HOW CLINICAL PSYCHOLOGISTS BECAME INVOLVED IN TREATMENT

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Clinical Psychology (PSY401)

LESSON 06

HOW CLINICAL PSYCHOLOGISTS BECAME INVOLVED IN TREATMENT

During the period of 1850-1890s, psychologists such as Kraeplin focused on the classification of

psychoses. But by the late 1800s, this focus shifted from psychoses to investigating new treatments for

neurotic patients, such as suggestion and hypnosis. Specifically, Jean Charcot gained a widespread

reputation for his investigations of hysterical patients. Although trained as a neurologist, Charcot

employed a psychosocial approach in explaining hysteria. At about the same time, the momentous

collaboration of Josef Breuer and Sigmund Freud began. In the early 1880s, Breuer was treating a young

patient named "Anna O", who was diagnosed with hysteria.

Anna O's treatment presented many challenges but also led to the theoretical breakthroughs that greatly

influenced the psychotherapy practice later. Based on Freud's work with Charcot and Breuer's

experiences with hysterics, Breuer and Freud published Studies on Hysteria in 1895. This collaboration

served as the launching pad for Psychoanalysis, the single most influential theoretical and treatment

development in the history of psychiatry and clinical psychology.

In 1900, Freud published The Interpretation of Dreams that resulted in mainstream acceptance of the

psychoanalytic perspective. The psychological conference at Clark University in 1906, where Freud

delivered his famous lectures to American professionals and general public, stimulated the acceptance

of Freud's psychoanalytic theories in United States.

For many coming years, the treatment of psychopathology was dominated by the field of psychiatry,

largely because of the influence of Freud and the development of psychoanalysis as the primary method

for treating psychopathology. With his training as a neurologist, it would have been natural for Freud to

assume that the treatment of psychopathology was an extension of the treatment of other disorders of the

nervous system and, therefore, a task best left to trained physicians. Surprisingly, it was not Freud but

his followers who argued that the practice of psychotherapy should be limited to those with medical

training. Consequently, the entry of psychologists into the therapy enterprise became quite difficult.

One of the earliest ways in which psychologists became involved in the treatment of psychological

problems was through the child guidance movement in the early 1900s. In 1909 William Healy

established a child guidance clinic in Chicago to provide services for children with psychological

problems. The clinic was staffed by psychiatrists, social workers, and psychologists who treated

children and adolescents, primarily for problems that are now labeled Conduct Disorder and

Oppositional Defiant Disorder in the DSM-IV.

A second trend that influenced early work in interventions with children was Play therapy. Based mostly

on Freud's psychoanalytic theory, psychologists conducted therapy in which children were encouraged

to engage in play and the therapist would offer psychoanalytic interpretations of their play.

Group therapy also began to attract attention. By the early 1930s, the works of both J. L. Moreno and S.

R. Slavson were having an impact. Another precursor of things to come was the technique of "passive

therapy" described by Frederick Allen (1934). With the exception of the early work of clinical

psychologists in child guidance clinics, the involvement of clinical psychologists in the treatment of

psychopathology has been primarily fueled by forces from outside psychology. In much the same way

that the First World War was critical in increasing the role of psychologists in assessment, the Second

World War played an integral role in the emergence of clinical psychologists as providers of treatment

for psychopathology.

Clinical Psychology (PSY401)

WORLD WAR II: CLINICAL PSYCHOLOGY AND THE TREATMENT OF

PSYCHOPATHOLOGY

The Second World War renewed the need for psychologists to evaluate the competencies of thousands

of men and women who were being enlisted in the armed services. Psychologists were once again asked

to administer psychological tests to draftees. World War II and the period that followed it are most

noteworthy, however, for the emergence of a new set of skills for psychologists. Clinical observations of

soldiers who had experienced the stress of combat led to the identification of a syndrome of symptoms

of psychological trauma that were displayed by many soldiers. This syndrome was labeled "shell shock"

or "battle fatigue" at the time, but is now known as Post Traumatic Stress Disorder (PTSD).

