Clinical PsychologyIntegrating Science and Practice

Arthur FreemanStephanie H. Felgoise

Denise D. Davis

John Wiley & Sons, Inc.

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Clinical Psychology

Clinical PsychologyIntegrating Science and Practice

Arthur FreemanStephanie H. Felgoise

Denise D. Davis

John Wiley & Sons, Inc.

This book is printed on acid-free paper.

Copyright © 2008 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data:

Freeman, Arthur, 1942–Clinical psychology : integrating science and practice / by Arthur Freeman,

Stephanie H. Felgoise, Denise D. Davis.p. ; cm.

Includes bibliographical references.ISBN 978-0-471-41499-5 (cloth : alk. paper)

1. Clinical psychology. I. Felgoise, Stephanie H. II. Davis, Denise D.III. Title.[DNLM: 1. Psychology, Clinical. 2. Mental Disorders—diagnosis. 3.

Mental Disorders—therapy. 4. Psychotherapy—methods. WM 105 F855c 2008]RC467.F74 2008616.89—dc22

2007011146

Printed in the United States of America.

10 9 8 7 6 5 4 3 2 1

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www.wiley.com

CONTENTS

v

Preface xi

Acknowledgments xv

PART IIntroduction 1

Chapter 1The History, Politics, and SocialEnvironment of Clinical Psychology 3

A Flying Carpet Tour of Clinical Psychology 5Back to the Future 9Major Organizations Concerned with

Scientific Practice 10Training Philosophy in Clinical Psychology 12Student Characteristics 14Licensure in Clinical Psychology 15The Practicing Role of a Clinical Psychologist 15Preview of the Text 16

Chapter 2The Fields of Clinical Psychology 19

Elements of a Clinical Psychology 21Training Qualifications and Ethics Regulations 25Specialties in Clinical Psychology 30Summary: Making the Right Choices for You 52Appendix: Professional Societies in Clinical

Psychology 53

Chapter 3Working with Cultural Diversity 55

Cultural Competence as Fundamental Practice 56The Diverse People of the United States 57Common Terminology 59Attunement to Cultural Diversity in

Clinical Context 61

Culturally Sensitive Practice 70Summary 82Appendix: Resources for Emerging Information on Diversity 82

Chapter 4Clinical Research and Outcome Assessment 83

Clinical Research and Research Methods 84Therapeutic Interventions: Are They All the Same? 94Summary 100

Chapter 5Why People Become Patients 103

Understanding Why People Become Patients 104Specific Types of Problems 113Summary 137

PART IIBasic Techniques for Clinicians—Assessment 139

Chapter 6Introduction to Assessment: The Biopsychosocial SystemsModel of Human Behavior 141

Goals of Assessment 142Specific Types of Assessment 149The Biopsychosocial Systems Model of Understanding

Human Behavior 156Summary 166

Chapter 7A Scientific Approach to Assessment and Methodsof Gathering Data 167

The Scientific Method 168Methods of Gathering Data 182Summary 193

vi Contents

Chapter 8The Logistics of the Assessment and a Closer Lookat Interviewing 195

Strategic Logistics and a Problem-Solving Approach 196Procedural Logistics and Clinical Skills 202Summary 233

PART IIIBasic Techniques for Clinicians—Intervention 235

Chapter 9Developing a Case Conceptualization 237

What Is Case Conceptualization? 239Functional Purpose of a Case Conceptualization 240Conceptual Approaches 241The Conceptualization Process 242Summary 254

Chapter 10Developing a Treatment Plan: Therapeutic Alliance andCollaborative Goals 257

Roles of Patient and Therapist 258Goals and Tasks of Treatment 267Building and Maintaining the Therapeutic Relationship 272Summary 280

Chapter 11Therapeutic Methods: Building Psychotherapy Skills 281

Applying Specific Procedures 282Interpersonal and Systems Interventions 283Affective Interventions 292Behavioral Interventions 299Cognitive Interventions 310Summary 317

