS Foundation 2020 , Edwards & Roy 2017 ).

In the face of these pressures, students are compelled to work long hours. Data from our survey revealed that over two-thirds (70.2%) of students work >50 hours per week, and over one-third (33.6%) work >60 hours ( M =55.5 hours). This is consistent with other evidence ( Rummell 2015 ), nearly 10% more than the average American graduate student ( M =51.3 hours; d =.34) ( Nature Research 2019 ), and equivalent to working an extra 4.7 months annually. Thus, it is hardly surprising that nearly half of students (45.5%) are unsatisfied by their work-life balance, and most feel over-committed (62.6%) and find it difficult to relax (59.8%).

Aside from the damaging consequences for student’s wellbeing and, potentially, the quality of their clinical service provision, this climate also poses a grave hazard to the quality and rigor of clinical science. As Harold Varmus, Nobel laureate and former NIH director, and colleagues emphasized, “Hypercompetition…suppresses the creativity, cooperation, risk-taking, and original thinking required to make fundamental discoveries…[These necessitate] time for thinking, reading, and talking with peers.” ( Alberts et al 2014 ). Crushing workloads also threaten workforce quality and diversity, either because talented individuals pursue a different career altogether or because they choose a non-academic path after graduation ( Alberts et al 2014 , Fuhrmann et al 2011 ). As one student emphasized, “I am no longer willing to consider a…career in academia…due to the near-impossibility of having work/life balance.” If clinical psychology is to realize its full potential, we need to address these problems.

Boulder Revisions

Despite significant efforts to reform clinical psychology training, concerns with student workload first identified in the late 1940s have yet to disappear; if anything, they have become much worse ( APA 1950 ). Implementing the recommendations outlined in earlier sections would go a long way to creating a more rigorous, equitable, and humane training environment, but they will not be enough to solve the fundamental imbalance between ever-growing expectations for student competency and productivity and the 4–5 years traditionally allotted to the doctoral degree. This imbalance cuts across many of the challenges outlined earlier.

At minimum, programs and departments need to frankly acknowledge that clinical psychology students require 6–7 years to complete their degree and provide them with a concomitant duration of guaranteed support ( CoA 2021a ). Of course, even bolder revisions may be necessary.

Three Ways Forward

At present, the best way to address the expectations-versus-time imbalance is unclear. Different solutions have different tradeoffs and require different levels of institutional change and coordination (e.g., internship and state licensure). Here, we briefly outline three potential revisions. In all likelihood, an optimal solution would encompass elements of each ( Strauman 2021 ).

Bi-Phasic Framework

Berenbaum and colleagues recently proposed a bi-phasic training framework ( Berenbaum et al 2021 ) and launched a website to promote discussion and refinement of their proposal and, ultimately, grassroots advocacy for change ( https://www.caaps.co/caapsdiscussion ). Here the doctoral degree is split into two consecutive phases, each 2–3 years long. In Phase I, students cultivate ‘foundational competency’ in basic and practical aspects of clinical psychology. The amount of time devoted to practical training in assessment and intervention would be reduced to <100 hours and focused on common mental disorders. Successful completion would provide a Master’s degree and path to licensure. In Phase II, students would cultivate advanced expertise in the subset of topics most relevant to their scientific interests and career aspirations, similar to the IDP approach outlined earlier. This could include training in service provision, public policy, or basic science. The internship year would be shifted to the postdoctoral period, akin to residency.

The bi-phasic framework has several potential benefits, including greater efficiency, reduced workload for some students, increased flexibility, and comparatively modest structural changes. But it also comes with some uncertainties and potential limitations.

First, it is not clear that allowing students to self-select into ‘light’ and ‘heavy’ clinical tracks would address student perceptions of conflict or guarantee adequate integration of clinical science and practice; indeed, it might exacerbate existing polarization.

