CLINICAL PSYCHOLOGY

A field of psychology devoted to psychological methods of diagnosing and treating mental and emotional disorders, as well as research into the causes of these disorders and the effects of therapy.The first American psychological clinic was established by Lightner Wit- mer at the University of Pennsylvania in 1896. It was devoted largely to mental testing, and most of the clients were children. The growth of the field was slow until World War II, but from that time to the present it has rapidly expanded in scope and importance. Clinical psychologists now deal with adult as well as child clients, engage in psychotherapy as well as testing, and conduct research projects in the entire field of mental and emotional disorders.According to the latest survey, published by the American Psychologist in March, 1966, approximately 37 per cent of all psychologists function in this general area, and it is therefore by far the largest single category in the field. Clinical psychologists occupy positions not only in mental institutions, out-patient clinics, and community mental health centers, but also in industry, schools, courts, correctional institutions, government agencies, and the armed forces, and approximately 14 per cent are in private practice. A growing number of clinical psychologists are engaged in all phases of community mental health, and the American Psychological Association now has a Division of Community Psychology. While many devote themselves to diagnosis, treatment and research, others are active in planning and administering community-based facilities such as the community mental health centers which are now in formation through the country.The work of clinical psychologists requires a background in practically every branch of psychology, but draws most heavily on the study of abnormal psychology, personality theory, and psychological testing. Preparation must also inelude specialized courses and supervised training in the clinical field. A growing number are obtaining specialty certification through the American Board of Examiners in Professional Psychology. To receive the ABEPP diploma, the candidate must offer a Ph.D. and five years experience, and must pass intensive written and practical examinations.The major activities of clinical psychologists fall into three related fields: diagnosis, therapy, and research. The rest of this topic will review some of their work in these areas with special emphasis on the techniques they employ and the problems they encounter.Diagnosis. The object of diagnosis is to make a full evaluation of the in- vidual’s personality and functioning, so that the most appropriate type of therapy can be applied. Although some classification of patients into categories of mental deficiency, neurosis, or psychosis is useful for screening purposes, there is less and less emphasis on specific diagnostic labels today. An increasing number of psychologists and psychiatrists have been pointing out, first, that the textbook cases are rarely found in clinical practice; and, second, that psychological disorders cannot be viewed as distinctive diseases like typhoid fever or diphtheria. Instead, they put the emphasis on specific behavior patterns, and construct a full and detailed personal description of each patient in terms of his particular defense and escape mechanisms. This approach gives the therapist leads for exploring the sources of maladjustment, and enables him to put his finger on ineffectual or distorted attitudes which need to be revised. In other words, diagnosis is aimed at treatment rather than at classification.There are two other important objectives. One is that an evaluation of the patient is important in predicting the possibility of improvement as well as in selecting the type of treatment that is most likely to be effective. Studies have shown that evaluation and prognosis must take many factors into account, including the form of the disorder (reactive schizophrenia has a better prognosis than process schizophrenia), the post-hospital environment of the patient (an oversolicitous family is a handicap) and the ego-strength of the patient. The other goal of diagnosis is the attainment of insight. During the exploratory, fact-finding process a client often comes to know and understand himself better, especially if he is encouraged to verbalize his feelings and speak openly about his problems. This is most likely to occur in the client- centered and psychoanalytic approaches, which therefore do not draw a hard and fast line between diagnosis and therapy.The clinical psychologist collects his diagnostic data in three principal ways: by compiling a case history, by interviewing the patient, and by administering psychological tests. In compiling the case history, or anamnesis, he gathers information on the client’s family background; psychological and physical development; medical, educational, and vocational history; and his current situation. To assemble as complete a biography as possible, he not only interviews the client himself but may also consult members of the family, teachers, the family physician, employers, and social agencies. In the diagnostic interview, or series of interviews, the client is encouraged to describe his problem and talk freely about himself, and the clinician notes his characteristic ways of reacting to his experiences, as well as telltale behavioral clues such as blushing, grimaces, gestures, and changes in posture as he tells his story. He refrains from expressing any judgments of approval or disapproval, but maintains a warm, relaxed and interested attitude. Clinical psychologists have found that if they establish a good rapport with their clients during the diagnostic process, they will not only elicit a wealth of material but set the stage for effective therapy.The clinician occasionally uses academic achievement, vocational and interest tests when they are relevant to specific problems; but his major instruments are intelligence tests and personality tests. Since the major tests in both of these categories are described under separate topics, they will receive a minimum of attention here. Individual intelligence tests, such as the Stanford- Binet and Wechsler, not only provide objective indexes of intellectual functioning, but give the clinician an opportunity to observe work habits, attitudes, problem-solving