History of Clinical Psychology

Clinical psychology has grown tremendously since 1896, the year

Lightner Witmer founded the world's first psychological clinic at the
University of Penn sylvania (Reisman, 1976). While once associated
merely with clinic-based eval uation and treatment of childhood
learning problems, the field of clinical psy chology has expanded
into a wide range of client populations, clinical activities, and work
settings.

Professional activities are no longer limited to children, but now

involve adults, couples, families, and groups as well. The range of
problems has expanded well beyond learning deficits and
encompasses everything from mild adjustment disturbances to
severe psychopathology. The settings in which clinical psychologists
conduct their work have extended beyond the academic psychology
clinics of years past to include college and university psychology
departments; medical and law schools; hospitals; community mental
health centers; educational facilities; prisons, police departments,
and other law en forcement agencies; rehabilitation centers; nursing
homes and other geriatric facilities; health maintenance
organizations; private practice; and numerous others. Finally, in
addition to assessment and treatment of psychological disorders,
contemporary clinical psychologists are engaged in research,
teaching, and professional consultation.

PSYCHOLOGY: THE EARLY YEARS

The study and treatment of mental illness can be traced back to at

least 2100 B.c., when its cause was believed to be demonic
possession, and its cure incantation ceremonies and prayer to
various gods (Ehrenwald, 1956).

Belief in demonically induced mental illness had diminished greatly

by the start of the 18th century. Unfortunately, treatment modes
had not advanced beyond confinement and cruel practice. Patients
were locked up, confined to restrictive cribs, shackled, placed in
spinning chairs, purged, and left hungry all in the name of a "cure"
for their mental illness (Altrocchi, 1980). Progressive treatment did
not begin in the United States until the mid- to late 18th century,
when Benjamin Rush (1745-1813), Dorothea Dix (1802-1887),
and others objected to the inhumane methods employed in most
institutions for the "insane."

Benjamin Rush was a physician who believed in the physiological

aetiology and treatment of mental disease, and he was also a strong
proponent of moral and humane intervention. He postulated that
mental illness originated in blood vessels, particularly those of the
brain. According to his theory, blood vessels were influenced by
emotional factors, and emotions could reduce their effectiveness. He
instituted treatments consistent with his etiological reasoning,
including bloodletting, purging, diets, and drugs as potential cures
(Mora, 1985). Obviously, these practices would not be viewed as
"humane" in present society; however, Rush's efforts represented a
move away from harsh custody toward more active and humane
intervention.

Dix extended Rush's efforts at reform by making mental illness more

of a political issue than a medical one (Brems, Thevenin, & Routh,
1991). Her contacts with Congress increased lawmakers' and public
awareness of the problems faced by the mentally ill. She advocated
successfully for hospitalization of the mentally ill confined to prisons,
and her activism resulted ultimately in more modern hospitals and
treatment for many in need.

Profound and influential reforms were taking place in Europe during

this time as well. William Toke (1732-1819) founded the York
Retreat in England, an institution devoted to humaneness and
respect for the mentally ill patients under care. Exercise, discussion,
kindness, and hobbies replaced the prior emphases on punishment
and control, making the York Retreat a model institution for others to
follow (Brems et al., 1991). In France, Philippe Pinel (1745- 1826)
worked to free patients from the senseless brutality, and instead
provided patients with attention, kindness, and a structured,
positive, and productive environment.

Pinel further advanced treatment by developing a diagnostic

system that differentiated melancholia, mania, dementia, and
idiocy, presumably to tie specific diagnoses to specific treatments.
Asylums in Belgium saw substantial change as Joseph Guislain
(1796-1860) incorporated Pinel's program into their institutional
plans.

Jean Esquirol (1776-1840) led reform in France both by using

Pinel's program and by providing the field with some understanding
of the role of etiological factors such as age, environment, and
events in mental health and illness (Brems et al., 1991).

Although a new awareness that patients could be helped, rather

than simply hidden, developed during the late 18th and early 19th
centuries, there were minimal advances in etiological theory
(Nietzel, Bernstein, & Milich, 1994). The ongoing controversy
remained between those who believed in physical causes of mental
illness and those who advocated psychological or moral causes
(Mora, 1985). It is clear, however, that groundwork for the field of
clinical psychology was laid by the mental health reform movements
of Europe and the United States.

