What does clinical psychology mean? - Chapter 16

Paul Meehl, wrote a book 'Clinical Versus Statistical Prediction: A Theoretical Analysis and a Review of the Evidence, in which he emphasizes the superiority of empirical data above clinical assessment when predicting behaviour described. He was a psychoanalytically oriented psychotherapist. The 1950s are also called the Golden Century for psychoanalysis in the US. Since then, the clinical psychology began to take shape.

Who were Molly Harrower and Hermann Rorschach?

After World War II, there was a shortage of professionals who had mental health problems treatment, especially the trauma. Psychologists were increasingly asked for psychiatrists to fill in. Molly Harrower (1906-1999) was a psychologist with a private practice in New York. Until then, this kind of privilege had only been reserved for psychiatrists. She was probably the first psychologist with a private practice in New York. She studied the psychological effects of operations and worked with neurosurgeon Penfield. Harrower looked at reactions from patients. She was also interested in the Rorschach projective technique, also known as the ink stain test, discovered by Hermann Rorschach (1884-1922). Rorschach was interested in the effects of mental states on perception. His test consisted of a series of unstructured stimuli - symmetrical ink stains. The tester shows the ink blot and asks: what could this be? Patients may then each give an answer. Rorschach found not the content but the perceptual processes of the answers important, and how this related to mental states or neurological conditions. The tester also looks at which determinants (color, shape, texture or movement) patients used when replying. Rorschach wanted to use it for diagnostics, but criticism was that the test was not properly validated. Harrower combined her interest in the Rorschach test with her interest in the psychological effects of operations. She discovered that the answers to the test of patients with brain tumours differed from patients without tumours. Harrower made it clear that diagnosing mental disorders is only one small task of a psychologist. Psychologists must have one overall picture of someone. According to Harrower, this is the distinction between psychiatrists and psychologists.

Who was David Shakow?

There was therefore a need for more clinical psychologists, and because of this the National Mental Health Act passed in 1946. David Shakow was chosen to participate in the 'Committee on Training'. He was prominent in designing a standardized graduation program for clinical psychology. He was trained as a researcher, just like Harrower. He became a professor in psychiatry at the University of Illionois Medical School, and psychology professor in Chicago. 

There was tension within the APA between 'pure' experimentalists and applied psychologists. Psychologists also received external opposition from psychiatrists and other medical staff. Shakow named three primary functions of the clinical psychologist: diagnosis, research and therapy. He found that objective tests had to be developed, but also that the patient had to be evaluated as a whole person. So it was not just about giving a label to the patient. The conducting research, according to Shakow, was also an important role for clinical psychologists. They must therefore also be trained scientifically. The third function, therapy, had, according to Shakow, to be the least prominent. Shakow provided the creation of the scientist practitioner model of clinical training. The emphasis of this model is on combining scientific training with training in practice.

What was the criticism of the scientist-practioner model?

According to George Albee, there was now too much emphasis on the medical model of mental illness and there was too little attention to social learning approaches and prevention. Albee was a pioneer in the community psychology, in which social and environmental factors that contribute to mental health and disease in communities are being studied. Hans Eysenck's criticism was that clinical experience and research do not necessarily have to influence each other. He designed a new model in which he removed psychotherapy from the training, he was more for one separate profession of psychotherapy. Yet psychotherapy was added to the training for clinical psychologist. This allowed them to better compete with psychiatrists who did not receive training in psychotherapy.

Who is Carl Rogers?

Carl Rogers made recordings of therapy sessions and studied them to study change in processes. Roger formulated the client-centred therapy, a new non-directive approach. His theory includes the actualization tendency, one's internal tendency to grow and improve. According to him, psychological problems arise when this tendency gets disturbed. In his form of therapy, there must be psychological contact between an incongruent client and a congruent therapist. Incongruity is defined as the discrepancy between the physical experience of a situation and his or her self-representation in that situation. The therapist aims for congruence. Second, therapists must be unconditionally positive towards clients. And finally, therapists must show empathic understanding for the inner world of the client. Rogers also wanted scientific research to be done on these therapy factors. He was pioneer in research into psychotherapy. More and more evidence showed that there are a number of factors are those that come back with every therapy.

Joseph Wolpe (1915-1997) was a pioneer in behavioural therapy, with a focus on the changing of behaviour. Systematic desensitization is a technique in which relaxation exercises are combined with gradual exposure to a fear object, this is an example of behavioural therapy.

How did cognitive therapy come about?

