Handbook of psychology phần 7

346 Clinical Psychology Clinical Psychology (Shakow, 1965). This committee rec-ommended that courses for clinicians should include psy-chotherapy and psychodynamics, with coursework in related areas—forexample,anthropology,medicine,andsociology— germanetotheparticularstudent.Theserecommendationsap-peared to extend the duration of graduate education beyond theboundsofwhatwasseemly,soin1949theAPAheldacon-ference in Boulder, Colorado, to discuss training policies in clinical psychology. The Boulder Conference had 73 attendees, most of whom were intimately involved in the graduate education of clini-cians. It was the first national meeting to consider standards for their doctoral training. Basically, the conference decided to endorse a solid grounding in science and practice, and this scientist-practitioner role for the clinical psychologist came to be called the Boulder model. (It reflected David Shakow’s own background, which included a lengthy research-clinical apprenticeship at Worcester State Hospital in Massachusetts, a personal psychoanalysis undertaken in part to prepare for research in that area, and a career dedicated largely to studies of motor performance and attentional deficits in schizophre-nia, both before and after he became chief psychologist at NIMH.) Despite its endorsement of the scientist-practitioner model, the Boulder Conference also urged graduate schools to be flexible and innovative in their training (Benjamin & Baker, 2000; Raimy, 1950). Of most significance was that psychotherapy or treatment became an essential component in the training of the clinical psychologist. Since it is rare to find unanimity about anything, not all clinicians welcomed this change in their profession. Hans Eysenck (1949), for one, spoke against it. He gave three rea-sons why it would be better for clinicians not to become ther-apists: Treatment is a medical problem; training in therapy reducesthetimeavailablefortraininginresearchanddiagno-sis; and becoming a psychotherapist biases the clinician from studying its effectiveness objectively. His comments, how-ever, had little immediate impact, and most students of clini-cal psychology saw the learning of psychotherapy as the sine qua non of their graduate education. While there was concern about standards and models, there was explosive growth in the profession. From a handful of universities offering graduate training in clinical psychol-ogy before the war, the number grew to 22 by 1947, 42 by 1949. Each of these programs reported it had far more appli-cants than it could accommodate. This interest in clinical psychology was spurred by a growing interest in psychologi-cal matters in the culture through movies, literature, news-paper accounts, art, self-help books, and so on. At the same time, clinical psychologists were beginning a national drive for legal recognition and protection of their field. Within the states, legislators were being asked to enact licensing and certification laws for psychologists. Acertifica-tion law restricts the use of the title “psychologist” by speci-fying the criteria that must be met by those who wish to use it. Alicensing law restricts the performance of certain activi-ties to members of a specific profession. Because some of the activities of clinicians overlap with some of the activities of other professions, the APA favored certification over licens-ing legislation. The first state to enact a certification law for psychologists was Connecticut in 1945; it restricted the title of psychologist to those who had a PhD and a year of profes-sional experience. In 1946, Virginia enacted a certification law for clinical psychologists that required the PhD and 5 years of professional experience. The passage of this legislation often encountered stiff re-sistance from the medical profession. Many psychiatrists, such as William Menninger, respected clinical psychologists and felt they had a major contribution to give to the psychi-atric team through their diagnostic testing and research. Ac-cording to this view, clinical psychologists could even do psychotherapy under medical supervision, but they should be barred from the private practice of treatment because they lacked the keen sense of responsibility felt by physicians for their patients (Menninger, 1950). Recognizing that certification or licensure by the states would be a difficult, lengthy process, it was decided in 1946 to establish a kind of certification by the profession, and thus was created the American Board of Examiners in Profes-sional Psychology (ABEPP). The board consisted of nine APA fellows who served 3-year terms, set and administered standards for professional competence, and awarded diplo-mas that signified professional recognition