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Clinical
Psychology (PSY401)
VU
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.
33
Clinical
Psychology (PSY401)
VU
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.
34
Clinical
Psychology (PSY401)
VU
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
35
Clinical
Psychology (PSY401)
VU
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
IN
THE
PREVENTION
OF
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
36
Clinical
Psychology (PSY401)
VU
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.
37
Clinical
Psychology (PSY401)
VU
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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