Contents vii

Chapter 12Understanding, Facilitating, and Evaluating Change 321

Understanding Change 322Facilitating Change 337Evaluating Change 340Summary 347

Chapter 13Impediments to Change 349

Definitions of Resistance 351Bordin’s Model of the Working Alliance 353Impediments to Treatment and Change 353Summary 381

Chapter 14Effective Termination 383

Rationale for a Termination Strategy 384Effective Termination Strategy 387Competence and Professional Standards of Care 394Applied Skills for a Sound Strategy 399Summary 417

PART IVWhat Every Clinician Needs to Know 419

Chapter 15Self-Care and Ethics: Applying the Techniques ofPositive Psychology 421

Ethics, Impairment, Personal Problems, and Burnout 423Therapists’ Reactions to Clients: Normal to Problematic and

What to Do about It 432Positive Psychology 444

viii Contents

Summary 448Appendix A: Self-Help for Stress Management and Relaxation 449Appendix B: Self-Help and Self-Exploration References

on Positive Psychology 450

References 451

About the Authors 465

Author Index 469

Subject Index 473

Contents ix

PREFACE

xi

There is an old saying that “the more things change, themore they stay the same.” This is true for the field ofclinical psychology. Despite the enormous changes and devel-opments in applied practice over the past 30 years, clinicalpsychology remains firmly connected to its scientific founda-tions. Clinical psychologists have made significant contribu-tions to the growing fund of empirically based methods andstrategies used in mental health applications today. Throughtheir commitment to the integration of science and appliedpractice, clinical psychologists have helped to raise the qualita-tive standards of mental health care, expand the range of thosewho have access to care, and lower overall costs of care by de-veloping targeted interventions that are effective and efficient.

Perhaps the most important psychology course taught isthe basic introductory course. It stimulates interest, providesbasic grounding; and establishes the foundation for futurework. Successful academic and professional advancement ingraduate work in clinical psychology is built on these sametenets. The course that introduces clinical psychology sets thetone for graduate training. Whether you are the teacher orthe student in such a course, a comprehensive, realistic, yetinteresting introductory text is an essential tool in this chal-lenging endeavor.

Much has been said about the importance of integratingscience and practice in clinical psychology; yet few texts illus-trate the actual workings of this process. Our goals in offeringthe present text are threefold. First, we want to provide be-ginning graduate students with a comprehensive introduc-tion to the field of clinical psychology. This text is intended tobuild an appreciation of clinical psychology’s richness andhistorical significance and its leadership in the scientific de-velopment of methods and techniques for clinical assessmentand intervention. Throughout the book, we emphasize clini-cal psychology as a vital force in today’s health care practice.The model that we use throughout the text is the biopsy-chosocial systems model of understanding human behavior.We direct students toward developing critical thinking skillsthat are applied in the context of this interactive model,rather than endorsing any single theoretical orientation.

Second, we offer students a detailed look at basic clini-cal tasks and skills that are the nuts and bolts of a practi-tioner’s work. We explain things from the ground up, so thatthe student can integrate the scientific, theoretical, and prac-tical underpinnings of their applied tasks. This will prepare

the student to acquire more detailed and specific information in later courseson research methods, ethics, cultural diversity, assessment, psychotherapy, andother specialized, advanced practice skills. Clinical cases and vignettes are usedliberally throughout the text to illustrate, emphasize, and help the student con-ceptualize professional, scientifically grounded clinical encounters. In readingthis text, students can gain a vivid picture of what the work of a clinical psy-chologist really looks like. Because so many case examples are used, it is impor-tant to note that this book is expressly intended as an educational resource forthe training of professional psychologists. All our case material is disguised andpresented in composite form so that no specifically identifiable person is dis-cussed. We sincerely hope that the tone of all case material communicates re-spect for the dignity of those whom we intend to serve.

Finally, we strive to make the life of a clinical psychologist more readilyvisible and perceptible through a variety of methods and illustrations through-out the text. We offer an overview of different fields of clinical psychology anddescribe different subspecializations that are possible career directions. Wedraw a descriptive picture of six contemporary, well-known colleagues as theyshare details of their work life. In these “day in the life” portraits, we see someimportant variations in what occupies the psychologists’ time, how they inte-grate science and practice, and also how they live their lives and care for theirpersonal selves and their families. In addition, we devote an entire chapter toan enormously important but often neglected subject—practitioner self-care.We specifically include the term ethics in the title to this last chapter because itis fundamental to the concept of self-care for the psychologist, but ethical fun-damentals are woven throughout the book.

