History of Clinical Psychology
Clinical psychology is a broad discipline concerned with the scientific study of psychopathology and with the assessment and treatment of persons with emotional, cognitive, and behavioral problems. It is perhaps the most common psychological specialty in the world (Sexton & Hogan, 1992), although it is defined and organized somewhat differently from one country to another.
Clinical Psychology Relation to Other Disciplines
Clinical psychology overlaps considerably with the neighboring field of psychiatry, especially in terms of the subject matter of its research. The distinction between the two is in terms of education, training, and scope of professional practice. Clinical psychologists receive more exposure to the behavioral sciences and have greater expertise in psychometrics (Anastasi & Urbina, 1997) and in behavioral approaches to treatment (Kazdin, 1978). Psychiatrists are medically trained and have more expertise in the biological aspects of psychopathology and in psychopharmacology (Shorter, 1997).
Clinical psychology was the first of many practice-oriented specialties that developed within psychology. Several other such specialties were originally part of clinical psychology and then split off from it and became more independent areas of practice. Thus at least a part of school psychology began as clinical psychology in a school setting. Part of counseling psychology began as clinical psychology in rehabilitation facilities or university guidance centers. Clinical health psychology was another spin-off field, applying similar concepts and assessment and intervention methods to the psychological problems associated with physical health conditions. Clinical neuropsychology works closely with the medical field of neurology and is concerned with the precise analysis of brain-behavior relationships. Psychoanalytic psychology was officially named as a specialty once psychologists achieved the legal right to be trained within psychoanalytic institutes in the United States in the 1980s.
Origins of Clinical Psychology
The first known use of the term clinical psychology was in a 1907 article by Lightner Witmer in the inaugural issue of Psychological Clinic, the journal he edited. The field has roots as an area of professional practice somewhat separate from those as an academic endeavor. Witmer founded the first psychology clinic in 1896 at the University of Pennsylvania (Witmer, 1897) and was one of the first to advocate the use of psychology in order to help people rather than only to carry out research. His clinic focused on work with school-aged children with academic and behavioral problems, including difficulties with reading and spelling, mental retardation, and what would today perhaps be labeled as childhood autism. At times it extended into the adult age range. Clients were examined at this psychological clinic using procedures adapted from the laboratory psychology of the day and the results were used primarily to direct remedial teaching to try to overcome the difficulties presented. Witmer trained many doctoral students in psychology at the University of Pennsylvania in such clinical methods. He encouraged them to seek more intensive training in the form of full-time internships at such nearby sites as the Training School at Vineland, New Jersey, a residential institution for persons with mental retardation. He traced the intellectual origins of his work to such European figures as Rodriguez Perreira (a Portuguese-French teacher of the deaf) and J. M. G. Hard (the French physician who had worked to try to socialize the Wild Boy of Aveyron). He identified others who influenced him as the physician Edouard Seguin, who founded a school in Paris to try to rehabilitate children with mental retardation, and the physician-educator Maria Montessori, who developed innovative educational procedures for use with slum children in Rome. Despite the historical importance of Witmer in relation to clinical psychology, the work he did resembles the diagnostic teaching done by special educators more than it does the activities of present-day clinical psychologists.
The fields of abnormal psychology and psychotherapy, which are key parts of present-day clinical psychology, had a much more ancient origin. The study of psychopathology can be traced back at least to the medical writings attributed to Hippocrates dating from the fifth century BCE and to the work of philosophers such as Democritus who were not physicians (Routh. 1998). The precise origins of psychotherapy are more elusive. According to Jerome Frank’s (1961) influential book, Persuasion and Healing, such practices may be ubiquitous in human societies.
The involvement of psychologists in the study of psychopathology and its treatment obviously had to wait until the late nineteenth century, when a formal discipline of psychology developed, but research on psychopathology soon became a part of this new field. The neurologist Charcot appointed Pierre Janet to direct a psychology laboratory at the Salpetriere Hospital in Paris in 1890 to study the female patients with hysteria there. Alfred Binet was another early French psychologist who worked with Charcot and was greatly influenced by him. The German psychiatrist Emil Kraepelin spent time working with the psychologist Wilhelm Wundt at the University of Leipzig. Kraepelin was an influential figure in the development of descriptive psychopathology and of psychopharmacology. He later carried out psychological research in his psychiatry service at the University of Munich.