It is also clear that the new emphasis on civilized care, respect, and
morality was influenced substantially by the social forces and ideas
of the time. Philosophers and writers were proclaiming the dignity
and equality of all, not just the mentally ill (Nietzel et al., 1994).

By the late 19th century, contemporaneous changes had occurred in

science as well, and the use of scientific experimentation to objectify
and quantify knowledge about human behaviour was initiated by
physiologists Wilhelm Wundt and William James (Brems et al.,
1991).

Fascinated by statistical analysis, Sir Francis Galton began to

explore individual differences by applying quantitative methods to
the assessment of acuity, motor skills, and reaction time. He
established an anthropometric laboratory in 1882 and investigated
the still-controversial idea of inherent intelligence. In 1885, he set up
the world's first mental testing centre in London. Anyone willing to
pay a modest fee could take a battery of tests and receive a copy of
the test results (Nietzel et al., 1994).

Agreeing with Galton's approach to the study of intelligence,

an American by the name of James McKeen Cattell focused his
research on reaction time differences among individuals. His
doctoral mentor, Wilhelm Wundt, did not approve of this approach to
the study of mental processes and discouraged Cattell from
pursuing this line of research.

Nonetheless, Cattell made significant contributions to measurement

theory and practice, and was the first to coin the term mental
tests to describe measures of intelligence (Nietzel et al., 1994).

It was in this period (1892) that the first professional society

of psychologists, the American Psychological Association
(APA), was formed.

Collaboration between Sigmund Freud and Joseph Breuer

marked the advent of psychoanalytic theory. They focused on the
causes and motives for behaviour, rather than the mechanics of
brain and nerve function associated with their predecessors (Brems
et al., 1991).

Their seminal work, Studies on Hysteria (1955), was a result of

Breuer's consultation with Freud concerning a patient he had been
treating and Freud's subsequent study of hysteria with Jean Charcot.
The consequent influence of psychoanalysis on clinical psychology
was immeasurable.

MODERN ROOTS OF CLINICAL PSYCHOLOGY

Influence of Lightner Witmer

On June 28, 1867, Lightner Witmer, the future "father of clinical

psychology," was born in Philadelphia, Pennsylvania (Reisman,
1981). Following his graduation from the University of Pennsylvania
in 1888, Witmer worked as an instructor of English and history, an
experience that stimulated his interest in psychological problems.
Because he could find no course of study in the United States
related to this interest, Witmer left Pennsylvania in 1891 to study
with Wilhelm Wundt at the University of Leipzig. On earning
his doctorate in 1892 under the supervision of Wundt, Witmer
returned to the University of Pennsylvania where, following in
Cattell's footsteps, he directed the laboratory for
experimental psychology. Besides his university position, Witmer
worked as a psychologist at the Pennsylvania Training School for
Feebleminded Children. In 1896, Witmer laid the foundation for the
future course of American clinical psychology by founding the first
psychological clinic (Reisman, 1976).

The clients of Witmer's clinic were children experiencing learning

difficulties or behavioural disturbances. One of his earliest clinic
cases was referred by a Philadelphia school teacher, Margaret
Maguire, who requested Witmer's assistance in remediating a child
who was a "chronic bad speller" (Reisman, 1976, p.42).

Witmer accepted the challenge and requested several evaluations of

the young boy, including an eye exam. The examination showed
that the child needed corrective glasses, and when they were
supplied, the boy's spelling improved immediately. This case
demonstrates one of Witmer's early influences, the
importance of assessment and diagnosis. Witmer believed that
these practices were essential components to treating learning and
behavioural problems in children and represented practical
applications of psychology.

