Clinical Psychology

HISTORY OF CLINICAL PSYCHOLOGY

ROOTS OF RESEARCH & ASSESSMENT IN CLINICAL PSYCHOLOGY

The evolution of the field of clinical psychology after Lightner Witmer can be best understood through an examination of how clinical psychologists came to be involved in each of four different activities:

Research, Assessment, Treatment, and Prevention.

Clinical psychologists became involved in these endeavors at different points during the twentieth century and for very different reasons. It is important to comprehend the role of clinical psychologists in these four activities both to understand forces in this field’s past and to anticipate changes in its future.

Likewise, it is important to possess an understanding not only of the events that shaped clinical psychology, but also of the broader social context in which the field has developed.

During the early years, clinical psychology was a science and profession dominated by males (Snyder, McDermott, Leibowitz, & Cheavens, 2000). For example, in 1917, only 13 percent of APA members were women. Although women made progress in the fields of developmental and school psychology, from 1920 through 1974 women comprised only 24 percent of graduates with doctoral degrees in clinical psychology (Snyder et al.).

By 1994, however, 58.7 percent of students admitted to doctoral programs in clinical psychology were women. Thus, the composition of clinical psychology has changed from being overwhelmingly male to being overwhelmingly female.

1. RESEARCH

HOW CLINICAL PSYCHOLOGISTS BECAME INVOLVED IN RESEARCH

Witmer and the other founders of clinical psychology were researchers who were interested in the application of their research to the benefit of others.

Clinical researchers try to add to these bodies of knowledge both to increase their understanding of psychopathology, illness, and health and to improve their methods for its treatment and prevention.

Because of their broad training in basic behavioral science, clinical psychologists are able to draw conclusions and contribute to research in a variety of different areas and to collaborate with professionals from other disciplines.

THE SCOPE OF CLINICAL PSYCHOLOGICAL RESEARCH

Clinical psychological research has steadily grown in its scope since the early 1900s. This subfield now includes:

Research on the basic characteristics and prevalence of psychopathology. (epidemiology), the causes of psychopathology (etiology), the measurement of behavior and psychological characteristics of individuals (assessment), the role of the brain and central nervous system (clinical Neuropsychology), the treatment of psychopathology (psychotherapy), The prevention of psychopathology and the promotion of psychological health, and the links between psychological factors and physical health and illness (health psychology/behavioral medicine).

There has been landmark research in each of these areas during the past 70 years, the results of which led to substantial changes in knowledge about a particular problem or issue.

RESEARCHES THAT SHAPED THE FIELD

Clinical psychology has been shaped not only by findings from research studies but also by important reviews of research evidence and by the development of new methods for clinical practice.

Two examples are particularly prominent in this regard:

1) Effectiveness of Psychotherapy

2) Statistical vs. Clinical Prediction

1) EFFECTIVENESS OF PSYCHOTHERAPY

In the early 1950s, the field of psychotherapy was in its early stages of development, and much of the practice of psychotherapy was based on the psychoanalytic model developed by Freud.

Research on the effectiveness of this approach to psychotherapy was very limited, however-most practitioners simply assumed that the methods they were using were effective in treating their patients.

Given this widespread acceptance of the belief that psychotherapy was effective, a paper published in 1952 by British psychologist Hans Eysenck created enormous controversy.

Eysenck argued that there was little or no evidence that psychotherapy was any more effective than no treatment at all.

He reached this conclusion by comparing (two sources of data: the results of 24 studies that had been conducted on the outcomes of psychotherapy, and information on rates of recovery from emotional distress in the absence of treatment, or what is referred to as spontaneous remission.

Eysenck reported that treated individuals actually did worse than did people who received no psychotherapy: Whereas 72 percent of the individuals who did not receive treatment recovered from their problems, only 44 percent of those receiving psychoanalysis and 64 percent of those receiving “eclectic” psychotherapy recovered.

Although the rates of improvement presented by Eysenck are much lower than those found in many studies that have been published since the appearance of his paper, his report had a significant impact on the field.

Eysenck challenged clinical psychologists and other mental health professionals to provide better evidence for the effectiveness of their treatment methods.

Initiated by Eysenck’s paper, more and better research on the effects of psychotherapy has been conducted, leading to more effective methods of treatment and a better understanding of how and why psychotherapy works. The current evidence on the effects of psychotherapy is much more positive than the perspective offered by Eysenck 50 years ago.

