READINGS IN CLINICAL PSYCHOLOGY EDITED BY R. D. SAVAGE Lecturer in Applied Psychology, University of Newcastle upon Tyne and Honorary Psychologist, United Newcastle upon Tyne Hospitals and Newcastle upon Tyne Regional Hospital Board P E R G A M ON P R E SS OXFORD · LONDON · EDINBURGH . NEW YORK TORONTO - PARIS · BRAUNSCHWEIG Pergamon Press Ltd., Headington Hill Hall, Oxford 4 & 5 Fitzroy Square, London W.l Pergamon Press (Scotland) Ltd., 2 & 3 Teviot Place, Edinburgh 1 Pergamon Press Inc., 44-01 21st Street, Long Island City, New York 11101 Pergamon of Canada, Ltd., 6 Adelaide Street East, Toronto, Ontario e Pergamon Press S.A.R.L., 24 rue des Écoles, Paris 5 Vieweg & Sohn GmbH, Burgplatz 1, Braunschweig Copyright © 1966 Pergamon Press Ltd. First edition 1966 Library of Congress Catalog Card No. 66-14652 2479/66 FOREWORD IN THE last few decades clinical psychology has begun to make significant con- tributions to our understanding of human behaviour. The territory scanned by the modern clinical psychologist is varied and extensive. It impinges at one extreme on problems that demand some knowledge of neurology, physiology or genetics for their solution and at the other of psychological development, the classification of psychiatric disorders and the complexities of psychiatric treatment. The literature relating to these many facets of the subject is widely scattered and the retrieval of information from the growing multitude of journals is fast becoming an unmanageable problem. In such a situ- ation, a judicious selection of scientificpapers illustrating the approach of the subject to a wide range of questions, can serve a valuable purpose. However, although the papers brought together in this volume by Dr. Savage cover a wide span, they clearly illustrate certain contributions of clinical psychology that are distinctive among disciplines concerned with human behaviour: its emphasis on the development of reliable and valid measures of behaviour, and the skilful, expert use of modern statistical techniques for the analysis of data. The philosophy underlying the approach of psychology to the problems of the clinic was epitomised in Thorndike's dictum, "Whatever exists, exists in some quantity, and can in principle be measured. " This probably over- simplified matters in that a premature insistence on quantification at all times, will, in a relatively young discipline, sometimes stultify thought. But there can be little doubt that the influence exerted by clinical psychologists' insistence on measurement has, in the past two or three decades been a largely benificent one. It has helped to import empiricism, objectivity and clarity into spheres of work where they were much needed. And if the scientific qual- ity of contributions in psychiatric journals has risen during the past 20 years, some of the credit for the change must go to clinical psychology. This collection of papers should help to make the subject known to students and practitioners of psychology, social science and medicine alike. It deserves its place in undergraduate and graduate education in all these areas. For although its scientific achievements have, in a sense, only recently begun, clinical psychology, through its permeation with the discipline of mathemat- ics, exemplifies in a more impressive way than some older behavioural studies the successful application of modern scientific method in the reso- lution of complex problems. MARTIN ROTH vii PREFACE Readings in Clinical Psychology represents a predominantly Anglo-American text on clinical psychology. It would be impossible to introduce the book without first expressing my sincere gratitude to all the authors who have contributed to it and the publishers who have allowed material to be reproduced. Individual acknowledgements are made in the text. I hasten to add that any limitations which the book has—and I realise that there are many—are in no way the responsibility of the contributing authors. Individual writers have expressed their views in the appropriate chapters and, as editor, I have not modified them, but the choice of articles— or should I say, the absence of papers of import, hangs on my head. I do not claim to have covered all areas of clinical psychology. I do not even claim to have exhaustively tapped the areas included. I hope to have col- lected representative papers of some of the major areas of interest to psycho- logists involved in applied work and research in the clinic. This book attempts to adequately sample recent advances in clinical psychology and, at the same time, pay homage to the best of the traditional work. The selection of papers stresses the importance of experimental and academic psychology as the basis of clinical psychology, and the need for behavioural research. It provides an introduction to the major tools and techniques needed by the clinical worker interested in scientific mea- surement, treatment and research into behaviour—normal and abnormal. There are five major sections in Readings in Clinical Psychology. In the first, the history and role of clinical psychology is briefly discussed. Then follow sections devoted to the measurement of individual differences, treatment techniques, psychometric and statistical considerations and, finally, diagnostic and research problems. The latter includes articles on children, neuroses, psychoses, brain damage, old age, animal behaviour and drugs. The papers selected are both reviews and original investigations intended for readers with a