We hope you will find this text to be user-friendly. As much as possible,we have attempted to engage the student reader as a direct participant in ourdiscussion. We frequently ask questions, or direct the reader to reflect, explore,or consider the concept at hand. We draw on illustrations or examples that arelikely to resonate with the students’ own life or personal experience. We dothis throughout the material, as one might raise such issues in the course ofteaching a class, rather than just listing questions for further thought at the endof a didactic chapter.

Every chapter begins with at least five learning objectives so that stu-dents have a structure and anticipatory focus for their reading of that mate-rial. The overall text is divided into four main sections. Part I containsintroductory material (Chapters 1 through 4). Part II includes four chapterson assessment methods and techniques, and Part III, six chapters pertainingto intervention strategies, techniques, and common challenges. In Part IV, wefocus on what every clinician needs to know, emphasizing ethics, self-care,and positive psychology.

In Chapter 1, the reader takes a journey through the ages, as the historicalbackdrop for the political and social development of clinical psychology comesalive in a uniquely vivid way. In Chapter 2, the professional culture and sub-cultures of today’s clinical psychologist are detailed. Chapter 3 presents anoverview of the vast topic of cultural diversity and the scientific concepts andpractical strategies that are important in culturally competent practice. InChapter 4, the student is introduced to basic research concepts in an easy-to-

xii Preface

understand and digest format. Chapter 5, explores why people become clientsand introduces the basic classifications of psychopathology via the DSM system.Part II, Chapters 6, 7, and 8 form an assessment trio where the goals, types, andpurposes of clinical assessment are described, the biopsychosocial systemsmodel for understanding human behavior is introduced, the application of sci-entific methods and approaches to data gathering in the assessment process isarticulated, and finally the logistics of actual assessment procedures are ex-plained and illustrated.

Proceeding to Part III, readers learn about the importance and basic strate-gies of case conceptualization (Chapter 9), followed by a discussion of the nutsand bolts of collaboration, treatment alliance, and effective treatment planning(Chapter 10). An extended illustration of interventions including strategies thatare systemic or interpersonal, affective, cognitive, and behavioral is offered inChapter 11. Chapter 12 focuses on the process of change; how to understand it,foster its development, evaluate it, and communicate about it. In Chapter 13,the traditional notions of resistance receive a more contemporary considerationas impediments to change. Concluding Part III is Chapter 14, a comprehensivediscussion of termination strategies and tactics suitable for today’s demandingpractice environments. Finally, in Part IV, the reader is directed to think aboutself-care as a “need to know” topic. In Chapter 15, the reader encounters thetopics of burnout, personal responsibility, and the use of positive psychology tomediate stress and facilitate well-being.

Although this may sound a bit scarier than it is, the authors of this texthave among them nearly a century of experience as clinical psychologists. Theyhave had the pleasure of learning from and working with many of the masters inthe field and knowing these eminent contributors over long periods of time. Theauthors of this text are qualified by advanced degrees, postdocs, diplomates, pastpresidencies, memberships, chairmanships, fellowships, authorships, and well-stamped passports. An integration of teaching, research, and clinical practiceaptly describes the past, present and future of our combined careers in this ex-citing field.

Preface xiii

xv

ACKNOWLEDGMENTS

Many hearts and hands have helped this book come tofruition. First and foremost, Tisha Rossi and IsabelPratt, our editors at John Wiley & Sons, have been amazinglypatient and supportive. A heartfelt “thanks for sticking withus” barely begins to express our gratitude for their efforts.Sweta Gupta, editorial assistant at Wiley, has been a whiz atsmoothing out our jagged edges and helping us spot our miss-ing pieces. We also want to collectively thank our anony-mous reviewers for excellent feedback on earlier chapterdrafts. A special thanks to our colleagues, Ron Fudge, GayleIwamasa, Anne Kazak, Sam Knapp, Chris Royer, and PattiResick, for giving us a glimpse into their lives as clinical psy-chologists, and allowing us to share that glimpse with ourreaders. Each of us has personal thanks to offer as well.