In the United States beginning toward the end of the nineteenth century, there was great interest in abnormal psychology and psychotherapy among many of the early psychologists, including William James, G. Stanley Hall, Boris Sidis, and Morton Prince. James presented the Lowell lectures on exceptional mental states in Boston in 1896 (Taylor. 1982) and was interested in research on automatic writing. Hall at one point served as the lay superintendent of a mental hospital in Maryland and later taught psychology to psychiatry residents at Worcester State Hospital in Massachusetts. Morton Prince. a psychologically oriented physician, studied a famous case of a woman with multiple personality. He established the Journal of Abnormal Psychology in 1906, and he founded the Harvard Psychological Clinic in 1926. What might be termed the Boston school of abnormal psychology and psychotherapy was active in the 1890s and at the turn of the century, though it tended to be absorbed by the psychoanalytic movement after the first decade of the new century.
Clinical psychology also had significant roots in psychoanalysis. The two fields have shared a century-long history and have a continuing relationship. Breuer and Freud published the book that established psychoanalysis, Studies in Hysteria, in 1895. From the beginning, Freud expressed the wish that psychoanalysis not be simply a medical specialty and was willing to train analysts with various backgrounds, including psychology. The psychoanalysts who were professional psychologists included Otto Rank. Theodore Reik, and many others.
One complication was that the American Psychoanalytic Association wished to restrict the practice of psychoanalysis and especially access to its training programs to psychiatrists only. For many years psychologists in the United States who wanted to be trained and supervised in psychoanalysis had to achieve this in irregular or devious ways. This restrictive policy was not overcome until four clinical psychologists lead by Bryant L. Welch sued the American Psychoanalytic Association for antitrust violations and won an out-of-court settlement in the 1980s.
Principal Figures in Clinical Psychology
In a field that is hardly more than a century old, the choice of a few individuals as principal figures is bound to be a bit arbitrary. We will confine this discussion to persons who are no longer living. One of these pioneers was Alfred Binet, the co-developer of the first valid intelligence test (Binet & Simon. 1905). This test significantly distinguished children with mental retardation from their typically developing peers, and various versions of it have been in continuous clinical use ever since that time. This line of research was significantly advanced by Lewis M. Terman (1916), who standardized Binet’s test and published norms for it using sizable groups of children of different ages. Terman (1925; Terman & Oden. 1947) went on to demonstrate the long-term reliability of this test and its predictive utility not only in relation to academic performance but also other life achievements. Then Jean W. Macfarlane of the University of California at Berkeley had the wisdom to convert a flawed study of the effects of clinical guidance of children into a life-span study of development within the general population. She and her colleagues (including Erik Erikson) paid attention not only to cognitive development but also to aspects of personality and social adjustment.
Carl R. Rogers in the 1940s helped move the field of clinical psychology from an overly exclusive preoccupation with mental testing toward a more balanced emphasis on psychotherapeutic intervention as well (Rogers. 1951). Rogers’ client-centered or person-centered approach to psychotherapy was original with him but was indirectly influenced by Freud as interpreted by the psychologist-psychoanalyst Otto Rank and the social worker Jessie Taft. Rogers had the boldness to carry out tape recordings of actual therapy sessions and to initiate controlled research on psychotherapy process and outcome.
Clinical psychological assessment came to encompass personality and psychopathology as well as cognitive functioning. One of the most innovative ventures in this domain was developed by Starke R. Hathaway, who was a coauthor of the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley. 1943). In contrast to earlier questionnaire measures of psychopathology, the MMPI was empirically validated using groups of patients with particular psychiatric diagnoses compared to normal control subjects. In addition, the MMPI provided novel “validity” scales enabling the psychologist to detect subjects’ attempts to dissemble or to present themselves in an unduly favorable or unfavorable light. The validity scales also detected patterns of incomprehension. Confusion, or random responding. The MMPI continues to be one of the most widely used measures of its kind and has been translated into many different languages.
George A. Kelly developed some original approaches to assessing how individuals construed their social world. His personal construct theory (Kelly. 1955) was also the basis of an approach to intervention that was perhaps the first example of cognitive therapy, presently one of the most widely used kinds of treatment.
In the United Kingdom, Hans Eysenck founded a Department of Psychology within the Institute of Psychiatry at the University of London. Eysenck devised his own questionnaires for the assessment of personality and psychopathology that were widely used and influential. He published a critique of the effectiveness of psychotherapy that, though not without its own flaws, spurred research on psychosocial intervention throughout the world (Eysenck. 1952). Eysenck was also a pioneer in promoting behavioral approaches to therapy. These emerged as a strong influence on clinical psychology beginning in the 1960s.