2) Statistical vs. Clinical Prediction

A second example of research that changed the field is a short but important book; “Statistical Versus Clinical Prediction” published by psychologist Paul Meehl in 1954 that had a significant impact on psychological testing and assessment. Before Meehl published his book, psychologists relied heavily on their subjective judgments and intuitions in interpreting the results of psychological tests.

This approach, referred to as clinical judgment or clinical prediction, was based on the assumption that clinical psychologists learn a unique set of skills that allows them to make accurate judgments about people and to predict such things as patients’ ability to benefit from psychotherapy, people’s potential for success in a job, or the likely course of individuals’ psychological problems.

Meehl challenged these assumptions by demonstrating that judgments based on statistical data representing patterns of behavior in large samples of people provide a more accurate basis for making judgments and predictions about specific individuals than do the subjective judgments of single clinicians.

The findings reported by Meehl in 1954 still hold true today (Dawes, Faust, & Meehl, 1989; Meehl, 1997), statistically based predictions are still more accurate than clinical judgment.

CONTRIBUTION OF RESEARCH IN CLINICAL PSYCHOLOGY

Although single groundbreaking studies and commentaries have clearly important effects on the field of clinical psychology, they are relatively rare and do not represent how most of the growth and development in the field occurs. Rather, the greatest contribution of research in clinical psychology is the slow and gradual accumulation of knowledge that comes from the results of dozens of studies on a particular topic.

For example, procedures for the treatment of anxiety disorders have been developed through the efforts of a large number of different researchers who have conducted many series of carefully designed studies using a wide variety of research methods (Barlow, 1998).

These procedures include the treatment of generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and specific phobias. One of the most striking features of research in clinical psychology today is the breadth of topics that are included within the field.

Throughout much of the first century of clinical psychology, three topic areas have been focal points of research:

The nature and etiology of psychopathology; The reliability and validity of methods of psychological assessment, especially psychological tests; and Psychotherapy efficacy (whether or not psychotherapy can work) and effectiveness (whether psychotherapy actually does work in practice).

RESEARCH IN CLINICAL PSYCHOLOGY TODAY

Today, however, research in clinical psychology extends well beyond these core topics of research. Areas that clinical psychologists now investigate include:

The role of psychological factors in the development of physical disease (e.g., cancer, heart disease), The relative effectiveness of psychotherapy as compared with medication in the treatment of psychopathology, The prevention of violent behavior,

• The long-term consequences of sexual assault, harassment and rape, and many, many other topics.

2. ASSESSMENT

CLINICAL PSYCHOLOGISTS INVOLVEMENT IN ASSESSMENT

Since its inception, psychology has been uniquely concerned with the measurement of differences between individuals on important cognitive and personality characteristics. The study of differences between individuals on psychological tests and measurements began with the work of Sir Francis Galton in England in the late 1800s.

Galton was fascinated by the work of his cousin Charles Darwin on differences in characteristics both between and within species, and in the process of natural selection that is influenced by these differences. Galton focused on the concept of individual differences between people, especially in various aspects of perception and menial abilities.

STUDY OF INDIVIDUAL DIFFERENCES

Early interest in individual difference testing in the United States is marked by the work of James McKeen Catell at the University of Pennsylvania. Trained in Wundt’s laboratory in Germany and influenced by a meeting with Galton in England, Catell constructed tests to measure various facets of sensori-motor functioning.

As a result of these early influences, one strong thread through the history of clinical psychology is the development of tests and other procedures to assess and measure characteristics of individuals.

THE INFLUENCE OF BINET’S INTELLIGENCE TEST

BACK GROUND TO BINET’S INTELLIGENCE TEST

Around the time that Witmer was developing an application of psychology to help children who were experiencing difficulties learning in school, events in Europe were also leading to the development of methods to measure children’s potential for learning.

In 1904, the Minister of Public Instruction in Paris wanted to ensure that children with limited intellectual skills were still provided with an education. Alfred Binet and Theodore Simon were commissioned by the French government to develop a tool to aid in decisions about the appropriate educational programs for French schoolchildren.

Binet was a French researcher trained in both law and medicine. In order to study individual differences, he felt it was necessary to sample a wide range of complex intellectual processes so that the spread of scores obtained by different individuals would be broad (Reisman, 1976).

Binet’s work resulted in the first formal test of intelligence, the 1905 Binet-Simon scale, consisting of 30 items of increasing difficulty.

By 1908 this original simple test had been expanded into an instrument composed of 59 tests grouped at age levels from three to thirteen years according to the percentage of children of a particular age who passed a given item (Reisman).