I have been fortunate, if not blessed throughout my ca-reer. I have somehow managed to be in the right place at theright time to cross paths with some of the foremost cliniciansin our history. As a graduate student, I heard Carl Rogersspeak many times, drove Rollo May home from a meeting,debated with Joseph Wolpe, collaborated with Mike Ma-honey on several projects, and had the opportunity to spendtime with Albert Ellis, Kurt Adler, and so many others.

As an adolescent, and at various points through myadult years, I had the chance to be helped by the late Dr.Emanual F. Hammer. Manny was the clinician’s clinician.Well trained, superb teacher, erudite, well versed in theoryand research, empathic, and kind. What I am today as a clini-cian, I can easily trace back to my emulation of his model ofwhat a clinical psychologist should be. To my teachers, men-tors, students, and patients, I owe a debt of gratitude. Theyhave taught me so very much about the human conditionand what is needed to help others effectively cope.

Two of my very fortunate discoveries have been Drs.Denise D. Davis and Stephanie H. Felgoise. I met Denise over25 years ago at a symposium at APA. She has become a su-perb clinician, colleague, collaborator, coauthor, and friend.

Several years ago as chair of the Department of Psychol-ogy at Philadelphia College of Osteopathic Medicine (PCOM),I had an opening for an assistant professor. I called Drs. Artand Christine Nezu at Drexel University and asked if they hada recent graduate who might be interested in the position.They recommended Stephanie Friedman, now Felgoise.Stephanie is now Vice-Chair of the Department, Director of

the Clinical Psychology program, an ABPP diplomate, and Associate Professor.These two younger generation women represent and will be part of the brightfuture of clinical psychology. Drs. Aaron T. Beck and Albert Ellis have been sup-portive and magnificent models and mentors. I could not have achieved what Ihave without them. My children and grandchildren are sources of great joy andencouragement. Finally, my wife Sharon is a superb clinician, personal consul-tant, partner, supporter, colleague, coauthor, coeditor, and best friend.

—A. F.

First and foremost, emphatic thanks are extended to my coauthors and col-leagues, Dr. D. Denise Davis and Dr. Art Freeman, whose collaborationmade the writing of this book exciting, challenging, and an enriching experi-ence. Thank you to student-colleagues Talya Hammer, Catherine McCoubrey,Leslee Frye, and Sara O’Neal for their dedicated and tireless efforts in searchingthe literature, fine-tuning chapter edits, and compiling references for inclusionin this book. Dr. Robert DiTomasso offered support, encouragement, and flexi-bility that allowed time for chapters to be written. He and Dr. Art Freeman havecreated a fabulous department of psychology in an already wonderful, collegial,stimulating, and family-oriented environment at PCOM. Work on the self-carechapter was enhanced by many conversations with Dr. Bruce Zahn regardingstudent self-reflection, self-care, and impairment in the context of our StudentProgress Evaluation Committee and NCSPP attendance, in addition to the dis-cussions we had with Drs. Diane Smallwood and Taka Suzuki in committeework surrounding these important topics. The prior and ongoing mentorshipprovided by Drs. Art and Christine Maguth Nezu, and their problem-solvingmodel have been monumentally influential on how I think critically, scientifi-cally, broadly, and ideographically about clinical psychology as a science andpractice. Their work’s influence on the research, assessment, and self-care chap-ters are evident.

My love, thanks, and appreciation are always due to my sisters and myparents. Their support, encouragement, friendship, and role-modeling ofcourage, achievement, and dedication to helping others have always been cen-tral to my success. My fabulous children, Benjamin and Elizabeth, are the mostwonderful daily reminders of reasons for self-care and what is most importantin life; they offer the innocent perspective of how to enjoy life to its fullest.Lastly, and of most significance, is the ongoing thanks to my best friend andhusband, Glenn; with his help and support anything is possible. Thanks for helpwith this book during many late nights.

—S. F.