of the quali-fications of the applicant. At its inception, these standards required the applicant to have: a doctorate in psychology; APA membership; satisfactory moral, ethical, and profes-sional standing; 5 years of professional experience; and pass-ing scores on written and oral evaluations that included samples of the applicant’s diagnostic and therapeutic skills. In 1949, the first ABEPP written examinations were held. (Subsequently, in 1968, this group became the American Board of Professional Psychology, or ABPP). By 1949, it was generally accepted that the roles of the clinical psychologist were psychotherapy, diagnosis, and re-search. Since the VA had been involved in so much of the training of clinicians and was a major employer, clinical psy-chology had gone from being largely a provider of services to children to being largely a provider of services to adults, of whom the majority were males. The membership of the APA had increased to 6,735, and there were 1,047 in the clinical division alone. About 149 graduate departments offered some Subsequent Professional Developments 347 training in clinical psychology to about 2,800 clinical majors. The profession was growing at a rapid and exhilarating pace. SUBSEQUENT PROFESSIONALDEVELOPMENTS In 1918, Leta Hollingworth suggested the creation of a new doctoral degree, the PsyD, which could be awarded to psy-chologists who sought not to be scientists but practitioners of psychology (Hollingworth, 1918). A similar suggestion was made by Crane (1925–1926) with a similar imperceptible response. In 1947, a commission appointed by Harvard Uni-versity published a report recommending that Harvard estab-lish a PsyD program for clinical psychologists (University Commission to Advise on the Future of Psychology at Harvard, 1947). The report included the following statement, which proved to be somewhat prophetic and a bit comical: “If the best universities deliberately dodge the responsibility for training applied psychologists, the training will be attempted there was more to it than that. After the first burst of post-war growth had waned, some universities (e.g., Chicago and Northwestern)haddroppedtheirclinicalprogramsandalmost allcollegeshadfarmoreapplicantsthantheycouldaccept;this alarmed some clinicians into thinking their profession would notbeviableuntiltherewereindependentschoolsforthetrain-ing of clinical psychologists.The alarm proved unjustified, as the number of graduate training programs in clinical psychol-ogyatuniversitieshascontinuedtoincrease.AsofJune2001, some 50 years afterAPAapproval began, 202 programs were approved or regularly monitored for approval. (Courtesy of Tia Scales at the Education Directorate of theAmerican Psy-chologicalAssociation.) In addition, 53 free-standing schools wereproducingclinicians(twowerecounselingprograms).In August 1976, these schools banded together into an organiza-tion of their own, the National Council of Schools of Profes-sional Psychology, in order to ensure that their interests were pursuedandprotected(Stricker&Cummings,1992). The trend toward state certification and licensure of psy- in proprietary schools but under conditions so deplorable that chologists reached something like a conclusion when the universities will either be begged to assume responsibility or blamed for not doing so” (p. 33). However, by the time this report was published, the Harvard psychology department had already acted by spinning off a new Department of Social Relations, which included the psychology clinic and its staff and which continued to offer the PhD. The first institution to offer a PsyD degree was the Uni-versity of Illinois (Peterson, 1992). It began its PsyD program in 1968 as an alternative for clinical graduate students who might find it more appealing than its PhD program.The PsyD program had a greater focus on training for practice and did not require experimental research; instead, the student could present a detailed case history or a documented attempt at clinicalinterventionandbepreparedtodiscussitstheoretical, practical, and research implications. Eventually this program was dropped at Illinois and its leading proponent, Donald Pe-terson, went to Rutgers University to become dean of its Graduate School of Applied and Professional Psychology. (One of the illustrious PsyD graduates of the Rutgers pro-gram was Dorothy W. Cantor, president of theAPAin 1996.) In the meantime, the California School of Professional Psychology opened its doors in 1969, offering a 6-year PhD program. Other universities, such as Baylor and Yeshiva, began to offer PsyD programs, and a number of proprietary schools of professional psychology were established, most of which offered the PsyD. WhatseemedtospurthegrowthofPsyDprogramswasthe Vail