Major Areas of Research in Clinical Psychology
The focus of the work of the principal figures in clinical psychology discussed above was primarily on assessment and treatment. Clinical psychology has also emphasized research on psychopathology throughout its existence. The research program of David Shakow, begun at Worcester State Hospital, for example, concerned attentional difficulties in schizophrenia (e.g., Shakow, 1962). He used the classic experimental paradigm of reaction time to demonstrate difficulties patients with schizophrenia have in maintaining “set/’ They are easily distracted and may be overly influenced, for example, by the timing of the RT signal on the immediately preceding trial. Paul E. Meehl (1962), another clinical psychologist whose research often focused on schizophrenia, elaborated an influential theory about how genetic factors are involved in this group of disorders. Meehl defined “schizotaxia” as the hypothetical genetic factors hypothesized to be necessary but not sufficient for the development of schizophrenia. Meehl used the term “schizotypy” to refer to the corresponding phenotype. A schizotype is thus a person at risk for schizophrenia and might manifest traits such as interpersonal aversiveness and subclinical cognitive slippage. Given an adverse environment, for example, perinatal difficulties or other stresses, the schizotype might manifest the clinical disorder of schizophrenia.
In another domain of psychopathology research, clinical psychologist Martin E. P. Seligman (1975) translated his basic research on “learned helplessness” in dogs into a prototype for understanding how clinical depression might develop in human beings. The dog, in a shuttle apparatus, learns that nothing it can do will avoid episodes of electric shock. Similarly, a human might acquire a predisposition to depression in the form of the habit of making internal, stable, and global attributions for failure (“I failed because that is just the way I am. I will always be that way, and this applies to every domain of my life”).
Other Significant Professional Concerns in Clinical Psychology
A concern of clinical psychology throughout its existence as an organized specialty group has been with the credentialing of practitioners. The purposes of these efforts are to give public recognition to psychologists qualified to offer their services to the public and to discourage practice by others not so qualified. Beginning in 1919, the American Psychological Association attempted to implement a plan to certify individuals who met certain criteria as “consulting psychologists.” This plan did not prove to be functional. Only 25 psychologists were ever so certified, and the scheme had to be discontinued after only a few years (Routh. 1994). During the period after World War II, from 1945 to 1977, every U.S. state passed legislation certifying or licensing psychologists to practice independently. Certification generally refers to the protection of the title “psychologist,” while licensing usually refers to protection of the practice itself. These laws typically required possession of a doctoral degree in psychology, plus two years of supervised experience in the field, one of which could be predoctoral. All Canadian provinces, the United Kingdom, most countries in the British Commonwealth, and the Scandinavian countries implemented similar licensing schemes, though not necessarily with the requirement of training at the doctoral level. Other countries in Europe and Latin America appear to be on the road to developing similar legislation, but this is far from a worldwide development. There are wide variations from one country to another in the legal qualifications for the independent practice of psychology. Such laws, where they exist, are usually generic to psychology and do not refer to clinical psychology separately by name.
In 1947, the organization presently known as the American Board of Professional Psychology was established and soon began to examine candidates for its diploma signifying advanced competence in clinical psychology. This process was intended to be the equivalent of board certification in psychiatry or other medical specialties.
Clinical psychologists in independent practice in the United States have fought a long, extensive battle for recognition by hospitals, insurance companies, and third-party payers. This has led to the establishment of a National Register of Health Service Providers in Psychology to provide insurance companies with the names of practitioners who have training at the doctoral level, active state licensure, and a formal internship involving at least a year of full-time clinical training.
Clinical Psychology Training Requirements
The University of Pennsylvania, among other academic institutions, has been training clinical psychologists for over 100 years, but for most of that time there was no public agreement on exactly what the curriculum in the field should be. As mentioned already, the tradition of a 1-year, full-time internship was established within 12 years after the field was founded, and by about 1920 there was an informal consensus that this was a necessary part of training for clinical psychologists who wished to provide services to the public. Besides the internship at Vineland, others were established at the Boston Psychopathic Hospital and elsewhere.