Interest in Binet’s work grew over the next few years, and versions of the Binet-Simon scale were imported to the United States. The version that eventually became the accepted U.S. translation and standardization of the Binet-Simon scale (the Stanford-Bind Intelligence Test) was developed by psychologist Louis Terman of Stanford University in 1916.

WORLD WAR I; A TEST FOR CLINICAL PSYCHOLOGY

As the United States prepared to enter the war that was raging in Europe in 1917, the American military was faced with an unprecedented task: the conscription and creation of a massive army and navy. There was an enormous need to evaluate quickly and accurately the qualifications of over 1 million young men as potential members of the armed forces (Driskell & Olmstead, 1989). Physicians were enlisted in the task of conducting physical evaluations of these draftees to determine whether they were physically fit to serve during the war. But the military recognized the need to also evaluate the mental and intellectual qualifications of these potential soldiers. Physicians could not fill this role, because the evaluation of mental functioning was not within their realm of expertise.

Based on their knowledge of human learning and memory and the measurement of individual differences in human intelligence, psychologists were called on to fill this role. In 1917, a group of psychologists, headed by APA president Robert Yerkes, undertook the task of developing tools to measure the mental abilities of future soldiers (Driskell & Olmstcad, 1989).

The psychological tests that were available and in use at the time (e.g., the test developed by Binet and Simon) required individual administration. Consequently, these tests were impractical for use with the large number of recruits involved in the military. Therefore, Yerkes and his colleagues set about the task of developing a quick and efficient test of intelligence that could be administered to large groups of individuals simultaneously.

There effort yielded two tests,

The Army Alpha (a test of verbal skills) and The Army Beta (a test of nonverbal skills).

The enduring consequence of this work is that it established psychologists as experts in the measurement of individual characteristics in ways that were practical and useful. This opportunity for psychology to contribute to the war through the application of psychological tests increased the status and visibility of psychologists and of psychological testing.

It is unlikely that this first large-scale application of scientific psychological knowledge and methods would have occurred without strong pressure from external sources, in this case the U.S. military.

ASSESSMENT AFTER WORLD WAR I

Following World War I, clinical psychologists became well known for their testing skills. A testing development occurred, such that by 1940 over 500 psychological tests had been produced.

These tests included both verbal and non verbal intelligence tests, career interest, personality and vocational skills tests. Tests were available for children of all ages and abilities as well as for adults.

ADVANCES IN PSYCHOLOGICAL TESTING AND ASSESSMENT

In addition to the powerful social forces that led clinical psychology to become involved in psychological assessment and testing, significant advances in research have also played an important role. For example, the publication of the Minnesota Multiphasic Personality Inventory (MMPI) by psychologist Starke Hathaway in 1943 represented a major change in the way that psychologists measured personality and psychopathology.

The MMPI relies on statistical comparisons of the test responses of an individual to those of a large sample of other people who have already been tested. These comparisons are used to determine the degree to which the individual is similar to a group of people with known personality characteristics, or people with a specific type of psychopathology. Thus, the MMPI represented an important shift away from the more clinical, subjective approach to assessment and toward a more statistical, empirically based method of assessment.

Another important advance in assessment occurred during the 1960s with the recognition that direct observations of people’s behavior might represent an important source of information, perhaps more valid than relying on their responses to psychological tests.

The first applications of behavioral observation as a means of assessment were conducted in schools and psychiatric hospitals, settings in which it was rather easy for a psychologist to observe an individual’s behavior and in which the environment was relatively contained and controlled.

For example, Bijou, Peterson, Harris, Alien, and Johnston (1969) described a method for the experimental study of young children in natural settings, including their home, school, and other institutions, as well as the behavior of parents, peers, and professional workers.

In general, research has shown that behavioral observations can be conducted in a manner that is reliable (different raters independently generate similar ratings of the same individual) and that these observations can be useful in formulating and evaluating the effects of treatment.

CONCLUSION

If the development of clinical psychology had followed the path set by Witmer, Terman, and others in the early 1900s, it would have slowly emerged as a field that was based on the careful application of the young science of psychology. This is not what happened, however. Indeed, much of the rest of the history of the field is marked by decisions made by psychologists to move into new areas and new applications even though the scientific knowledge in these areas may not have been sufficient to warrant such an application.

There were often powerful social forces pressing psychologists to step forward to address an important issue or assume an important role. The results of these decisions have been far-reaching, because the field of clinical psychology has expanded at a rate that has at times challenged its scientific knowledge base and expertise.