Conference held in Colorado in 1973 (Korman, 1974). That conference endorsed the practitioner-training model as an alternative to the scientist-practitioner one. But of course Missouri in 1977 became the last state to enact licensing legislation—though concerns remained about the revocation of laws and legal challenges to them. Clinicians themselves used legal suits to gain admission privileges in hospitals and to be counted as part of medical staffs. Their goals were to compel medical insurance companies to reimburse them for their services and (in 1988 in Welch et al. v. American Psy-choanalytic Association et al.) to force an end to the restric-tions imposed on lay analysts and their training and practice. Often the APA was involved in this litigation, attesting to a growing involvement in professional issues both within that organization and among clinical psychologists. In the days of NIMH training grants to PhD programs in clinical psychology, it was considered a policy failure for graduates to enter into independent private practice. Indeed, most of those PhDs took public-sector jobs, whether in teach-ing, at the VA, or in community mental health centers. That is no longer the case. More and more clinical psychologists are in private practice, and they have promoted the passage of freedom-of-choice legislation, mandating that if insurance companies pay psychiatrists for psychotherapy, they must do the same for clinical psychologists. In a world of managed care, clinical psychologists find themselves competing vigor-ously for their share of the market. To aid third-party payers in determining which psychologists merit reimbursement, a National Register of Health Service Providers was developed by Carl Zimet and others. To be listed in the register, a psy-chologist must hold a state license or certification, have suc-cessfully completed at least 1 year of internship, and must have 2 years of supervised experience in a health setting. 348 Clinical Psychology During the 1970s, the APA was forced to become defini-tive about what constituted a psychological training program. Thiscameaboutwhengraduatesofguidanceorcounselingor sundry other programs demanded to be certified or licensed as psychologists and brought suit if their qualifications were questioned. They asserted, unfortunately correctly, that the courses that went into a psychology education were unspeci-fied. Therefore, the APA made it known that as of 1980 all graduate programs in psychology must require courses in the history and systems of psychology; the biological, social, developmental, and learned bases of behavior; and statistics and research design. Moreover, clinical students were also required to have instruction in psychological assessment and intervention, individual differences and psychopathology, practicum training, and a 1-year full-time internship. So, what does all this suggest, aside from more regulation and specification than anyone would have thought possible or desirable a few years before? First, clinical psychologists were increasing their numbers and becoming a dominant force within American psychology and perhaps elsewhere as well. They were evident in Canada, the United Kingdom, and Scandinavia. Norway, for instance, was training about 100 psychologists a year at the doctoral level. These countries, unlike the United States, had publicly supported health sys-tems, which were major employers of clinical psychologists. Although the United States has continued to emphasize a rather lengthy, and somewhat indefinite, period of graduate educationleadingtothedoctorateforclinicalpsychologists,a variety of other models exist elsewhere. In the United Kingdom, a 3-year program leading to a doctor of clinical psychology degree (D.Clin.Psy.) has emerged. In Germany, Hungary, Mexico, and Spain, the PhD is usually reserved for academiciansand/orresearchers;practitionersofclinicalpsy-chology study in undergraduate-graduate programs lasting up to 6 years, perhaps supplemented by postgraduate training in psychoanalysis or behavior therapy (Donn, Routh, & Lunt, 2000). Believing that it was about time that the largest psychological field of specialization had its own international organization, Routh (1998) and colleagues founded the Inter-national Society of Clinical Psychology in 1998. This organi-zation holds its meetings with various larger international groups, such as the InternationalAssociation ofApplied Psy-chology,theInternationalCouncilofPsychologists,theInter-national Union of Psychological Science, or the European Federation of Professional PsychologyAssociations. (See the chapter by David & Buchanan in this volume for a full de- scription of the international contacts in psychology.) Second, with increasing numbers come