sound knowledge of psychology. They stress the academic scientific origins of applied psychology, but an attempt has been made to be comprehensive in terms of topics and approaches. Though primarily intended for postgraduate applied psychologists in the clinical arena, they should be of value to all applied psychologists in the educational, indus- trial and clinical fields. The book should also be suitable for senior under- graduate and postgraduate psychologists in universities, clinics, hospitals, schools and industry as well as to graduates in related disciplines such as education, medicine and the social sciences. Finally, some people consider "Readings-type-edited books" of little value and, to say the least, the easy or the coward's way out. I can only reply that for the scope desired when I thought of a book on clinical psycho- lb CP ix χ PREFACE logy I know of few psychologists, if any, who could have written with such scholarship on the wide variety of topics envisaged and presented here. I would certainly not claim, nor indeed have dared, to have done so. I realise that books are not enough for the clinical psychologist. One is reminded of the famous medical teacher and practitioner, Osier, who said that to study the phenomena of disease without books is to sail in an uncharted sea, while to study books without patients is not to go to sea at all. _ _ R. D. SAVAGE CHAPTER 1 Clinical Psychology R. D. SAVAGE Department of Psychological Medicine, University of Newcastle upon Tyne, England MUCH has been written, and even more said, about the role of the clinical psychologist. Is he a lay psychotherapist, or is he just a diagnostician, an I.Q. recordist? For reasons numerous and intricate, clinical psychologists have adopted a multitude of roles. No formal definition could indicate with any accuracy the variety of different functions which they do or should fulfil. They serve universities, hospitals, children's clinics, prisons, "coun- selling" units, government agencies and the armed forces, to name a few. One thing, however, clinical psychologists do have in common is a basic knowledge, usually in the form of a first degree in psychology. This leads me to feel that the roots of clinical psychology lie in basic academic psycho- logy. The distinctive contributions which the psychologist can bring to applied problems derive from his academic training in psychology. The develop- ment of standardised, reliable and, above all, valid measures of cognitive and personality characteristics, the increase in our understanding of per- ception and learning, derive from our work and training as psychologists. The application of scientific attitudes and methods to problems of human behaviour—normal and abnormal—epitomise the development and teach- ing of academic psychology. Why all this as a universal prerequisite to training in clinical psychology, if it is not to be used there? Is academic psychology a valid pre-clinical requirement? I think so, though many psychologists act as though it were not. Instead of behaving like a trained psychologist, we see clinical psychologists adopting the role of well-meaning, but misguided, laymen, oblivious to the value of their three or four years university training in the clinic or hospital. I am not advocating the dynamic rather than the atomistic approach to human bevaviour, nor vice versa. I am simply arguing for a sound, rigorous, scientific, and at the same time humane role by the clinical psychologist. I am not suggesting the clinician should become a basic experimental psychologist, but an applied experimental psychologist. I do not say he should just diagnose or just treat or just do research. He may and should do any one or all three of the above. The crucial point is that he should approach the problem with psychological knowledge and techniques—well 3 4 INTRODUCTION standardised, reliable and valid tests for diagnosis, sound experimentally based techniques for treatment, and a good knowledge of research problems and techniques—not just clinical intuition and a well-meaning attitude. The latter, though important, are not the prerogative, nor the unique contri- bution of the psychologist in the hospital or clinic. The psychiatrist, the social worker, the educationalist have them and also bring their own training and techniques to the aid of the patient; the psychologist must do the same to justify his existence. At the same time, it must be realised that the task of the clinical psychologist is a difficult one, because he has to confront patients. He is unlike, for example, biochemists, or patho- logists, who are concerned only with "specimens". The clinical psycho- logist on the other hand has to be in contact with patients and this un- avoidable relationship complicates his work and its interpretation, and introduces the "magic elements"—suggestion, transference and the like. He must, therefore, also receive training and experience in this field. The traditional gap between the academician and the applied psychologist is narrowing, and indeed, for the benefit of both, it must. The role of the clinical psychologist is inextricably bound up with the history of psychology, and events are bringing academic and applied psychologists together. Indeed, as early as 1904 Cattell predicted that there would be a profession as well as a science of psychology. THE PSYCHOMETRIC, DYNAMIC AND EXPERIMENTAL TRADITIONS IN CLINICAL PSYCHOLOGY Clinical psychology, as such, has only a short history, though its pre- cursors