Many thanks to friend, mentor, and colleague Art Freeman for invitingme to participate in this valuable and challenging project. I am gratefulfor our dozens of years of collaboration on various projects, and for his encour-agement and inspiration. It was certainly a pleasure to become acquainted with

xvi Acknowledgments

Stephanie Felgoise over the course of writing this book. Both Art and Stephaniebrought a very special wisdom and perspective to our shared task of explainingthe integration of science and practice. I deeply appreciate having had this op-portunity to learn from both of them.

Special thanks to my student colleagues Monica Franklin and HollisterTrott, and former-student-now clinician Christopher Mosunic, for insightfulcomments and helpful suggestions on health psychology, working with diver-sity, and the case of Doris (Chapter 3). My wonderful consultation group;Kirsten Haman, Laurel Brown, and Dotty Tucker, have provided much encour-agement and many discussions on details of treatment and termination. I hopethey know how much I value and appreciate their contributions. Steve Hollon’sleadership in developing a cadre of clinicians committed to integration of sci-ence and practice provided vital collegial support. Thanks, Steve. I would alsolike to acknowledge the community of psychologists at Vanderbilt University(including our adjunct clinical faculty!) who represent and inspire excellence inall aspects of science and practice. And finally, but certainly not least, thanks toCharlie for taking care of everything and keeping a steady rhythm.

—D. D.

Acknowledgments xvii

INTRO D U C TI O N

Chapter 1 The History, Politics, and SocialEnvironment of Clinical Psychology

Chapter 2 The Fields of Clinical Psychology

Chapter 3 Working with Cultural Diversity

Chapter 4 Clinical Research and Outcome Assessment

Chapter 5 Why People Become Patients

PART

I

3

1C h a p t e r

The History, Politics, and SocialEnvironment of Clinical Psychology

This chapter sets forth our theme of integrating clinical science and clinicalpractice. We discuss the philosophical and practical or applied aspects ofclinical psychology and place clinical psychology in perspective relative to thehistorical, social, gender, cultural, and scientific environments in which it wascreated and in which it and we, as clinical psychologists, exist.

Our model is based on clinical psychology as a general treatment model,with the clinical psychologist serving as a primary care practitioner: the “psy-chological family doctor.” This chapter also delineates the direction and plan forthe book.

Learning Objectives

At the end of this chapter, the reader should be able to:

• List five historical markers in the conceptualization and treatment ofclinical phenomena.

• Identify three scientific eras that have influenced the development ofclinical psychology.

• Describe the contemporary organizational environment of the field ofclinical psychology.

• Explain the concept of the clinical psychologist as a primary carepractitioner.

• List at least 10 learning objectives for reading the chapters ahead.

Mary, a doctoral-level psychologist, was at a party where the hostess in-troduced her to someone by saying, “This is Mary. She’s a psychologist.” The

4 Introduction

other person smiled and said, “Whoops. I better be careful what I say so youwon’t be analyzing me.” Mary’s response was that she was not a clinical psy-chologist, but an experimental psychologist working on aspects of language ac-quisition in chimpanzees.

It is of more than passing interest to know that many people who hear theword psychologist assume that the person so identified is a clinical psychologist.Many people use variations of the term psychology to denote motivation (“I amreally psyched for that date”), readiness (“I am psyched for that exam”), intim-idation (“I really psyched him out”), or a person who appears to be out of touchwith reality or with societal norms (“That guy is really psycho”). The range ofpsychology applications and practice is discussed in Chapter 2. In this introduc-tory chapter, we discuss the history and development of clinical psychology asa practice, a science, and a treatment; and we place clinical psychology in per-spective relative to the historical, social, gender, cultural, and scientific envi-ronments from which it emerged.

Writing a text such as this one takes a great deal of thought and discussionamong the authors. We have had to decide what to include, what to exclude,and how to present the material in as scientific, readable, and useful way aspossible. We have, between us, over a century of experience, first as studentsand then as university faculty members and practitioners. We are aware of thechallenges in developing a text. Will it hold your interest? Will it allow your in-structor to elaborate on the ideas we present? Will it provide the requisite in-formation? The latter two points are in fact relatively easy to fulfill. To keepyou interested is a much harder job. For this reason, we have decided to talk toyou directly and to think of you as one of our students.