divisions and splits. When there are few psychologists, the interests of one or two can be regarded as idiosyncrasies. When there are thousands of psychologists, the interests of 1% or 2% may constitute the beginning of a new field of specialization or a new social grouping. APA membership has increased from about 7,250 in 1950 to 16,644 in 1959 to 30,830 in 1970 to 50,933 in 1980 to about 150,000 in 2000. At one time, a school psychologist was a clinical psychologist who worked in a school setting, but eventually school psychology became a field of specialization in its own right (Fagan, 1996, and the chapter by Fagan in this volume). Similarly there are more and more areas of specialization within clinical psychology that could become separate fields, such as clinical neuropsy-chology, clinical child psychology, and health psychology. This differentiation is probably inevitable, but it is not with-out the possible consequence of fostering less unity among clinicians unless care is taken to ensure cohesiveness. Third, there has been an increasing professionalization within clinical psychology. Until World War II, very few clinical psychologists were involved in private practice. The role of the clinician changed from one of diagnosis and re-search to diagnosis, treatment, and research. Correspond-ingly, along the way from its inception in 1892, the APA’s aim—“to advance psychology as a science”—has changed: “to advance psychology as a science and as a means of pro-moting human welfare” and “to advance psychology as a sci-ence, as a profession, and as a means of promoting human welfare.” As this is being written, the APA membership is being polled on whether “health” should be inserted into the aim of the association. Since many psychologists who ob-jected to the growing professional interests of the APA left it in 1989 to form a more exclusively scientific American Psy-chological Society and since clinical psychologists constitute more than half the APA membership, the professionalization of the APA is not likely to be reversed. (See the chapter by Benjamin, DeLeon, Freedheim, & VandenBos and the chap-ter by Pickren & Fowler, both in this volume.) A concern here is that clinicians not become divorced from their scien-tific roots and function. Treatment interventions can serve to illustrate much of what we have discussed, and it is to that topic that we turn. TREATMENT INTERVENTIONS By World War II, many of those who had broken with Freud (such as, Adler, Jung, and Rank) established personality the-ories, schools, and therapeutic systems of their own that were unified by the importance they ascribed to unconscious moti-vation in determining psychopathology. These “psychody-namic” psychotherapies were augmented by those of Horney, Sullivan, and Fromm, who, impressed by social forces and Treatment Interventions 349 relationships, did much to make psychotherapy responsive to changing conditions. Among those just mentioned, Rank and Fromm were not physicians, and both had been trained in Europe. As time went on, Erik Erikson’s (1950, 1959) inte-gration of a psychosocial theory of development with Freud’s psychosexual theory opened psychoanalysis to the concepts of many of the rebels: an oral stage of trust versus mistrust; an anal stage of autonomy versus shame and doubt; a phallic stage of initiative versus guilt; a latency stage of industry ver-sus inferiority; an adolescent stage of identity versus identity diffusion; a young-adult stage of intimacy versus isolation; a middle-adult stage of generativity versus stagnation; and an old-age stage of integrity versus despair. The first American psychologist to develop a form of psychotherapy that was highly influential was Carl Rogers (1902–1987), who received his PhD in 1931 from Teachers College, Columbia University, where Leta Hollingworth su-pervised his clinical experiences with children. He continued clinical work with children until 1940, when he left to be-come a professor of psychology at Ohio State University and later the University of Chicago. By then his clinical work was mostly with college students. Rogers was heavily influenced by social worker Jesse Taft and especially by child psychia-trist and former school psychologist Frederick Allen, who in turn were much affected by what they had learned from Otto Rank. Originally, Rogers called his system of psychotherapy “nondirective” (Rogers, 1942). Later he called it “client-centered therapy” (Rogers, 1951), and eventually he and his followers referred to it as “person-centered.” No matter what it was called, it was distinguished by Rogers’s willingness to subject it and its practitioners to scientific scrutiny. Rogers pioneered the recording of therapy sessions so that they could be analyzed in detail