Second, the steep reduction of practical training raises some important concerns. On the one hand, we agree with the spirit of this proposed revision. Restricting practicum hours has the potential to substantially reduce student workload. Driven by fierce competition for clinical internships and the adverse financial and professional consequences of not securing an internship (‘matching’), many students accrue what could be perceived as an excessive number of hours (e.g., in comparison to Master’s or medical students). We also agree with the underlying argument that there is compelling evidence that extensive training or specialized credentials are not necessary to perform rudimentary assessments (e.g., using psychometric screeners) and effectively deliver simplified psychosocial protocols (e.g., behavioral activation) targeting a single sign (e.g., tobacco use), symptom (e.g., anhedonia), or syndrome of mild-to-moderate severity in patients with uncomplicated presentations ( Baker et al 2008 , Berenbaum et al 2021 , Levenson 2017 , McFall 2006 , Singla et al 2017 ). On the other hand, it is not clear that the proposed approach (<100 predoctoral practicum hours) is sufficient to prepare future generations of clinical psychologists to take the lead in the clinic—as providers, trainers, supervisors, and managers—or in sponsored research. The existing literature precludes firm conclusions. For example, it is unknown whether providers with different training credentials (e.g., MSW, Ph.D., M.D.) differ in their general effectiveness ( Stein & Lambert 1995 ), although the absence of rigorous evidence is often treated as the absence of effect. Likewise, the degree to which less-intensively trained providers require specialized supervision and consultation to be safe and effective in general practice is unknown ( Singla et al 2017 ). Given these considerations, we call on accreditors and other national stakeholders (e.g., APCS, CUDCP) to actively foster the rational development of evidence-based caps on practicum hours and coordinate the collective action that will be necessary to uniformly enforce caps.

Third, the proposed licensure-eligible Master of Clinical Psychology degree would further divide an already fractionated mental healthcare landscape and undermine efforts to create a positive association—in the minds of consumers and managed care organizations—between doctoral degrees from PCSAS programs, on the one hand, and the highest standards of evidence-based clinical care, on the other ( Baker et al 2008 , Levenson 2017 , PCSAS 2021 ).

Finally, the bi-phasic framework will only increase efficiency if a sizable number of students forgo substantive practical training in Phase II. To the extent that most students see intrinsic value in the scientist-practitioner model, as our survey results suggest; are fearful of not securing an internship; or simply want to maintain a viable path to a healthcare job in the face of a dispiriting academic job market, it seems implausible that very many will choose to forgo practical training without additional incentives or structural reforms. To the extent that this intuition is true, it undermines one of the main attractions of the bi-phasic framework.

M.D.-Ph.D. Framework

An alternative solution is to adopt features of the M.D.-Ph.D. framework ( Brass & Akabas 2019 ). M.D.-Ph.D. programs are split into 3 phases. In Phase I, students complete basic science coursework (2 years). In Phase II, they complete their Ph.D. (~4 years). In Phase III, students perform clinical rotations and apply to residency programs (2 years). Traditionally, the focus of each training phase was strictly segregated. Phase I, for instance, was focused exclusively on coursework-based instruction, with no effort devoted to either research or practical clinical training. Contemporary training models strive for somewhat greater integration, and include elements like research-centered journal clubs and summer laboratory rotations in Phase I, and limited clinical practica (~120 hours) in Phase II (e.g., UW-Madison SMPH 2021 ). The M.D.-Ph.D. framework has a number of strengths, including reduced conflict and ‘code switching’ between basic and applied training, a heavy but more carefully managed workload, greater integration of science and practice, strong preparation for multiple careers, and decades of evidence documenting increased research success relative to M.D.-only graduates. The major limitation of this approach is the lengthy time-to-degree, which would also exacerbate student financial strains.

Back to the Future: The Transdisciplinary Scientist Framework

A third solution is more cultural rather than structural, and involves changing our expectations about the degree and breadth of competency that doctoral students can realistically achieve in a reasonable timeframe. As noted in Challenge 1, clinical psychology research increasingly relies on approaches that are complex, technical, and multidisciplinary, from neuroimaging and molecular genetics to machine learning and digital phenotyping. In our experience, there is a temptation to expect clinical psychology students to master core facets of clinical psychology and achieve outstanding technical competence in one or multiple methods. This expectation can be unrealistic and create disappointment when, as often happens, students are unable to reach the level of expertise achieved by peers in other degree programs (e.g., neuroscience)—who are not tasked with basic and applied training. Our survey data suggest that this expectation may fuel perceptions of conflict between basic and applied training, contribute to unmanageable workloads, and undermine students’ wellbeing.

