Recent History of Clinical Psychology

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Recent History of Clinical Psychology
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Lecture Preview

• Clinical Psychology Immediately after World War
  II
• The Rise of Alternatives to the Psychodynamic
  Approach
• A New Training Model Emerges The Vail Model and
  Professional Schools of Psychology

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Clinical Psychology Immediately after World War
II

• Following the war, over 40,000 veterans were
  hospitalized. Psychiatrists were unable to meet
  the treatment demands of these huge numbers of
  veterans. It resulted in increase in the number
  of clinical psychologists.
• Veterans Administration hospitals became the
  largest single employer of clinical psychologists
  in the USA.

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• Many others preferred to focus on the science of
  psychology in academic environments.
• There was a division between science and practice
  from the beginning.

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Training

• The APA Committee on Training in Clinical
  Psychology recommended that training be
  comprehensive in research, treatment, and
  assessment.
• In 1948, the APA began to carefully evaluate and
  accredit doctoral training programs. Psychology
  departments in universities across the USA had a
  freedom to determine their training programs.

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The Boulder Conference

• Prior to 1949, psychology departments in
  universities across the country had a great deal
  of freedom to determine how they should run their
  training programs.
• The Boulder Conference was called (convened) in
  1949.
• It was the first national meeting to discuss
  standards for doctoral training.

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The Boulder Conference

• This training model stated that a PhD degree in
  psychology from a universitybased training
  program plus a one-year clinical internship were
  necessary for adequate preparation.
• The Boulder model became known as the
  scientist-practitioner model.
• Clinical psychologists should be competent in
  both conducting research and providing
  professional services such as psychotherapy and
  assessment.

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Post-Boulder Conference Events

• Additional conferences convened to discuss the
  pros and cons of the clinical psychology training
  model.
• The growth of clinical psychology during the
  1950s was enormous.
• APA membership more than doubled during the
  1950s.

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Post-Boulder Conference Events

• In 1952, American Psychiatric Association
  published diagnostic categories in Diagnostic and
  Statistical Manual (DSM - I).
• In 1953, the first attempt to outline ethical
  principles for psychologists was published by the
  APA.

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The Rise of Alternatives to the Psychodynamic
Approach

• During the first half of the 20th century, the
  psychoanalytic approach founded by Freud and the
  behavioral conditioning approach founded by John
  Watson.

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The Rise of Alternatives to the Psychodynamic
Approach

• During the 1950s, 1960s, and 1970s, many new
  approaches were developed as alternatives to the
  traditional psychodynamic approach
• humanistic,
• behavioral,
• cognitive-behavioral, and
• family systems approaches

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The Rise of Alternatives to the Psychodynamic
Approach

• In the 1960s, the community mental health
  movement rose. Psychotropic medication in
  treating mental illness introduced. These two
  events had powerful influences on clinical
  psychology.

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The Behavioral Approach

• The behavioral approach applies theories of
  learning and conditioning to the understanding of
  human behavior and the treatment of problems.
• It had its roots in the conditioning research of
  Ivan Pavlov in Russia. The behaviorism and
  learning theory in the USA conducted by
• John Watson, Edward Thorndike, Clark Hull, John
  Dollard, Neal Miller, and B. F. Skinner.

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The Behavioral Approach

• Behaviorism became an attractive alternative to
  medical and psychodynamic strategies during the
  1950s and 1960s.
• Some research-oriented clinicians felt that
  behavior therapy proved more effective in
  empirical research trials relative to traditional
  theories and methods such as psychoanalysis.

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The Behavioral Approach

• The behavioral approach was viewed by many as
  more scientifically based than the psychodynamic
  approach.
• Behavioral techniques were more readily
  operationalized to allow for research and
  statistical analysis. It was easier to measure a
  person had a panic attack than measuring
  constructs such as the id, transference, or
  unconscious conflicts.

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Pavlov (18491936)
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The Behavioral Approach

• Behavior therapy approaches to treatment were
  developed in South Africa by Joseph Wolpe (1915 -
  1997). He developed systematic desensitization to
  treat phobias.

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The Behavioral Approach

• Behavior therapy was well suited to the Boulder
  model because clinical psychology training was
  designed to emphasize both the science and
  practice.
• The behavioral approach was well suited to the
  social and political influences of the time. It
  was an optimistic notion that we could create a
  more perfect society using social engineering and
  conditioning techniques.

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The Behavioral Approach

• There are various types of behavior therapy such
  as applied behavioral analysis, social learning
  theory-based treatment of Bandura and CBT.
• Their commonality is that most problematic
  behavior is learned and can be altered through
  the use of learning principles.
• Treatment methods are scientifically based
  procedures and can be objectively used and
  evaluated.