for purposes of research, su-pervision, and training. He argued that psychotherapy could become a science and believed there was a discoverable orderliness as the sessions continued to a successful end. Hypothesis testing was one of the hallmarks of his approach, and he tried to make explicit what conditions were essential for personality change: the therapist’s possession and mani-festations of unconditional positive regard, accurate empathy, genuineness, and congruence (Rogers, 1957). A consider-able research effort was undertaken to measure these attrib-utes and determine if they indeed were related to effective therapy. The results of 20 years of research led to the conclu-sion that the relationship between these attributes and positive change in patients remained in doubt (Parloff, Waskow, & Wolfe, 1978). This period, extending from the 1930s through the 1950s, was the high-water mark in the prestige of psychotherapy, especially psychodynamic psychotherapy. In the 1960s, psychotherapy came under attack from four “revolutions” or “movements”: (1) community psychology, which argued that psychotherapy was futile and not provided to those most in need of it, and that clinicians should direct their efforts to-ward preventing psychopathology through bringing about changes in deleterious social policies and conditions (see the chapter by Wilson, Hayes, Greene, Kelly, & Iscoe in this volume); (2) humanistic psychology, which emphasized the importance of present experiences, ongoing events, and confrontational approaches in groups, as contrasted with traditionalapproachestotheindividual’sexplorationandinte-gration of the past; (3) the increasing use of drugs, by physi-cians and by free spirits, to alter moods, regulate behaviors, and enhance self-esteem and experiences; and (4) behavior therapy. It was the English clinician Hans Eysenck who was less than enthusiastic about clinical psychologists becoming psy-chotherapists and raised the question of whether scientific studies had demonstrated the effectiveness of psychotherapy (Eysenck, 1952). Culling the research and pulling together a motley group of studies, he concluded that they failed to demonstrate that control groups were significantly less likely to improve than groups that received psychotherapy. Al-though psychotherapists strongly disagreed with his conclu-sion and manner of arriving at it, the fact remained that it was their responsibility to prove otherwise. In South Africa, psychiatrist Joseph Wolpe made use of Hullian concepts and learning principles to develop proce-dures that would reduce neurotic symptoms. In essence, he sought to elicit responses, such as relaxation, that would be incompatible with or inhibit a symptom, such as anxiety or fear. (This is similar to the previously discussed decondition-ing or reconditioning approach of Mary Cover Jones.) After coming to the United States to spend a year at Stanford Uni-versity’s Center for Advanced Study in the Behavioral Sci-ences, Wolpe (1958) published a book, Psychotherapy by Reciprocal Inhibition, which was hailed by Eysenck as a promising advance in effective treatment. Wolpe took a position at the University of Virginia Med-ical School, and in 1962, along with Salter and Reyna, spon-sored a conference there that got the behavior therapy ball rolling (Wolpe, Salter, & Reyna, 1964). The clinical journals were soon filled with a variety of studies, many of them quite ingenious, demonstrating the effectiveness of behavioral approaches. One of the first of these studies was one by Peter Lang and David Lazovik (1963) of college students who were identi-fied by a questionnaire, the Fear Survey Schedule, as being afraid of snakes. The students were then given a Behavioral Avoidance Test (BAT) in which they were placed in a room 350 Clinical Psychology with a nonpoisonous snake and encouraged to go as close as they could to it and, if they were willing, to pick it up. Each student completed a Fear Thermometer, a rating of how much fear was experienced. The therapy consisted of devising a hierarchy of imagined scenes involving snakes, with scenes arranged from neutral to the most fear arousing. Then the stu-dent was taught to relax, asked to imagine the least fear-arousing scene, asked to relax, and so on until the student became able to imagine scenes higher and higher in the hierarchy without feeling anxious, a procedure known as “systematic desensitization.” Finally the BAT and Fear Ther-mometer were readministered, and it was found that these students had become significantly less afraid of snakes than randomly assigned students in a control group. Critics of such analogue studies noted that the results might have been less impressive had neurotic patients and their fears been tested. Nevertheless, later