techniques, and emotional responses to the test situation. Performance tests usually reveal perceptual and spatial rather than numerical and verbal behavior, and are particularly useful in testing infants, preschool children, illiterates, foreigners, and clients with disabilities (dyslexia, cerebral palsy, etc.) which prevent the administration of verbal tests. A number of tests have also been constructed for assessing intellectual impairment due to brain damage, psychosis, senility, and certain types of mental defect.In contrast to the tests of intellectual functioning, personality tests are designed to assess the client’s emotional, social, and motivational patterns. Since these tests are of more debatable value than the intellectual tests, they are used primarily for exploratory purposes, and greater weight is usually given to the case history and interview data. The three major types of personality tests are self-report inventories, such as the MMPI in which the client responds to printed statements about feelings, attitudes, and behavior; the various projective techniques (Word Association Test, Sentence Completion Test, Rorschach, TAT) in which the individual responds in his own way to relatively unstructured material; and tests which reveal the way the client views himself and others (self-concept tests, attitude and interest tests).Therapy. The involvement of the clinical psychologist in therapy has broadened in recent years, and now includes an immense variety of procedures. One indication of this expansion is the fact that this volume describes more than eighty different kinds of treatment, although some of them are of an auxiliary nature and others primarily experimental. The psychologist should be conversant with every type of therapeutic approach, even those he does not himself apply, since he is often called upon to participate in clinical conferences and to evaluate the procedures of others.The psychologist does not administer somatic treatments—shock therapy, drugs, psychosurgery—since these require medical training. However, he may collaborate with physicians in determining which approach to use, in evaluating the progress of therapy, and in applying psychotherapy when the patient is amenable to it. In many instances, too, he is deeply involved in environmental therapy, which is now a major feature of the treatment program in mental institutions. The object of this approach is to make the hospital a “therapeutic community” by focusing the entire milieu on the single objective of bringing patients back to a normal life. Among the techniques used are occupational therapy, sheltered workshops, recreational and social activities, contacts with the community, and self- government by the patients. Clinical psychologists frequently act as advisers or administrators in these programs.The clinical psychologist also serves as a psychotherapist in his own right, dealing primarily with cases of milder emotional disturbance, neurosis, and behavior disorders, and rarely with psychotic patients except when they are on the road to recovery.Since the various types of psychotherapy are described under individual topics, we will only stop to enumerate some of the major approaches at this point. Some therapists are nondirective and client-centered in their approach, others are more directive and serve as guides or counselors. Some put the emphasis on insight and interpretation; others stress learning processes and behavioral change. A few clinical psychologists utilize an analytic approach for some types of disorder and conditioning techniques for others. In addition, psychologists apply many varieties of group therapy in institutions and clinics, and may use play therapy and psychodrama when they appear most appropriate. Some specialize in briefer forms of therapy, including hyp- noanalysis; others engage in more extended treatment, practicing either a Freudian or a neo-Freudian form of psychoanalysis. But, interestingly, a sizable number of psychotherapists do not confine themselves to a single procedure or school but adapt their approach to the particular needs of the patient. There is evidence for this trend in a 1960 survey conducted by the American Psychological Association’s Division of Clinical Psychology which showed that 49 per cent of the respondents described their orientation as “eclectic.” Research. This is the area in which the clinical psychologist can probably make his most needed and distinctive contributions, for only through research can present mental health techniques be evaluated and new ones developed. Unfortunately there was little attempt to apply scientific methods to the study of clinical problems before World War II, and even now there are far more questions than answers. However, some promising approaches have been made in four areas—diagnosis, the process of therapy, the outcome of therapy, and causes of mental disorder. Some examples of significant research in each of these areas will now be given.The validation of projective tests and other diagnostic techniques presents a particularly knotty problem. The difficulties arise from a variety of factors —for example, a TAT may provide different kinds of information about different individuals because of its unstructured nature, and much of this information is in the form of inner attitudes and reactions (such as unconscious feelings of inferiority) that cannot easily be translated into observable, verifiable patterns of behavior. Also, as Anastasi (1964) has pointed out, many of the attempts to evaluate diagnostic tests have been inconclusive because they have used questionable procedures or inappropriate statistical techniques. There have been, however, a few carefully constructed investigations, and she cites as an example a study conducted by Little and Shneidman (1959), in which four groups of subjects (neurotic, psychotic, psychosomatic, and normal) were administered the Rorschach, TAT, MAPS and MMPI, with a detailed case history compiled independently for each subject. A thoroughgoing blind analysis was performed by two sets of judges: forty-eight clinical psychologists analyzed the test results, and twenty-three psychiatrists and one psychologist evaluated the case studies. Analysis of their findings revealed little correspondence between the diagnostic labels assigned to the subjects and their previously