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The Cognitive-Behavioral Approach

• became popular during the 1970s. Many behavioral
  researchers and clinicians admitted a number of
  significant limitations in their model. The
  approach ignored the contributions of thinking
  and attitudes in human behavior.

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The Cognitive-Behavioral Approach

• Albert Elliss Rational-Emotive Therapy
• Aaron Becks cognitive treatments for depression
  
• the cognitive restructuring work of M. Mahoney
• the stress inoculation work of Meichenbaum
• the self-efficacy work of Bandura
• led the integration cognitive approaches with
  behavioral approaches.

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Aaron Beck (1921- )
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The Cognitive-Behavioral Approach

• Ellis REBT focuses on to alter the patients
  irrational beliefs about themselves and others.
• Becks cognitive approach focuses on to alter
  maladaptive thought patterns and developing more
  adaptive ways of thinking. Depressed people tend
  to view themselves, others, and the world as more
  negative.
• Meichenbaums self-instructional approach uses
  self-talk to alter problematic thinking and
  behavior..

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Their commonalities are

• that learning and behavior are cognitively
  mediated by attitudes and attributions.
• that the role of the therapist is to serve as a
  coach and educator in assisting the alteration of
  maladaptive cognitive processes and behavior.

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The Humanistic Approach

• employed philosophy, existentialism, and theories
  of human growth and potential.
• It focused on the patients experience or
  phenomenology.
• It offered warmth, empathy, and unconditional
  positive regard in psychotherapeutic
  interactions.

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The Humanistic Approach

• During the 1950s and 1960s, the humanistic
  approach gained common acceptance.
• Psychodynamic and behavioral views perceived the
  human nature as negative. The humanistic school
  accepted the more optimistic and approval views.
• The humanistic approach became known as the third
  force following the psychodynamic and behavioral
  approaches.

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The Humanistic Approach

• It was strongly influenced by philosophy and the
  existential approach. The existential approach
  became popular after World War I and in response
  to Nazi Germany during World War II.
• Kierkegaard, Nietzsche, Sartre, Buber, and
  Heidegger were existantialists.
• This approach focused on the meaning of life.

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The Humanistic Approach

• American psychologist Rollo May and psychiatrist
  Irvin Yalom helped to popularize the existential
  approach to humanistic therapy in the USA.
• Psychoanalytic writers such as Hans Kohut and
  Otto Kernberg have integrated some of the
  humanistic perspective into their writing.
• Carl Rogers, Abraham Maslow, Frederick Perls,
  Victor Frankl contributed to the development of
  the humanistic approaches to psychotherapy.

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Their commonalities are

• that humans are able to be consciously reflective
  and have the ability to experience
  self-determination and freedom. Thus, therapists
  must be able to fully understand a persons
  perception.
• that humans struggle toward growth and are not
  trying to maintain homeostasis by satisfying
  various primitive needs and conflicts.

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Existantialists

• Sartre Kierkegaard
  Nietzsche

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Their commonalities are

• that defended a belief in free will and regarded
  human behavior as not just a by-product of early
  childhood experiences or only conditioned
  responses to the external environment.
• that is person-centered with maximum respect for
  the individual and his or her experiences.

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Carl Rogers (1902-1987)

• The client-centered approach of Carl Rogers
  became the most influential humanistic therapy.
• The approach emphasizes empathy,
• unconditional positive regard, congruence,
• intensive active listening, and support to
  reach full human potential.

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The Family Systems Approaches

• tend to use the whole family in understanding and
  treating problematic feelings and behavior.
• Prior to the 1950s, the family members of the
  identified patient were left out of the treatment
  and not viewed as potentially active agents of
  dysfunction and recovery.
• During the 1950s, 1960s, and 1970s, the family
  systems approach became popular.

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The Family Systems Approaches

• Therapists observed that patient functioning
  often worsened when the patient interacted with
  family members. Therefore, all family members
  were treated together.
• The family systems approach emerged from the
  Bateson Project during the 1950s. Gregory
  Bateson, an anthropologist, was interested in
  communication styles, collaborating with Jay
  Haley to examine communication styles such as
  double-bind communication. Double-bind messages
  include impossible-to-satisfy requests.

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The Family Systems Approaches

• Jay Haley later joined with Salvador Minuchin to
  develop the structural family therapy model and
  focused on family boundaries and generational
  hierarchies.
• Haley, in the 1970s, founded the Washington
  Family Institute where his wife, Cloe Madanes,
  developed the strategic therapy model. Strategic
  therapy uses paradoxical intention.