Seventy-five years ago, the Shakow report offered a solution to this problem, admonishing clinical psychologists to “ work closely and in cooperative fashion with those whose methods may be different but whose goals are quite similar. In these settings [s/he] learns to…value the ‘team’ approach to…problems…which, because of their difficulty and complexity, require a concentrated group attack” ( APA 1947 , p. 545). McFall and colleagues recently made a similar recommendation, urging students and faculty to “leave their silos, drain their moats, and build bridges,” arguing that, “because no individual psychologist can become an expert in all fields, collaboration across traditional disciplinary boundaries is essential” ( McFall et al 2015 , p. 5). In short, students should not be expected to develop deep expertise in multiple fields during the doctoral training phase. Instead, they should cultivate strong transdisciplinary science skills, as detailed below.

Clinical psychology is often cast as a transdisciplinary science ( Baker et al 2008 , McFall et al 2015 ). Indeed, most of the authors of this review have played precisely this kind of ‘hub’ role on team science projects. Successful transdisciplinary scientists are not masters of every project-relevant domain and technique. They are innovative team leaders with two key skills ( Gilliland et al 2019 ). First, armed with sufficiently broad foundational knowledge, they are able to fluently communicate and productively work with experts from other disciplines. Second, they are subject-matter experts, with deep expertise in their primary discipline. To achieve this scientific skillset, it is essential that all clinical psychology students cultivate deep expertise in the nature, nurture, and biological bases of psychopathology; rigorous grounding in core aspects of contemporary psychometrics, statistics, and research design; and practical expertise in clinical assessment and diagnosis. This is crucial if they are to successfully perform the role of ‘clinical psychologist’ on sponsored projects and other kinds of team science. In addition, students must develop foundational-level expertise in the concepts, language, and techniques of the relevant ‘other’ discipline(s) and have the opportunity to practice working with expert teammates from that discipline(s). The development of more advanced technical skills would be shifted to the post -doctoral phase, as is typical of physician-scientists. Naturally, for this approach to succeed, faculty will need to communicate clearly and transparently with applicants and students about training goals.

The transdisciplinary framework has several strengths, not the least of which is that it does not require major institutional reforms. It promises to strengthen the features that make clinical psychologists desirable science teammates, while maintaining a shorter time-to-degree than the M.D.-Ph.D. approach. Whether a change in culture—alone or in combination with other revisions—is enough to address the expectation-time imbalance is unknown.

We encourage programs to creatively experiment and empirically examine the consequences of revising local training models. For some clinical science programs, it will make sense to drop APA accreditation. Doing so may not, in itself, solve all problems, but it would create new opportunities for re-envisioning clinical psychology training to address unsustainable student workloads and other urgent challenges. In this sense, dropping APA accreditation is not an end, but a new beginning, with PCSAS serving as a catalyst for structural and cultural revisions. In considering bold reforms or even minor modifications, careful attention must be paid to our field’s core values and the potential for adverse ‘off-target’ effects (e.g., increased time to first full-time position).

CHALLENGE 8. INSUFFICIENT DATA FOR RECURSIVE REFINEMENT

Contemporary clinical psychology training is “based on a patchwork of accumulated wisdom, historical practices, observation of past successes and failures, and feedback from past trainees. It is particularly seductive … to enumerate the students … who have gone on to do great things … and to conclude that we must be doing something (probably a lot of things) right. However, we all know that good intentions, anecdotal outcomes, and personal endorsements are a weak basis for making important decisions” —Robert Levenson ( Levenson 2017 , p. 18)

Available data streams are not sufficient for recursive refinement of training practices. Existing national surveys provide detailed assessments of the graduate school experience, but it can be challenging to obtain program-level data ( ACHA 2021 , CSHE 2021 , gradSERU 2021 ). APPIC and APA financial and occupational surveys are aggregated across degrees and neither is readily available at the program level. Data collected by accreditors lack detailed assessments of workload, climate, mental health, financial strain, discrimination, and other key challenges. None of these surveys collect data from faculty or supervisors. Indeed, it was this gap that led us to collect our own survey. While useful, there are crucial limitations to such grassroots efforts (e.g., selection biases). In short, none of the existing data collection efforts is sufficient to allow recursive refinement of training practices at either the national or local levels.