research supported the effectiveness of desensitization procedures of various kinds in dealing with a variety of symptoms. For example, exposure with response prevention (allowing a patient to experience what happens when a compulsion is not permitted) is a kind of in vivo de-sensitization that has come to be regarded as appropriate in the treatment of obsessive-compulsive disorders (Foa & Goldstein, 1978). Another major behavioral approach to treatment is behav-ior modification, or applied behavior analysis, which comes from the experimental work and writing of B. F. Skinner (1938).AlthoughSkinner’sexperimentalworkwasalmostex-clusivelywithanimals,neitherhenorhisfollowershavebeen reluctant to apply his principles to humans, including clinical populations (Skinner, 1971). Sidney Bijou, who served as di-rector of clinical training when Skinner chaired the psychol-ogy department at Indiana University, pioneered in the use of operant conditioning with persons with mental retardation (Bijou, 1996).Applied behavior analysis has become a main-stay of psychological treatment of persons with mental retar-dationandpervasivedevelopmentaldisorderssuchasautism. It has been used to teach social and self-help skills like dress-ing, toileting, and proper table manners, as well as dealing withdefiant,aggressive,andself-injuriousbehaviors. Nathan Azrin at Anna State Hospital in Illinois demon-strated the utility of behavior modification with adult mental patients (Ayllon & Azrin, 1968) and the usefulness of token economies, in which the performance of desired behaviors earns tokens that can be exchanged for rewards (much as oc-curs in our society where money is given for work). Exten-sive research on token economies in mental hospitals was done by Gordon Paul and his colleagues (e.g., Paul & Lentz, 1977). Their research with long-term, regressed, and chronic schizophrenics focused on developing such practical behav-iors as making their beds, behaving well at mealtime, partic-ipating in the classroom, and socializing with others during free time. Paul’s research showed that his program of behav-ior therapy and milieu therapy (moral treatment) improved symptoms when compared with the results of routine hospi-tal management, and that behavior therapy was more effec-tive than milieu therapy alone in bringing about the desired changes. The principal assessment procedure advocated by Skin-nerians is the functional analysis of behavior: a determination of what may be rewarding or maintaining undesirable behav-iors and what may serve to reward or establish the perfor-mance of behaviors that are desired. A functional analysis requires observation, preferably in the setting where the behaviors are to be modified, in order to assess the frequency of their occurrence and their consequences. Gerald Patterson (1974) pioneered in the use of direct behavioral observations in natural settings to record the behavior of aggressive chil-dren and their families in their homes. His research led to a theory of coercion in which the child is seen as both the de-terminer and victim of episodes of escalating violence in the family and to controlled research on the behavioral treatment of child aggression. Another major category of behavior therapy is cognitive therapy or cognitive behavior therapy. Two pioneers in this area were George A. Kelly and Albert Ellis. Kelly (1955) viewed his clients as resembling scientists in their attempts to make sense of the world around them. He used a diagnostic procedure called the Role Construct Repertory Test to ascer-tain their beliefs about themselves and others. The therapist then negotiated with the client about what changes might be desired and how these could be accomplished. Using fixed role therapy, the client was encouraged to rehearse or play-act the new role, first with the therapist, then with others. Albert Ellis (1958) developed rational emotive therapy; here the patient’s opinions and attitudes are explored for irrational beliefs (“I can’t make a mistake and must be perfect. My feel-ings are out of my control”), which the therapist then at-tempts to make more reasonable and rational. Martin Seligman (1975) stimulated much research on the treatment of depression. Based upon previous research with dogs that were prevented from avoiding or escaping an elec-tric shock, he noted that when they were in a situation where the shock could not be avoided, such animals simply gave up and endured the pain. They had learned to be helpless, and perhaps, he reasoned, the same process of ineffectiveness and feeling unable to cope occurred among humans who were depressed. This had obvious treatment implications, but fur- ther study indicated the need for the concept of attribution ... - tailieumienphi.vn