The primary symptoms of PTSD are high levels of anxious arousal, recurrent and persistent intrusive

thoughts and emotions pertaining to the trauma, and persistent efforts to avoid all reminders and

thoughts about the traumatic event. Physicians and others involved in providing medical assistance to

combat soldiers noted that the symptoms could be managed most effectively if the victims were treated

as quickly as possible and in the context of battle. Those soldiers for whom treatment was delayed and

administered in a hospital removed from the battlefield were more likely to suffer extended and more

severe reactions than those who received immediate psychological attention.

The dilemma faced by the armed services in addressing the needs of these thousands of "psychological

casualties" was the insufficient number of trained individuals available to provide treatment. Medical

personnel, including those physicians trained in the relatively young field of psychiatry, were needed to

treat physical casualties. Psychologists were called on once again to fill a need because they were

perceived as having the most representative set of skills needed for the task (StrickSand, 1986).

THE NATIONAL COUNCIL OF WOMEN PSYCHOLOGISTS

During this time the majority of people who pursued college and graduate degrees were male, and as a

result, most clinical psychologists were men. However, women in psychology emerged as an important

force during the Second World War (Strickland, 1988). Experimental, social, applied, and clinical

psychologists all developed new respect for each other as they worked together and brought their own

special skills to the military and to national defense. Interestingly, women psychologists were excluded

from APA's war mobilization effort. Women within psychology founded the National Council of

Women Psychologists and worked to help with community problems, such us reducing the stress of war

on civilians and giving advice about child care to women who worked outside their homes during the

war, many for the first time. This organization was just one example of the struggles of women to

achieve equal status with men in clinical psychology.

THE VETERANS' ADMINISTRATION

The end of World War II brought rapid and dramatic changes in the field of clinical psychology. At the

conclusion of the war, the armed services and the Veterans' Administration (VA) were faced with the

task of providing care for more than 40,000 psychologically wounded veterans who had returned home.

Too few psychiatrists were available to manage this task; consequently, the VA chose to draw on

psychology as a new source of professionally trained mental health personnel. At this time, the

membership of APA, including psychologists in all specializations, was barely 4,000. The VA system

estimated that 4,700 clinical psychologists were needed to provide treatment for psychological

casualties from World War II. To meet this need, the VA invested enormous amounts of money to pay

for the training of doctoral-level clinical psychologists.

Consequently, whereas in 1946 there were no formal university programs to train clinical psychologists,

by 1950 half of all PhDs in psychology were being awarded in clinical psychology.

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ALTERNATIVE APPROACHES TO PSYCHOTHERAPY

The role of psychologists in conducting psychotherapy was expanded by more than just the military and

VA hospitals. Carl Rogers, one of the founders of humanistic psychology, was also influential in

involving psychologists in psychotherapy during this period. Rogers provided a strong impetus to move

psychotherapy out of the exclusive realm of medicine, psychiatry, and psychoanalysis. While he was

director of the Rochester Child Guidance Center, Rogers spearheaded an effort to loosen the hold of

psychiatrists on the practice of psychotherapy, arguing that trained and qualified clinical psychologists

could perform as well as medically trained analysts.

With the publication in 1942 of his book Counseling and Psychotherapy, Rogers not only identified

psychotherapy as a legitimate activity for clinical psychologists but also offered the first model of

psychotherapy that was not based on psychoanalytic theory.

THE BEHAVIORAL APPROACH

Finally, the role of psychologists in providing treatment for psychological disorders was also fueled by

advances in theory and research on learning and conditioning processes that led to behaviorally oriented

treatments. As models of classical conditioning and operant conditioning of behavior emerged over the

course of the early i and mid 1900s, psychologists began to see the potential value of these models for

explaining and treating maladaptivc behavior. For example, the early work of Watson, Raynor, and

Jones showed the role that conditioning and learning play in the development of fears (e.g., Jones,

1924a, 1924b).

Among the first to apply behavioral models to treatment was psychiatrist Joseph Wolpe (1958), who

suggested that "neurotic" behaviors (anxiety disorders) were learned through a process of conditioning

and could be unlearned by a similar process, which he called "reciprocal inhibition". The principles of

conditioning and learning theory were applied to treat variety of clinical problems including phobias,

obsessive-compulsive disorder, anxiety and disruptive behavior in children. In 1967,Association for

Advancement of Behavioral Therapy (AABT) was founded and remains one of the major professional

organizations for clinical psychologists.