Recommendation: Develop New Data Streams

To fully understand the challenges facing today’s trainers and trainees and determine whether revised training practices are having the desired effects, we need new data streams, which ultimately can be used to develop evidence-based standards for training ( Levenson 2017 ). At the local level, we recommend that programs collect anonymous annual surveys of faculty and students. Items can be adapted from existing surveys (e.g., gradSERU), and new items can be devised based on the challenges and interventions of greatest local interest. Longitudinal data collection will be particularly important for understanding the consequences of local innovations. To enhance efficiency and rigor, survey design should be coordinated across institutions via APCS or CUDCP workgroups. In some cases, it may be possible to organize randomized trials of particular training or climate interventions. At the national level, we recommend that accreditors harmonize and institutionalize these efforts, for instance, by expanding the scope of accreditation-related data collection. This would also serve as an institutional incentive to invest in healthier and more sustainable environments for students and faculty alike. We also recommend that programs transparently advertise 5- and 10-year post-graduation career outcomes. This would enable applicants to make informed decisions and, we hope, will promote more realistic and respectful conversations about jobs outside of academia. We urge professional groups to advocate for these changes, accreditors to nurture them, and funders to provide the modest level of necessary support. For maximal transparency and return on investment, de-identified national data should be made publicly available to allow for data mining.

CHALLENGE 9. SYSTEMIC HEADWINDS

“I vividly remember…seeing Charlie Chaplin’s film ‘Modern Times.’…[where] machine-like workers are forced to work more and more quickly to the point of absurdity. Little did I know then that I would find myself in a strangely similar position in academia. Over the past 50 years, I have experienced increasing pressure to ‘speed up.’” —Uta Frith ( Frith 2020 , p. 1)

Substantial work will be necessary to overcome the challenges facing clinical psychology, and much of the burden will (and should!) fall on the shoulders of faculty. Faculty’s most precious commodities are time and mental energy. Yet they are buffeted by the same systemic headwinds that students face. Decades-long declines in government support for higher education and psychopathology research fuel a hypercompetitive culture and faculty burnout ( Alberts et al 2014 , Barrett 2019 , CACTUS Foundation 2020 , Edwards & Roy 2017 , Frith 2020 ). Stretched to the limit by their existing research, instructional, service, clinical, and administrative responsibilities, many faculty lack the surplus ‘bandwidth’ that will be required to reimagine and rebuild clinical psychology training. Data from our survey revealed that over two-thirds (63.1%) of faculty work >50 hours per week, and close to one-in-five (19.6%) work >60 hours ( M =53.6 hours). On average, faculty already provide 4.1 months of ‘overload’ effort. Not surprisingly, most feel over-committed (63.1%) and over one-third (33.9%) say they do not have enough time for existing professional responsibilities. One-quarter (26.8%) feel overwhelmed and 16.7% say they rarely have time for self-care, family, and other personal endeavors. These challenges are exacerbated for female faculty, who report greater burnout, are less satisfied with their work-life balance, and have less time for self-care and family responsibilities than their male colleagues ( d =.32–.48). Of course, these unfortunate consequences of long-term economic forces are not unique to clinical psychology; a similar pattern is evident across higher education ( Azubuike et al 2019 , CACTUS Foundation 2020 , Jaremka et al 2020 , Urbina-Garcia 2020 ).

Recommendation: Work Together

To ensure feasibility, a ‘team science’ approach will be necessary to solve the challenges confronting today’s clinical psychology trainers and trainees. Workgroups, task forces, and other kinds of creative grassroots approaches that cut across programs provide an immediate means of forging the necessary collaborations. We urge accreditors, professional organizations (e.g., APCS and CUDCP), and other institutional partners to encourage and support their development. No single agent or intervention will be sufficient to cure the system, but by working together we can mitigate some of the most urgent challenges.