The clinical psychologist, in the simplest definition, works in a clinical set-ting, with clinical populations, and uses clinical interventions. But what does thatmean? Clinics are usually for people needing treatment of one sort or another. Alook at a hospital directory might list the hours of operation for the spine clinic,the asthma clinic, the well-baby clinic, or the mood clinic. That is where youwould expect to find clinical psychologists. Although this has been true for muchof the existence of clinical psychology, the appellation of clinical has now been af-fixed to other terms such as clinical health psychology, clinical child psychology,or clinical neuropsychology.

The notion that people have emotional problems is not new. That somepeople act unacceptably within their social or family group and are thought tobe deviant from their fellows is, instead, an ancient belief. Rather than dazing(or amazing) you with the historical or prehistorical experience of psychology,we have decided to make it easy.

We are going to take you for a ride on an incredible magic carpet. Notonly can it fly though the air, it allows you to board without going through ametal detector. Second, it can travel through time so that we can view manyexperiences, circumstances, and situations. Third, it renders us invisible so thatwe can observe others and not be seen. Fourth, it is soundproof so that we candiscuss what we are seeing without being heard. Fifth, if, for any reason, ourtrip is interrupted, you can climb aboard again and take up where you left off.Sixth, this magic carpet has a universal translator that allows us to listen in towhat is going on in front of us. Finally, it will safely return us to our starting

The History, Politics, and Social Environment of Clinical Psychology 5

point. Please note that no snacks will be served on this flight so before embark-ing, collect your favorite snacks to take along.

A Flying Carpet Tour of Clinical Psychology

If you are safely aboard, our first stop is prehistory. We can feel the heat. Weare on a plain in Africa. A formerly social and well-adjusted member of thetribe has been howling at the moon, attacking other members of the tribe, andhaving uncontrolled seizures or other acts against the best interest of the tribe,clan, or group. He has been caught and subdued by other members of the tribeand has been rendered unconscious by being forced to drink a potion the tribalhealer has concocted from herbs and flowers. The healer is about to perform asurgical procedure still used today, called trephining. She is using sharpenedflints to bore a hole in the person’s skull to release the demons and spirits thathave been trapped there. Releasing the demons should relieve the patient oftheir “possession.”

Although we might expect the patient to die from what we see as a bar-baric operation, skulls dating back thousands of years have been found withholes drilled in the skull, and the regrowth of bone indicates that the personsurvived. Scientists think that the holes were drilled to release demons that in-habited the individual causing aberrant behavior. In other cases, the clan healermight simply offer potions made from roots, barks, or leaves of plants as pre-scriptions for various disorders. Some combinations of drugs calmed the angrypatient, and others likely energized the inactive individual. What we now call“folk” remedies were the earliest attempts at dealing with the broad range of ill-nesses, including those that we now label as psychological disorders. If we listencarefully, we might hear the healer give the man’s wife a bag of herbs andleaves, and instruct her to brew a tea with them when the man awakens fromhis surgery.

If you will hold on tight, we are going to move on to ancient Greece. Be-fore we fly into the office of a healer, there are some things that you need toknow. The Greeks posited that there were four basic elements; fire, water,earth, and air. As all persons were constructed of these elements, their balancewithin the body was of major importance. Each element would correspondwith a particular characteristic that would create a humor within the body: fire= blood humor; earth = black bile humor; water = yellow bile humor, and air =phlegm humor. Fire, of course, was hot. Water was wet. Earth was dry, and airwas cold. The particular humoral mix could be seen in the person’s personalityand behavioral style. These ideas seem quaint to us today, but we still refer backto them. An angry person is said to be “hot-blooded” or to have a “fiery tem-per.” The old term for depression, melancholy, stems from the terms melan(black, as in melanin) and choli (bile, as in colon). Melan + Coli = melancholy.We may describe someone as phlegmatic, meaning “subdued.”