Subsequently, he referred to this applied field as "clinical

psychology" (Brotemarkle, 1931). Witmer's therapeutic approach
typically involved the use of behavioural interventions to teach
clients new skills and knowledge, a therapy modality he termed
"pedagogical treatment" (Kendall & Norton-Ford, 1982).
Witmer was responsible for initiating many aspects of clinical
psychology. Under Witmer's influence, the University of Pennsylvania
began offering a course of study in clinical psychology in 1904, and
in 1907, he began publishing the first clinical psychology
journal, The Psychological Clinic (Bohart & Todd, 1988). Although
Witmer continued to contribute to the field, not all of his subsequent
work proved equally influential as the work characterized in his
clinic.

Advances in Assessment and Impact on Clinical Psychology

The primary function of clinicians in the United States during the late
19th and early 20th centuries was the assessment of learning
difficulties in children. Interest in child assessment prevailed in
Europe during this period. In 1904, Alfred Binet and Theodore
Simon were asked to develop a method that could reliably
differentiate children with mental retardation from normally
developing children in the schools of France.

This request resulted in the original Binet Simon scale (Binet

& Simon, 1905) as well as the 1908 scale (Binet & Simon,
1908) and its revision (Binet, 1911). The Binet-Simon was an
objective test assessing areas and levels of intellectual deficiency,
and was used to guide special programs of education for children
identified as deficient. Although Binet cautioned that the scale was
not a completely objective measure of innate intelligence, the Binet-
Simon was widely accepted throughout Europe and the United
States.

The Binet-Simon scale and Lewis Terman's American

revision, the Stanford Binet (Terman, 1916), exerted a
profound influence on both the measurement of intelligence and the
development of clinical psychology in the United States (Peterson,
1925).

Witmer, however, failed to accept the utility and popularity of the

Binet scales, a decision that removed him from the mainstream of
clinical psychology. He was alienated further by his rejection of the
prevailing psychoanalytic views of Sigmund Freud that were
introduced and accepted throughout the United States following
Freud's invited address at Clark University in 1909.

That same year, psychiatrist William Healy founded The Juvenile

Psychopathic Institute in Chicago, a child guidance clinic for
juvenile delinquents (Reisman, 1976). Unlike Witmer, Healy
focused on conduct disturbances in children rather than
learning problems. Further, Healy employed the Binet Simon
scales in his assessment of children and adopted Freud's views of
abnormal behaviour. Subsequent child guidance programs were
modelled after Healy's clinic.

Witmer's clinical practices became more closely associated

with school and educational psychology than with clinical
psychology (Nietzel et al., 1994). The demand for clinical services
increased during this period, leading to new professional challenges.
Foremost among these was the need for specialized training
programs for clinical psychologists. Although clinical psychology
programs and internships were developing, no formalized education
was required to engage in clinical activities. Furthermore, the APA
focused on the scientific aspects of psychology and provided
little guidance on emerging issues surrounding clinical
training and practice.

APPLICATION OF PSYCHOLOGY DURING WORLD WAR I

The United States' entry into World War I in 1917 presented

psychology with an opportunity to engage in more clinical activities.
Eager to predict the intellectual and psychological stability of
recruits, the U.S. Army turned to psychology. Robert Yerkes,
president of the APA, was asked to oversee the development of
appropriate screening measures.

The resulting Army Alpha and Army Beta tests were among the
first group of intelligence measures developed (Yerkes,
1921). Army Alpha was designed for literate, English-speaking
adults, while Army Beta was designed for illiterate or non-English-
speaking recruits. The Army Beta Test served as the forerunner of
performance tests of intelligence. An additional measure of this
screening battery was the Psychoneurotic Inventory (also called the
Personal Data Sheet), developed by Robert Woodworth, to detect
abnormalities in behaviour (Woodworth, 1917).

By the end of the war, millions of military personnel had been

evaluated by psychologists. Interest in intelligence and
psychodiagnostics assessment remained quite high, continuing until
the next World War. Another important postwar development was
the recognition of clinical psychology as a distinct discipline.
Although disgruntled clinicians broke away from the more scientific
APA in 1917 to form the American Association of Clinical
Psychology (AACP), this group rejoined the APA in 1919 as
its Section of Clinical Psychology (Fernberger, 1932).
In 1921, according to Hilgard (1987), a new organization called the
Association of Consulting Psychologists (ACP) was
independently founded in New York. This group was notable for its
publication of the Journal of Consulting Psychology and for its
adoption of a code of ethics for professional psychology, the
first organization to do so (Hilgard, 1987).