SUMMARY POINTS AND FUTURE DIRECTIONS

CONCLUDING THOUGHTS

“We cannot perpetuate the status quo in clinical training simply because it is familiar and comfortable…If evolving circumstances render past approaches no longer defensible or sustainable, then we must face this reality and deal with it forthrightly.” —Richard McFall ( McFall 2006 , pp. 22–23)

Addressing the burden of mental disorders requires new etiological insights and the development and implementation of more effective, scalable, and equitable approaches to disease prediction, prevention, and treatment. To be successful, clinical psychology needs to honestly confront some uncomfortable truths about the unsustainable current state of clinical psychology training 1 . Fully addressing the challenges that we have identified will require fundamental changes. These changes are necessary and, in many cases, long overdue. Some of these changes will be difficult to implement. Some will be disruptive in the near-term. In short, they need to be made with great care and transparency. This will require debate, advocacy, and action at both the individual and the institutional levels. As a first step, we call on accreditors, professional organizations, and funders to create the necessary meetings (‘Boulder 2.0’) and other resources that will be necessary to discuss the challenges and recommendations we have highlighted. Students, alumni, and other key constituencies must have a robust voice in these discussions. Of course, the 75-year history of clinical psychology is replete with debates, and discussion alone will not be sufficient to overcome the urgent challenges facing today’s trainers and trainees. Bold thinking, creative collaborations, novel incentives, and new institutional investments will be necessary to create a sustainable training environment where talented students and faculty can focus their energies on understanding and reducing the suffering caused by mental health conditions. Given the staggering burden that mental disorders impose on public health and the critical role that training plays in preparing future generations of clinical scientists to tackle this burden, we urge all stakeholders to lobby policy makers and demand greater parity in the resources allocated to clinical psychological science.

Supplementary Material

Acknowledgements.

Authors acknowledge assistance from L. Friedman and critical feedback from A. Anderson, H. Berenbaum, L. Dougherty, M. Dougherty, N. Eaton, S. Glass, A. Heller, A. Holmes, C. Larson, R. Levenson, B. Nacewicz, R. Nusslock, C. Seitz-Brown, D. Stout, and C.-W. Woo. This work was partially supported by funding from the National Institutes of Health (DP5021370, MH107444, MH121409, NS119709) and University of Maryland. Authors declare no conflicts of interest.

Additional Elements : Supplement

Resource Sharing

De-identified survey data have been or will be made publicly available via the Open Science Framework.

1 Our perspective on these issues is strongly influenced by Varmus and colleagues’ landmark commentary on the state of the larger biomedical research ecosystem Alberts B, Kirschner MW, Tilghman S, Varmus H. 2014. Rescuing US biomedical research from its systemic flaws. Proceedings of the National Academy of Sciences of the United States of America 111: 5773–77.

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Search NYU Steinhardt

PhD in Clinical/Counseling Psychology

Research from faculty in the Clinical/Counseling Psychology program is conducted in laboratories at New York University and the schools, hospitals, neighborhoods, and community settings in New York. Additionally, international research is a cornerstone of the program, with faculty and students engaged in studying developmental processes and contextual influences across countries such as China, Argentina, Denmark, and Korea. We work closely with our affiliated global faculty at NYU Shanghai and NYU Abu Dhabi campuses.

Student Research

Students participate in the research team of a faculty member of the Clinical/Counseling Psychology program (or another Applied Psychology faculty, by program approval), beginning the first semester of the first year. Students are expected to allocate half of their time (at least 20 hours per week) to this research team throughout their graduate career. Students are free to transition to another team or collaborate with other research labs and/or research centers during their doctoral training. It is expected that student research experience will entail research productivity, including papers, grant writing, presentations, and publications.