established diagnoses. Moreover, the test judges disagreed widely among themselves, and there was a strong tendency to classify the normal subjects as neurotic or psychotic. There was a somewhat higher than chance agreement among their personality descriptions, but the correlation between the case studies and the test results was low. Also, there was little agreement from one test to another and even among different judges using the same test. The findings, in other words, were not very promising.Another area of research, which has yielded happier results, is the study of the changes occurring during psychotherapy. Seeman (1949) analyzed client and therapist statements taken from sixty nondirective sessions with ten clients, and found that in the course of psychotherapy the percentage of statements dealing with problems or symptoms sharply declined, and statements that showed understanding or insight increased in number. Toward the end of the process, the clients also showed increased optimism and interest in future plans. Some studies using the Q sort technique have shown that the client’s self-concept becomes more favorable as therapy progresses. Other studies have shown that defensiveness decreases and expressions of hostility tend to increase, indicating a growing ability to express feelings freely. Still another line of investigation has suggested that the personality characteristics of the therapist enable him to function more effectively with one type of therapy than another, and with one kind of patient as well. Snyder (1961) has found a close correspondence between the way a client feels toward the therapist and the way the therapist feels toward the client in the different therapeutic sessions. The importance of compatability between therapist and patient is now well recognized. See SELF-CONCEPT TESTS.A third area of research—evaluation of the outcome of therapy—presents more problems than may be expected. First of all, what criteria should be used? The patient’s own judgment is likely to be misleading because he may be defensive about admitting failure to improve, and may be influenced by the “hello, good-bye” effect—that is, the tendency to exaggerate his difficulties when seeking therapy and to minimize them at the end, out of courtesy or gratitude. The therapist’s report may be influenced by expectation and belief in his procedures, and he may judge improvement more by changes in the patient’s attitude during the process than by changes in behavior outside his office. The same may occur in the hospital, where apparent improvement may be due only to better adjustment toward life, not to the real world. It is even hard to judge changes in adaptation to the outside world because the experimenter has no control over the circumstances of the patient’s life, which may be favorable in one case and highly unfavorable in another. In view of these difficulties it should not be surprising that the correlations between different criteria are rather low (Fulkerson and Barry, 1961), and that a patient may be judged to be greatly improved according to one criterion and unimproved according to another (Fair- weather et al. 1960).It is also extremely difficult to design conclusive experiments in this field. One method is to compare treated with untreated groups, yet it is hard to match them completely in all important variables such as age, sex, socioeconomic level, duration of illness, type of onset. In comparing different kinds of psychotherapy, different therapists are generally used, and variations in the results may be due to the therapists rather than the therapies. In evaluating drugs, a possible placebo effect must be taken into account. In a recent study hospitalized psychiatric patients were divided into an experimental group and a control group; the experimental group was given either “a new tranquilizer” or “a new energizer,” and the control group received no tablet at all. After a six-week period the experimental group was evaluated by psychiatrists, nurses, and themselves, and from 53 per cent to 80 per cent appeared to have benefited. Yet the fact of the matter is that all the drugs administered were placebos, although neither the patients nor the staff were aware of this (Loranger, Prout, and White, 1961).Research on the causes of mental disorder is even more tentative than research on the effects of treatment Since many of the theories and findings are reported under separate topics, such as schizophrenia and manic-depressive psychosis, we will confine ourselves here to enumerating some of the approaches currently under exploration. In attempting to assess hereditary factors, some specialists have investigated the incidence of a given disorder in closely intermarried families, in isolated inbred communities, and in different members of the same families. Others have studied the incidence of disorders that follow Mendelian ratios (phenylketonuria, amaurotic idiocy), and have attempted to trace the physiological mechanisms through which the defect manifests itself. Still others have explored the incidence of schizophrenia and other disorders among fraternal and identical twins, and the extent to which close association and similar environment may be an explanatory factor.Two other sets of factors are receiving their share of attention today. Clinical psychologists are frequently concerned with assessing the effects of organic conditions on behavior—among them, birth injuries, minimal brain damage, disordered metabolism due to stress, endocrine dysfunctions, brain wave irregularities, and vitamin deficiencies. They are especially involved in the study of the relation between life experience and psychological disorder. Here, too, there are many avenues of inquiry: the effects of emotional deprivation, parent-child relations during the formative years, the “schizophreno- genic mother,” cultural differences in child-rearing practices, characteristic symptom patterns, and disorders among different nationalities and other social groups.These factors—hereditary, organic, environmental—are hard enough to investigate when attacked singly, but in many cases all three collaborate to produce a single disorder—which poses the further problem of appraising the interrelationships among them. This requires the collaboration of many specialists from many disciplines, which in itself can be a problem.