In the quarters of the ancient Greek healer, we have an opportunity towatch a treatment. The healer is assessing the patient’s humoral mix and willthen prescribe a treatment. The patient reports that he is often angry, and the

6 Introduction

anger involves him in physical fights with family, friends, and even strangers.The healer is recommending bloodletting as the treatment of choice to lower theforce of the blood humor that is obviously creating the problem. The patient lieson a couch and the healer cuts into the patient’s arm and blood flows copiouslyinto a bowl held by the healer’s assistant. When the healer has seen enoughblood flow, she will stanch the bleeding with folded linen and pressure. The pa-tient will then rest. Other treatments might include enemas to relieve the ex-cess of black bile, forced purging or the use of emetics for yellow bile, orcompression of the chest for too much air.

If you found that scene a bit unpleasant, be forewarned that the next stopmay be even more visceral. We are now in medieval France. We are flying over awalled town, and in the middle of the town square workers are preparing for anexecution. They are piling branches and wood around a stone column. Set highin the column is an iron ring. We are all thinking the same thing. They are plan-ning on burning someone to death. There, off to the right we can see a womanbeing dragged toward the post. We can hear the charges against her being read.

Fortunately our carpet allows us to understand medieval French. Theprisoner was found guilty of practicing the black arts, witchcraft. The court, achurch court it seems, has sentenced her and two other women to be burned aswitches. Her hands are tied to the iron ring and her feet secured. She is gaggedso she cannot say anything or cast a spell. A torch is lit. I think it is time for usto leave this place.

In the Middle Ages, the church developed as an arbiter of both what isnormal and what is abnormal, and then offered “cures” for the abnormal behav-ior. These cures ranged from prayer and meditation to exorcism and execution.The inquisition brought with it the beating, flogging, burning, hanging, anddrowning of those suspected of trafficking in the black arts. Interestingly, thoseblack arts included healing and midwifery. If a town was unfortunate enoughto have a disease manifestation such as the plague, it was considered the workof witches. Only a concerted search for the witches and their immediate eradi-cation could cleanse and heal the community.

Our next stop is going to be the seventeenth-century town of Salem,Massachusetts. We think that you know what we will find. We are in a court-room. As you can see, everyone is dressed just like the Pilgrims in the picturesof the first Thanksgiving. This, however, is no celebration. A woman isdragged into the courtroom and brought before the two judges. The chargesagainst her involve witchcraft. The accusers are three teenage girls who re-port having seen the woman muttering “spells” and having a conversationwith her cat. Some of the woman’s neighbors testify that they, too, saw her“acting strangely,” though other townspeople testify that she is a harmlessperson who caused no problems for anyone.

At that moment, we see something incredible. The teenage accusers fall tothe floor of the courtroom and seem to be having spasms and convulsions. Theypoint to the woman as they are doing it. Amazingly, the girls’ behavior is en-tered as “evidence” against the woman and she is pronounced a witch and sen-tenced to burn. We would later learn of the death of several women based onthe report of these teenage girls. Interestingly, when it was decided to stopusing the girls’ behavior as evidence, the girls’ spasms ceased.

The History, Politics, and Social Environment of Clinical Psychology 7

Our next stop on this magic carpet is outside Paris on a sunny Sunday af-ternoon. The year is about 1785. It is before the French Revolution, and thewealthy and elite of Paris are obvious. We can see carriages arriving, and well-dressed men and women are emerging from the carriages. It seems that theirdestination is a mental hospital called Salpetriére. The visitors do not seem intenton seeing a relative who might be residing in this particular hospital, but ratherthey are strolling along and viewing the inmates as if visiting a zoo. We can seesome inmates posed in postures that they seem to hold for exceedingly long pe-riods. Other inmates are playing with pieces of wood. A woman is cradling a ragas if it were a baby. The onlookers delicately cover their noses with perfumedhandkerchiefs to block the odor coming from feces-encrusted inmates, rottingfood, and inadequate hygiene facilities. Servants are setting a picnic lunch forsome of the sightseers . . . far away from the hospital building.