Areas of Research Focus:

• Women and depression; immigrant women; cross-cultural research; feminist epistemology and social action
• Development of prevention, intervention, and service delivery models for youth at risk for or affected with disruptive behavior disorders
• Development of, and social response to, violence and antisocial behavior, focusing on psychopathology, criminal justice systems response, and the role of gender and adolescence
• Immigration, community contexts, individual differences, and racial minority status and the mental health of Asian American individuals and families
• Multicultural assessment and counselor training; qualitative research methods; intelligence testing with diverse populations
• Psychosocial and cultural predictors of health among ethnic minority cancer survivors; development of culturally-sensitive psychosocial interventions; individual differences in emotion regulation and negative self-reflection
• LGBTQIA+ psychology (including homonegative microaggressions) and psychological assessment

Affiliated Research Centers and Institutes

The Consortium for Research and Evaluation of Advanced Technologies in Education (CREATE)  engages in research on the design, critique, and evaluation of wide-ranging advanced digital technologies for learning. Projects housed in the consortium involve interdisciplinary teams of scholars and developers who bridge basic and applied research, development, and evaluation.

The Institute of Human Development and Social Change (IHDSC) 's mission is to stimulate interdisciplinary research and influence social policy on children, youth, families, and communities in the context of a rapidly changing social world.

Metro Center

The Metropolitan Center for Research on Equity and the Transformation of Schools (Metro Center)  promotes equity and opportunity in education through engaged science work: applied research, program evaluation, policy analysis, community engagement, and professional assistance to educational, governmental, and community agencies serving vulnerable populations.

Affiliated Research Labs/Projects

Chinese Families Lab (CFL)

The project draws from both the Nanjing Adolescent and Nanjing MetroBaby study, which are longitudinal, mix-methods studies with over 1100 Chinese families and children starting at 7th grade for the adolescent study and birth for the MetroBaby study. The project is led by  Dr. Niobe Way,   Dr. Hirokazu Yoshikawa ,  Dr. Sumie Okazaki,  and  Dr. Sebastian Cherng  from NYU, and is a collaboration across NYU, NYU-Shanghai, NYU-Abu Dhabi, University of Pennsylvania, and Southeast University in China. We are interested in how the changing social, economic, and cultural context influences Chinese parents' parenting practices and children’s development. The project has finished a ten-year follow-up from the MetroBaby project in 2016. Ongoing research papers under development include examining Chinese mothers’ and fathers gender socialization, adolescents' gender beliefs and their academic achievements, gender beliefs and friendship quality, parents' workplace climate and families' mental health, etc. 

The Culture, Emotion, and Health Lab (CEH)

CEH is directed by  William Tsai, Ph.D.  The lab studies how people regulate their emotions, cope with stress, and how these processes lead to health and well-being. We focus our research questions on how cultural tendencies and values can shape the development and use of these processes. Our work is interdisciplinary, spanning across social, clinical, and health psychology. Recently, we have begun a line of research with ethnic minority cancer survivors, which is a population that experiences significant cancer health disparities. We are interested in applying cultural psychology theories with psychosocial interventions to overcome cultural barriers to reduce the undue burden of cancer experienced by ethnic minority cancer survivors.

The Families and Children Experiencing Success (FACES) Lab

FACES is directed by  Anil Chacko, Ph.D . The lab was developed to serve the families of youth exhibiting disruptive behavior disorders such as Attention-Deficit/Hyperactivity Disorder, Oppositional-Defiant Disorder, and other conduct disorders. Its research aims to understand how to develop the most effective prevention, intervention, and service models for youth with disruptive behavior disorders and related conditions, or those at high risk for developing them.

The Researching Inequity in Society Ecologically (RISE)

RISE is directed by Erin Godfrey, Ph.D.,  and  Shabnam Javdani, Ph.D . The team’s research and activities serve traditionally marginalized populations, focusing on health and mental health disparities in women and youth who are involved, or at risk of involvement, with the justice system. As such, the RISE Team takes a contextual, multi-level and interdisciplinary approach to systems change and implementing evidence-based practices promoting health and well-being, working closely with community partners to bridge the gap between research and practice.

Faculty Publications

To find out more about a faculty member’s research, please visit their NYU Scholars page by clicking on the professor’s name below.

Anil Chacko

Shabnam Javdani 

Lisa Suzuki

William Tsai

A. Jordan Wright

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