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• In Europe, Maria Selvini-Palazoli and colleagues
  founded the Milan Associates to treat families
  confronted with anorexia nervosa in a family
  member.
• Murray Bowen used psychoanalytic theory in their
  application of family therapy.

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The Family Systems Approaches

• Carl Whitaker and Virginia Satir focused on
  experiential models.
• Nathan Ackerman and Salvador Minuchin developed
  structural family therapy and focused on family
  boundaries and generational hierarchies.

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The Family Systems Approaches

• While there are various types of family
  therapies, commonalities are
• a focus on the role of the whole family system in
  producing and maintaining problematic behavior,
• communication patterns associated with family
  problems,and
• ongoing maladaptive relationship patterns among
  family members.
• Intervention at the family level rather than at
  the individual level became the goal of these
  treatment strategies.

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Psychotropic Medication

• Biological treatments and medications such as
  opium, insulin, and electric convulsive therapy
  (ECT) were used to treat mental illnesses during
  the early and mid part of the 20th century.

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ECT
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• Clinical Psychology Immediately after World War
  II
• Boulder Conference in 1949, standards for
  doctoral training, scientist-practitioner model.
• Alternative psychotherapies rose to the
  Psychodynamic Approach

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Psychotropic Medication

• In 1950s, the effective medications were
  developed to treat severe disorders such as SCH
  and bipolar illness. It was by accident.
• In 1952, Jean Delay gave the chlorpromazine
  Largactil to patients. They found that
  schizophrenic patients experienced fewer
  hallucinations and delusions.

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Psychotropic Medication

• Benzodiazepines (such as Diazem) were found in
  the 1960s to be effective in reducing anxiety.
• The prophylactic use of neuroleptics increased
  the possibility of community residence and
  decreased the demand for hospitalization. There
  was a trend to deinstitutionalize for
  schizophrenic patients.
• The increasing use of medication to treat
  psychiatric problems gave the leadership role
  physicians.

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Psychotropic Medication

• Today, about 20 to 30 of all medications
  prescribed are related to depr and anx.
• Psychologists obtained prescription privileges in
  Louisiana, New Mexico and Guam.

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Community Mental Health Movement

• During the period of deinstitutionalization,
  patients needed outpatient services to adjust to
  the society, obtain employment, and cope with the
  stresses of life and social demands. Interest in
  the prevention of mental illness as well as the
  social factors that contribute to mental illness
  such as poverty, homelessness, racism,
  unemployment, and divorcedeveloped community
  mental health movement.

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• The community mental health clinics opened
  throughout the USA. Psychologists provide a wide
  range of professional services in these clinics.

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The Integrative Approaches

• After the explosion of new theories and
  approaches during the 1950s, 1960s, and 1970s,
  many researchers and clinicians felt dissatisfied
  with one particular theory. Each school such as
  behavioral, CBT, humanistic, family systems,
  psychodynamic developed their own philosophy or
  worldview.

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The Integrative Approaches

• Many psychologists felt dissatisfied with one
  particular theory. During the late 1970s and
  early 1980s, many professionals sought to
  integrate the best.
• Research was unable to demonstrate that any one
  treatment approach or theoretical orientation was
  superior relative to the others. Majority of
  clinicians identified themselves as being
  eclectic or integrative.

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The Integrative Approaches

• Dollard and Miller (1950) tried to understand
  psychodynamic concepts through behavioral or
  learning theory language.
• Jerome Frank examined the commonalities of
  various methods and found that they all include
  instilling hope in the patient, encouraging
  improved morale and understanding of self and
  others, a healing setting (e.g., psychotherapy
  office), and supporting change outside of the
  treatment environment.

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The Integrative Approaches

• Others focused on the nature of the professional
  relationship as being a common curative factor in
  all types of therapies.

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The Biopsychosocial Approach

• Since the 17th century and the influence of
  Descartes and Newton, theories of health and
  illness have tended to separate the mind from the
  body. Western medicine view sickness as being
  influenced either by biology, such as genetics
  and neurochemical imbalances, or by the mind,
  such as personality and interpersonal conflicts.

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The Biopsychosocial Approach

• During the last half of the 20th century,
  advances in medicine, science, psychology,
  sociology, ethnic and minority studies have
  provided evidence for interactive
  multidimensional influences on health and
  illness.

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The Biopsychosocial Approach

• New discoveries in genetics and neurochemistry,
  such as neuroimaging, have hardened the
  contribution of biology to emotion and behavior.
  The effectiveness of psychotropic medications
  provided evidence to the biological influences
  impacting behavior.

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• The new theories provided evidence to
  psychological and social factors influencing
  health, illness, and behavior. The community
  mental health movement demonstrated the influence
  of social, cultural, and economic factors.