BETWEEN THE WORLD WARS: CONTINUED GROWTH OF

CLINICAL PSYCHOLOGY

The period between World War I and World War II was notable for
three general trends:

(1) The Continuation and Expansion of Assessment Activities by

Psychologists.

(2) The Entry by Psychologists into The Medically Dominated

Practice Of
Psychotherapy; and

(3) The Increasing Professional Recognition Of The Practice Of

Psychology.

Continued Domination of Psychological Assessment

After World War I, clinicians continued to perform their traditional

child testing role, but also began to do adult testing, probably
because of their wartime experiences with similar activities and
responsibilities.

Psychodiagnostics, intelligence, aptitude, and interest tests

began to flourish. Other measures developed during these years
included the Rorschach Inkblot Test (Rorschach, 1921), the
Strong Vocational Interest Test (Strong, 1931), the Thematic
Apperception Test (Morgan & Murray, 1935), and the Bender-
Gestalt Test (Bender, 1938), all of which are in current use.
Particularly noteworthy was the 1939 development of the
Wechsler-Bellevue Intelligence Scale, an individual measure
of adult intelligence (Wechsler, 1939).

Personality tests were developed widely following the success of

Wood worth's Psychoneurotic Inventory during World War I. The first
comprehensive, empirically derived personality test, the
Minnesota Multiphasic Personality Inventory (MMPI; Hathaway
& McKinley, 1943), was published several years after the Wechsler-
Bellevue Scale. In fact, so many novel testing instruments were
developed during this time that Buras (1938) published the Mental
Measurements Yearbook as a reference for clinicians and
researchers.
Perhaps the most significant development between the wars was the
intro duction of projective tests. Although their roots extended
back before World War I (e.g., Galton, 1879; Jung, 1910, 1918), it
was not until 1921 that projective assessment, grounded in
psychodynamic principles, began to gain in popularity. During
that year, Hermann Rorschach (1921) published
Psychodiagnostics. In this seminal work, the Swiss psychiatrist
outlined his method of using patient responses to ambiguous test
stimuli (i.e., inkblots) to arrive at diagnoses.

Child psychiatrist David Levy brought the Rorschach to the

United States in 1924. It came into prominence during the
1930s, a period of great psychoanalytic influence. Additional
projective tests were introduced during this time, such as the
aforementioned Thematic Apperception Test (Morgan &
Murray, 1935) and the Bender-Gestalt Test (Bender, 1938).

The term projective technique was coined several years later

by L. K. Frank (1939). His article "Projective Methods for the Study
of Personality" offered a rationale for the projective approach and
stimulated research and theoretical efforts related to such
techniques. Psychodynamically based projective assessment grew
rapidly during this decade, resulting in expanded functions for
clinical psychologists.

Growing Role of Psychologists in Treatment

The number of clinical psychologists engaged in the medically

dominated activity of treatment increased in the years between
World War I and World War II. Most clinical psychologists were
working primarily with children's educational problems in child
guidance clinics under the supervision of psychiatrists. Some,
however, were extending their work to children with psychiatric
problems, while others were moving out of the clinic setting into
private practice. Psychologists' role in treatment was a natural
extension of their assessment and consultative functions. Although
psychodynamic theory was associated primarily with the practice of
psychiatry, the writings of Freud and Adler (e.g., Adler, 1930) were
particularly useful to clinical psychologists in their work with
children.

Play therapy techniques derived from Freudian principles

developed during this period (e.g., A. Freud, 1928), as did other
therapies. Carl Rogers began to formulate client-centered
therapy, his therapeutic alternative to psychoanalytic treatment
during these pre-World War II years (Watson, 1953), although his
ideas would not come into prominence until the 1940s and 1950s
(Rogers, 1951). Behaviour therapy, which would not become an
integral part of clinical psychology until the 1960s, was also
beginning to receive some recognition. Interest in behavioural
applications was fuelled by the fear conditioning work of
John B. Watson and Rosalie Rayner (1920) and Mary Cover
Jones (1924).