go back about a century. The psychometric and dynamic traditions have long influenced clinical practice and more recently experimental psychology has been playing its part. I do not intend to review these develop- ments in detail, but merely to point out some of the major milestones. The strong psychometric tradition in clinical psychology owes its be- ginnings to the work of Francis Galton, who, in 1883, published "Inquiries into Human Faculty and its Development". In the U.S.A., J. M. Cattell, a student of Wundt, pioneered the need for measurements in individual dif- ferences, norms and standardised procedures in the 1890's. Most of the work of these early investigators was influenced by the nineteenth-century German psychology, and related to sensory-motor tasks and associative functions. In the early twentieth century, Binet made one of the most significant contributions to the measurement of individual differences when dealing with the problem of assessing the cognitive attributes of French school- children. Later, Lewis M. Terman developed the Binet-Simon Scale for American subjects, an outstanding event in cognitive measurement for the English-speaking world. Though Goddard, Healy and Rachman intro- duced Binet's tests to America, and Burt had, independently, done so in England, Terman's work overshadowed all. In 1916, he published the first Stanford Revision of the Binet-Simon Tests, 1937 and 1960 realised im- proved revisions available to clinicians, educationalists and the like. CLINICAL PSYCHOLOGY 5 The Work of David Weschler in developing the age-scaled Weschler- Bellevue Forms I and II for adults by 1946, the Weschler Intelligence Scale for Children (1949) and the more recent Weschler Adult Intelligence Scales (1955) is perhaps the next psychometric development of major import to clinical psychologists. The work of Burt in the 1920's, and later of Schonell, on scholastic and mental testing in England cannot go without mention. Indeed, Burt deserves to be far more widely read than he is today. In the last half-century, many studies on the validity and reliability of psychometric tests have appeared; papers on the application of cognitive tests to the clinical and educational areas have poured forth; group tests, achievement batteries, personality measures have emerged. The dynamic tradition dominated early British medical psychology: indeed Freud, himself, lived in England for many years. When Dr. Rivers inaugu- rated the Medical Section of the British Psychological Society in 1919 psychoanalysts formed the most coherent group in this section. The analytic influence is still present in British clinical psychology, epitomised by the Tavistock Clinic, London. However, other voices are being increasingly heard as the British Journal of Social and Clinical Psychology, established in 1960, illustrates. In America, the Boston group including William James and Stanley Hall were important pre-Freudian influences. Hall gave Freud his first academic hearing in America in 1908 and invited both Freud and Jung to lecture in the United States. The New York Psychoanalytic Society was founded in 1914 and the Psychoanalytic Review, first started in 1913, demonstrates the psychodynamic tradition in American clinical psychology and psychiatry. Many of the present developments emphasising the understanding of personality function stem from the work of Freud and his successors. The influence of the psychoanalytic dynamic traditions shows itself in the development and extensive use of projective techniques in measurement, the theoretical work on personality and the treatment of mental illness by psychoanalytic techniques in both America and England. The methods of Freud, Jung, Adler, Rogers and their followers, to name a few of the dynamically orientated clinicians, have been widely used in child guidance clinics and hospital situations. The influence of experimental psychology on clinical practice is, oddly enough, fairly recent. The contribution of areas such as perception and learning to diagnostic and therapeutic problems in the clinic is minimal compared with the influence of psychometrics. Bender et al. have used per- ceptual information to try to diagnose brain damage and the arch-behaviour- ist, Watson, demonstrated the learned nature of phobic anxiety, but it has been only in the last 15 years or so that a systematic applied experimental psychology has been seen in the clinical setting. This emphasis stems predominantly from the work of Eysenck, Shapiro and their colleagues at the Institute of Psychiatry, London University, and from Skinner et al. from Harvard University, U.S.A. Both "schools" have attempted to apply knowledge acquired from academic psychology to the clinical setting in relation to the diagnosis and treatment of mental illness 6 INTRODUCTION as well as to personality theory. Both schools stress the need for a sound experimental basis for clinical psychology, and adequate research training as well as diagnostic and therapeutic competence. EARLY CLINICAL PSYCHOLOGY Many psychologists, clinical and educational, are involved in child guidance. Galton's "anthropometric laboratory" was essentially the first child guidance centre in Great Britain. It was established in 1884 and later attached to University College, London. Then, in 1913, Burt began work as an educational psychologist for London County Council and founded the first formal education child guidance clinic in England. Meanwhile, in America, Witmer (1896) had