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The Biopsychosocial Approach

• emerged during the late 1970s. In 1977, George
  Engel published a paper that proposed the
  biopsychosocial approach as the model of
  understanding and treating illness. The approach
  suggests that physical and psychological problems
  are likely to have a biological, psychological,
  and social element that should be understood in
  order to provide effective intervention
  strategies.

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The Biopsychosocial Approach

• The biological, psychological, and social aspects
  of health and illness influence each other.
• When designing treatment and prevention
  interventions, an understanding of these
  interactions should be taken into consideration.

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The Vail Conference

• A turning point in the training of clinical
  psychology occurred during the 1973 Vail
  Conference.
• The Conference aimed to discuss how training
  could be altered to accommodate the changing
  needs of both clinical psychology students and
  society.

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The Vail Conference

• In addition to the Boulder or scientist-practition
  er model, the Vail or scholar-practitioner model
  was an alternative.
• This model suggested that clinical training could
  emphasize the delivery of professional
  psychological services while minimizing research
  training. Graduate training need not occur only
  in university psychology departments but could
  also occur in professional schools of psychology.
  

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The Vail Conference

• The Conference approved the PsyD (or doctor of
  psychology) degree as an alternative to the PhD
  degree.

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Salt Lake City Conference

• During 1987, the National Conference held another
  meeting to examine how training models best fit
  the needs of students, society, and the
  profession.

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Salt Lake City Conference

• This Conference approved the notion that all
  graduate training in clinical psychology,
  regardless of the degree (PhD or PsyD) or setting
  (university or professional school), should
  include a core curriculum containing courses such
  as research methods, statistics, professional
  ethics, history and systems, psychological
  assessment, and on the biological, social,
  cognitive, and individual difference bases of
  behavior.

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Salt Lake City Conference

• The Conference stated that all APA accredited
  programs should at least be affiliated with a
  regionally accredited university. This measure
  was passed in order to maintain better control
  over the professional schools. But, this
  recommendation has been ignored. The majority of
  professional schools of psychology are still not
  associated with any university.

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New training model

• Clinical scientist model is a more
  research-oriented and scientific approach to
  training relative to Boulder and Vail models. It
  developed in the 1990s.

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Michigan Conference on Postdoctoral Training

• The APA accredits and provides detailed
  guidelines for graduate and internship training,
  no APA guidelines have been provided for
  postdoctoral training.
• The Michigan Conference developed guidelines and
  plans for control and regulation of postdoctoral
  training.

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Michigan Conference on Postdoctoral Training

• Recommendations included
• the completion of APA accredited doctoral and
  internship training programs prior to admission
  to accredited postdoctoral training programs
• at least two hours per week of face-to-face
  supervision by a licensed psychologist and
• a systematic evaluation mechanism for examining
  the trainees.

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The rise of Empirically Supported Treatments

• Empirically supported treatments are
  well-established treatment approaches.
• Standards for empirically supported treatments
• They have received significant research support
  demonstrating their efficacy using between- group
  design or single-case design methods.

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Empirically Supported Treatments

• Results must have demonstrated superiority to
  placebo or other treatments.
• Experiments must have used enough subjects.
• They must have used treatment manuals.
• The effects must be found by two independent
  researchers.

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Empirically Supported Treatments

• Examples
• Exposure treatment phobia, PTSD.
• CBT headache, panic, bulimia, irritable bowel
  syndrome
• Insight-oriented dynamic therapy depression,
  marital discord.

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Evidence-based practice

• Evidence-based practice attempts to integrate the
  best available clinical research with quality
  clinical expertise to help the unique individual
  seeking professional services get his/her needs
  met.

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Significant recent events

• 1970 DSM II published
• 1973 Vail conference,
• 1980 DSM III published
• 1981 APA ethical standards revised
• 1982 Health psychology defined
• 1985 ???????
• 1987 DSM III-R published
• 1987 Salt Lake City conference

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Significant Recent Events

• 1988 American Psychological Society founded
• 1992 Michigan Conference
• 1994 DMS IV published
• 2002 APA ethics code revised
• 2002 New Mexico allows psychologists
  medication prescription authority

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Present Status

• Diversity in gender, culture, ethnicity,
  language, religion, sexual orientation, physical
  ability and disability, and the entire spectrum
  of individual differences has been important for
  the practice.
• Training itself is undergoing significant
  changes.
• The gender distribution of clinical psychologists
  has changed from being mostly men to being mostly
  women.

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Present Status

• Economic factors in health care are altering the
  field. Significant reductions in funding
• Solo independent practice may become less
  attractive as a career option in the future.
  Clinical psychology has expanded beyond the
  mental health field into the general health care
  and preventative health care fields.

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