After World War II, there was a move to standardize training in clinical psychology in both North America and in parts of the United Kingdom and northern Europe. At that time, clinical psychology became part of the national health care system in the United Kingdom and several other countries that had such systems. At that time in the United States, both the Veterans’ Administration (VA) and the newly established National Institute of Mental Health (NIMH) began to offer training grants in clinical psychology. These organizations requested the American Psychological Association to set up a formal system for accrediting training in clinical psychology, and it did so. An APA committee on training in clinical psychology, headed by David Shakow, wrote up recommendations for such training. They were essentially ratified by a national conference held in Boulder, Colorado, in 1949. Thus was born the “Boulder” or scientist-practitioner model of clinical training. Clinical psychologists were to be trained at the Ph.D. level, including a required predoctoral internship in the third year, with the expectation that upon graduation they would go into careers involving both research and service, either in universities or in public sector positions in the VA, state hospitals, child guidance centers, and the like. A separate accreditation program was set up by the APA for internship programs. Graduates of Boulder-model clinical psychology programs deviated from the above expectations in two ways. Many of them did little research, and eventually quite a number of them went into private practice.
By the end of World War II, some university psychology departments already had long traditions of training clinical psychologists primarily for research rather than service activities. These universities included many elite schools such as Harvard, Columbia, the University of Chicago, and Stanford, who either never endorsed this new accredited training model or gradually dropped away from participating in it. They tended to resist the standardization demanded by the new APA accreditation system but continued to train at least some psychologists interested in the scientific study of psychopathology.
On the other end of the academic spectrum, some programs arose that offered training for professional practice, perhaps involving a doctor of psychology of Psy.D. degree (originally suggested by Hollingworth, 1918), rather than for both research and practice. Eventually, a national conference at Vail, Colorado, in 1973 endorsed this “practitioner” training model (Korman, 1974). In the United Kingdom, the pattern has now grown up of offering professional training and awarding Doctor of Clinical Psychology (D.Clin.Psych.) degrees. Elsewhere in the world, training for practice takes place in master’s degree or 6-year undergraduate “licenciado” programs, with doctoral level training being reserved for academics.
Professional Organizations in Clinical Psychology
The first professional organization in this field was the American Association of Clinical Psychologists (AACP), founded in 1917. This group met in Pittsburgh, Pennsylvania. on the campus of the Carnegie Institute of Technology in connection with the APA meeting going on there at the time (Routh, 1994). Its founders were motivated by the wish to establish professional standards, in particular in the administration of the Binet test, which at the time was being inappropriately given and interpreted by school teachers untrained in psychology on the one hand, and by academic psychologists with no clinical experience on the other. The AACP was absorbed back into the APA two years later in 1919, becoming the “Clinical Section” of the APA. In 1937, the Clinical Section of the APA dissolved itself because of distress at the restrictions put by the APA on its continued attempts to promote professional standards. It reconstituted itself as the Clinical Section of a new organization known as the American Association for Applied Psychology (AAAP). Then, in 1945, the AAAP and the APA merged. The Clinical Section became APA Division 12, originally called the Division of Clinical and Abnormal Psychology.
Similar clinical psychology organizations were formed in Canada, the United Kingdom, and various other countries, typically as a division or section of the national psychological organization. Many are also affiliated with regional organizations such as the European Federation of Professional Psychology Associations (EFFPA).
Major Publications in Clinical Psychology
One of the most prestigious peer-reviewed scholarly journals in clinical psychology is the Journal of Abnormal Psychology. It was founded by Boston physician Morton Prince in 1906 and later given by him to the American Psychological Association. This journal was known for a number of years as the Journal of Abnormal and Social Psychology but then reverted to its original name and scope. In addition to research on psychopathology, this journal has always provided a niche for articles on hypnotism or dissociative phenomena, in line with Prince’s research interests. Prince was the same man who founded the Harvard Psychological Clinic (a research-oriented facility rather than one concerned mainly with service delivery), expressing his view that the study of psychopathology belonged to the liberal arts rather than the medical school. True to form, he had also founded the American Psychopathological Association as an organization for researchers in the field of psychopathology, including psychologists as well as psychiatrists.
A second high-prestige journal in clinical psychology is the Journal of Consulting and Clinical Psychology, also now published by the APA. It was founded under the name. Journal of Consulting Psychology and was published for its first ten years as a “house organ” by the AAAP. Upon the merger of the AAAP and the APA, it became a peer-reviewed scholarly journal.
The British Journal of Clinical Psychology is also a highly respected journal and is one of those published by the British Psychological Society. Many other scholarly journals devoted to clinical psychology exist in various countries.