THE COGNITIVE BEHAVIORAL APPROACH

The treatment focus in 1970s was on changing thoughts; feelings and expectations became important as

the goal of changing overt behavior. The works of Albert Ellis using Rational Emotive Behavior

Therapy, Aron Beck using Cognitive treatments for depression; and the self-efficacy work of Bandura,

led to the changes in the integrative cognitive approaches with behavioral approaches.

PRESENT APPROACHES

During the late 1970s and early 1980s professionals sought to integrate the best methods of the various

approaches on case-by-case basis. An emphasis was placed on the common factors leading to an

Eclectic Approach.

Emerged in late 1900s, the Bio-psycho-social approach suggested that the biological, psychological

and social aspects of health and illness intimately influence each other. Thus psychologists must

understand the multidimensional bio-psycho-social influences in order to treat and understand others.

Psychotherapy research has been one of the most active areas of empirical investigation for clinical

psychologists. We have already noted several important events in psychotherapy research, including

Rogers's (1942) early research on client-centered therapy, Eysenck's (1952) critical evaluation of the

effectiveness of psychotherapy, and Wolpe's (1958) work on the use of behavioral methods to treat

anxiety. Other landmark studies in psycho- therapy research include the first evidence of the efficacy of

Clinical Psychology (PSY401)

cognitive therapy in the treatment of depression (Rush, Beck, Kovacs, & Hollon, 1977), the first use of

the statistical technique of meta-analysis to integrate and evaluate large numbers of different studies of

the effects of psychotherapy (Smith & Glass. 1977). The first evidence that behavioral methods could he

used to treat sexual dysfunction (Lobitz & LoPiccolo, 1972), and comparisons of the efficacy of various

forms of psychotherapy and pharmacotherapy in the treatment of depression (e.g., Rush, Beck, Kovacs,

& Hollon, 1977) and anxiety disorders (Power, Simpson, Swanson, & Wallace, 1990).

CLINICAL

PSYCHOLOGISTS

INVOLVEMENT

THE

PREVENTION

PSYCHOPATHOLOGY

The treatment of psychopathology, like the treatment of any problem or disorder, can reduce the

prevalence or number of existing cases of disorder. Treatment cannot, however, reduce the incidence of

new cases of a disorder. That is, no matter how effective psychologists become in treating problems

related to anxiety, depression, eating disorders, or substance abuse, to name but a few, the treatment of

existing problems will not reduce the number of new individuals who develop these problems.

Recognition of this simple fact provided the impetus for the development of prevention efforts in public

health in general and for the prevention of psychopathology in particular. Prevention of psychological

problems was not an integral part of the goals of clinical psychology as the science and profession

developed during the first half of the twentieth century. Beginning in the 1950s, however, a number of

factors increased psychologists' awareness of the importance of prevention in dealing with mental health

concerns in American society.

The report of the United States Joint Commission on Mental Illness and Health in the late 1950s,

President Kennedy's initiative for new programs to combat mental retardation and psychological

disorders in 1963, and the development of comprehensive community mental health centers in the 1960s

were all landmark events in moving prevention into mental health programs and policies in the United

States. All these initiatives highlighted the need to reduce the incidence of new cases of

psychopathology. In addition, they emphasized the unequal access of Americans to mental health

treatment. Individuals of lower socioeconomic status (as reflected in levels of education and occupation)

have less access to mental health professionals and are less able to pay for such services because of lack

of income and lack of health insurance to cover the costs of such services.

Prevention programs that can eliminate some of the social factors that contribute to the development of

psychological problems may be able to eliminate some of these inequities. Clinical psychologists have

played a central role in the development of prevention programs to reduce the incidence of new cases of

a wide range of psychological problems and disorders. Prevention programs focus primarily on children

as psychologists attempt to prevent the onset of disorders early in children's lives.

Prevention includes programs to prevent aggressive behavior and conduct disorder, depression, and

substance use and abuse.