established a psychological clinic at the Uni- versity of Pennsylvania and published the journal, Psychological Clinic. The first child guidance clinic per se was founded by William Healy in Chicago in 1909 called The Juvenile Psychopathic Institute. Clinical psychology, particularly in the post-war period, has seen the establishment of many child guidance clinics representing the Witmer- Burt and Healy-Tavistock traditions. The former have been concerned primarily with the intellectual aspects of individual functioning in mental defective and school retarded children, the latter have stressed the affective aspects of personality, working primarily with behaviour problems and delinquency. In the mental hospitals field in Great Britain, the Maudsley Hospital, the Tavistock Clinic and the Crichton Royal Hospital pioneered clinical psycho- logy as such. The Maudsley Hospital, London University Institute of Psychiatry has, under Professor Eysenck and Dr. Shapiro, stressed a scienti- fic, non-dynamic approach to clinical psychology. The Tavistock Clinic represents the more psychoanalytic branch of British clinical psychology. Shepard Ivory Franz established the first psychological laboratory as such at McLean Hospital in Massachusetts, America, in 1904. Later, in Washing- ton (in 1907) Franz introduced what was probably the first routine clinical examination of all new patients in a mental hospital setting. The psychological assessment of the mental defective in Great Britain was first stressed by Sully in 1892 and the British Psychological Society's recom- mendation to the Royal Commission on Mental Illness and Deficiency in 1957 demonstrates its growing concern in the area. In America, Goddard's Vineland Training Centre, begun in 1906, is still doing extensive work on feeble mindedness, and illustrates the psychologists' involvement in this area. TRAINING OF CLINICAL PSYCHOLOGISTS In both America and Great Britain clinical psychology in the sense of a formally trained, established profession may be regarded as a post-1945 development. America may be seen to have the initiative at present, but British clinical psychology is developing rapidly. CLINICAL PSYCHOLOGY 7 The issues of standards and types of training for clinical psychologists, ethical problems and the like have been met, though not fully resolved, in a series of publications by the American Psychological Association in the American Psychologist. The 1945-1955 decade is perhaps the most significant in this respect. Training methods in America are now controlled by the American Psychological Association. The Veterans Administration train- ing programme embraces a four-year internship period of instruction and clinical practice with about 50 per cent of the work in V. A. hospitals and 50 per cent under the direction of an approved university department. The universities are responsible for planning the curriculum and trainees are usually given financial support by the V.A. hospitals. The trainee gains the relevant diagnostic, therapeutic and research experiences together with a Ph. D. by the end of the four years. Thus he is able to qualify as a clinical psychologist. About half the States insist on certification by either the State Psycho- logical Association or statutory procedures. The latter require the precise nature of a psychologist's practice to be stated—not an easy task. Straight certification is often practised, whereby a person may not call himself a psychologist, nor offer psychological services so designated to the public for remuneration, unless he meets certain standards (usually a Ph.D. plus two years experience). In Britain the profession of clinical psychology has developed somewhat less and somewhat differently. The establishment of a National Health Service has been a most influential factor. The first of several P.T.A. circu- lars, No. 16, on the qualifications of full-time clinical psychologists was issued in 1952. Two main methods of training in clinical psychology were accepted by the Health Service—In-service training and Diplomas awarded by universities. The Tavistock Clinic in London and the Department of Psychological Research at the Crichton Royal Institution, Scotland, have specialised in In-service training schemes lasting for three years during which a person holding an honours degree in psychology from a recognised university obtains supervised clinical instruction and practice. On the other hand, the Maudsley and Bethlma Royal Hospitals in 1946 instituted a 13-month course (the equivalent of two academic years) which was recog- nised in 1950 by London University, for a Postgraduate Diploma in Psychology Section D—Abnormal Psychology. Recently the Maudsley Hospital have established a two-year course leading to M.A. in clinical psychology. Variations on these two themes permeate training in clinical psychology in Britain. The universities of Edinburgh, Glasgow, Liverpool and Newcastle upon Tyne to name a few, award recognised qualifications based on a two-year course for a Diploma in Clinical Psychology. The South-West Regional Hospital Board and numerous other hospitals have organised In-service training schemes for three years or two-year schemes in conjunction with the universities. Furthermore, the British Psychological Society is considering the advisability of the Society awarding a recognised qualification in clinical psychology, and has already set up a Committee of Professional Psychologists with clinical and education sections to continually