Aaron Beck was a psychiatrist who withdrew from psychoanalysis. He designed the Beck Depression Inventory, a questionnaire that measures depression on the basis of objective criteria.  During research, he found out that the theory of inward-going anger, which according to Freud was responsible for depression, was not quite right. According to Beck, there were systematic biases in depressed thinking. 

Beck was introduced to Albert Ellis (1913-2007), who also had broken with psychoanalysis and developed a new therapy he called 'rational emotive therapy '(RET). In this he used the ABC model. In this model, someone's response to an activating or negative event is (A) often influenced by a person's beliefs, assumptions and world view. These beliefs (B) influence the emotional and behavioural consequences (C) of the negative event. Beck and Ellis suddenly saw how much their approaches were similar each other. In 1960 Beck published his research in which he put cognition as the central mechanism of depression. In 1967 he published his book: Depression: Clinical, Experimental and Theoretical Aspects. His cognitive theory of depression consisted of a number building blocks. An important concept is the cognitive schema, a core conviction that organizes information about the self, the world and the future. Beck calls this the cognitive triad. People with depression have negative schemas that cause cognitive disturbances. Patients often see nothing between two extremes, also called all-or-nothing thinking, or they only see negative aspects of a situation, which is called 'ignoring the positive'. Beck realised that these negative automatic thoughts often lead to a depressed mood. These thoughts are fed by one's underlying assumptions and core beliefs. To help patients improve, Beck created the cognitive therapy. The focus in it is on the here and now, and the focus is on discovering core beliefs and challenging and changing them. Beck carried out the first randomized controlled trial (RCT) on the effectiveness of psychotherapy to demonstrate against antidepressants. Cognitive therapy is currently one of the most used and examined forms of therapy.

What happened after 1980?

In 1980 the 3rd edition of the DSM was published. In it, every disorder was defined in terms of symptoms. A multi-axial system was also introduced, involving patients who were assessed on different axes or operational areas. Cost effectiveness was also important: which therapy is most effective in the shortest time? There was a big study in which different treatments for depression were compared: Treatment of Depression Collaborative Research Program (TDCRP). A therapy that was examined here was interpersonal psychotherapy (IPT), designed by Klerman and Weissman. The focus is here on social and interpersonal processes associated with depression. Results showed that CBT, IPT and antidepressants were approximately equally effective, especially at low to average depressions. The most important outcome of the TDCRP study was that it showed that research into psychotherapy are carried out in the same scientific way as biomedical research.

What was the MMPI?

The Minnesota Multiphasic Personality Inventory (MMPI) is a statistical measurement method of personality factors that are relevant for the understanding of psychopathology. Starke Hathaway (1903-1984) received money for the development of a psychological test measuring psychopathology after WW II. The MMPI had to meet a number of requirements for Hathaway: it should be relevant to understanding clinical problems and thus measure personality variables that are related to psychopathology. It must add substantial information to what you can find out about someone in a short interview. It must be efficient in purchasing, easy to score and interpret, and objective. He used an empirical, objective, statistical approach for forming the test: the criterion-group method. He produced like that a questionnaire with 566 items on 10 clinical scales. The MMPI was also capable of identifying response patterns that would reveal that the test information would not be valid.

Paul Meehl (1920-2003) researched the phenomenon of 'false positives' on the MMPI: response patterns that make it seem like there is psychopathology, while those who answer are in fact a normal person. To correct this, he developed the K scale. He also became interested in profile analysis, because he felt that this predicted someone's diagnosis better. The disadvantage of the MMPI is that it takes very long for patients to fill it out, and that not everyone feels at ease with naming everything honestly. The Rorschach test also remained popular after the war but hit criticism under the influence of Meehl. In 1980 the MMPI became the most used personality test in the USA.

What are contemporary discussions?

Much research is being done into the question which specific therapy works best for which type of client and which therapy works best for which disorder. Because of this, the focus is now on evidence-based practice (EBP), the use of treatments that have been scientifically tested. Some think this is a good development, others do not. 

Another contemporary debate is about the validity and use of the Rorschach test. In 2009, a Canadian doctor posted photos of the ten ink spots on Wikipedia. According to psychologists, the test could no longer be used in a valid way because people could simply look up answers. However, according to others, this did not matter.

ExamTips

• For your exams, it is important that you can link all these pioneers to their believes and the stream of psychology they belonged to. It is okay if you do not remember whose father died of a stroke or whose grandfather was a religious priest
• Be able to draw schemata. If there is a scheme-like description of a theory of an idea, make sure you are able to draw it out. Professors love their schemes and therefore, so should you. Make sure you can recognise who it is from and what it describes when it is suddenly in front of you.