THE DEVELOPMENT OF CLINICAL PSYCHOLOGY AS A PROFESSION

As clinical psychologists have acquired new skills and roles, particularly in the areas of assessment, and

treatment, psychology has needed to organize itself as a profession to monitor and regulate the activities

of those who present themselves to the public as clinical psychologists. What does it mean to say that

you are a clinical psychologist? What skills, competencies, and credentials must you have in order to

use this label for yourself? What are the ethical and professional standards that govern psychologists'

interactions with their clients? What assurances are provided to the public that the methods used by

clinical psychologists have been proven to be effective?

These issues have all had to be addressed as clinical psychology has worked to define and regulate itself

as a profession. The APA has played a leading role in the development and regulation of the profession

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of psychology, including establishing ethical principles for the practice of psychology, accrediting

training programs in clinical psychology, and working with state legislatures and the U.S. Congress to

support legislation to monitor and regulate the practice of psychology. Academic research-oriented

psychologists and applied psychologists have often found it difficult to integrate scientific psychology

and professional psychology.

CLINICAL PSYCHOLOGY'S INTERACTIONS WITH APA

During the early part of the twentieth century, clinical and other applied psychologists complained that

their interests were not being met within the APA. As a result, in 1917 fifteen of the 375 members of

APA broke off to form the American Association of Clinical Psychology (AACP). With the threat of

losing more members, APA reluctantly agreed to consider certifying some members as "consulting

psychologists" and two years later established a special Clinical Section to handle professional issues. In

the early 1930s, the New York State Psychological Association, in an attempt to deal with issues of

ethics, licensing, and standardization of training, became the Association of Counseling Psychologists

(ACP). In 1937, the clinical section of the APA disbanded, left the APA again, and joined ACP, which

was renamed the American Association for Applied Psychology (AAAP).

This move represented a significant split between the scientific and applied aspects of psychology. In a

reflection of this split, in 1939 Carl Rogers discussed the possibility of awarding professional

psychologists a doctor of psychology degree (similar to the current PsyD degree) rather than a PhD. In

1939 AAAP published a model certification act for state affiliates who could use such a document in

their state legislative efforts within states to gain certification or registration for psychologists.

This model certification was a major factor leading to the establishment of state boards for the licensing

of psychologists. The split between scientific and applied psychology was addressed in the 1940s when

APA changed its membership standards. The APA previously had required that its members must have

at least two research publications beyond the dissertation. In 1945 APA was restructured in ways that

were particularly supportive of practitioners, including an elimination of the requirement of publications

for membership.

The impetus for this change came from the need to unify psychologists for the purpose of responding to

the country's wartime needs. The APA by laws were expanded to include the advancement of

psychology not only as a science but also as a profession and as a means of promoting human welfare.

An arm of the APA, the Practice Directorate, is devoted specifically to issues that pertain to psychology

as a profession. The Practice Directorate supports legislation that is important to psychology, conducts

public education campaigns, and engages in efforts to support practicing psychologists.

FORMATION OF A NEW ORGANIZATION: THE AMERICAN PSYCHOLOGICAL

SOCIETY (APS)

The tension between research and applied interests of psychology arose again in the 1980s when

academic psychologists raised concerns that APA had become too involved with the practice of

psychology and was ignoring psychological research. These concerns led to the formation of a new

organization, the American Psychological Society (APS), in 1988. The APS is strongly committed to

the promotion of scientific research in basic and applied psychology and provides an alternative for

psychologists who worry that APA has become more of a guild to protect the practice of psychology in

ways that are not tied to the scientific basis of the field.

The two groups function independently of one another with separate governing bodies, separate annual

conventions, and separate scientific journals. However, many psychologists, and many scientifically

oriented clinical psychologists in particular, are members of both organizations.

Clinical Psychology (PSY401)

CONCLUSION

The history of clinical psychology can be traced through advances and landmark events in research,

assessment, treatment, and prevention and through the development of the profession of clinical

psychology. Contemporary clinical psychology is ever evolving, currently adapting to numerous

changes and challenges.

Clinical psychology has now found its way into general health care with applications to numerous

medical problems and issues. Although the changes in clinical psychology have been radical, the goal

that binds clinical psychologists together remains the same: to apply their knowledge and skill to the

mental health needs of people everywhere.

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