A quick trip over the English Channel takes us to an English hospital forlunatics: St. Mary Bethlehem, also known as the Bethlem Royal Hospital.Coming from within the walls of this building we hear the rumble of humanvoices. Some are shouting, some are crying, and some are making noises thatwe cannot interpret. When we hear the cacophony, we think that this placesounds as if it is out of control. It seems to exist without any sense of order.There is confusion and uproar everywhere. It is, in fact, pure bedlam—a con-traction of the hospital’s name still used to denote what we are witnessing.Bedlam is the uncontrolled and confusing events and actions we see in themidst of crises. We see visitors touring the hospital who, like their Parisiancounterparts, are laughing and mocking the residents. Some are even carryinglong poles to prod the patients and make them angry within their cages so thatthey will react with outrage and produce a better “show.” The guardians ofthese patients do nothing to protect their charges.

We fly back to eighteenth-century Paris and stop at the salon of a physi-cian, Dr. Franz Anton Mesmer. He was born in 1734 and died in 1815. He wascredited by some as having accidentally discovered the idea of group therapy.Mesmer argued that health or illness was a result of the harmony or discord be-tween the bodily fluids and the planets (e.g., “lunacy” was a result of the grav-itational pull of the moon). He later redefined his theory and suggested thatharmony or discord within the individual was a result of some distortion of theinternal magnetic fields.

Let’s observe Mesmer at work. Several patients are sitting around an oaktub, and the “magnetic fluid” is sending magnetic forces through iron barsthat patients are holding as extensions from the tub. Mesmer is walkingaround and speaking soothingly and quietly to the patients. He lays his handson them and evaluates the balance of their magnetic fluid. Some of the pa-tients in his treatments appear to faint or swoon and others seem to sit trans-fixed during their treatment. We would later learn that in the spirit of thetime, scientific support was deemed to be the mark of any treatment. After aninvestigation by the Paris Academy of Sciences, Mesmer’s model of treatmentwas found to be without merit and the academy would not support it. Al-though Mesmer later died in obscurity, his name lingers far beyond his treat-ment to describe someone who is mesmerized as being fixed on an object or ina trancelike state.

8 Introduction

We now fly ahead to Vienna in the early twentieth century, where ayoung neurologist has been building quite a reputation for himself. Dr. Sig-mund Freud, frustrated at not getting the faculty appointment that he sobadly wanted in the Department of Neurology at the University of Vienna, isabout to give a lecture. He has abandoned his academic quest and has starteda practice to treat patients who have what he calls “nervous disorders.” Freudhas not yet come to the podium and we can hear comments and discussion bymembers of the audience. “I’m aghast at some of the things that I heard abouthim,” commented a lawyer. “Well, he writes rather nicely, but some of hisstatements are a bit, how shall I say this? Over the edge,” responded anaccountant sitting nearby. A businessman commented, “His work is unsavory,at the least.” A fourth commented, “Well, he is one of us, so we should listenrespectfully.”

Freud comes to the stage and is introduced as the speaker of the evening.The president of the Vienna lodge of B’nai B’rith, a group of Jewish profession-als, presents Freud and his topic: The Interpretation of Dreams. We can only won-der what Freud has done or said to make it so difficult for him to get a hearingon this subject from his medical colleagues. He has sought to go to the peoplefor this presentation. The group listens to his presentation, but by the shakes oftheir heads, and the shared smiles, they are finding his presentation of dreamsas the “royal road to the unconscious” a bit much.

Let’s get back on our carpet and take a quick trip forward. World War Ihas broken out, and we are in an army recruitment center in 1917. Recruits arebeing given a test to determine their abilities and aptitude. The results of thetests will help in placing the soldiers where the military can gain the greatestvalue from their contributions. Two officers are discussing the testing program.“Darn shame this test. What they need to do is fight. Just courage and a gun iswhat they need. They’ll do what we tell them to do just like before, and heavenhelp them that doesn’t do what we tell them.” The second officer responds thathe had experiences in Cuba some 20 years earlier with soldiers who appearedto understand instructions, but were later killed. “We need to build a core ofcompetent, intelligent soldiers and more intelligent officers. Maybe this way ofselecting them will make a difference.”

The second officer does not know how prophetic he is. Binet’s work willbe the basis for the Army Alpha and the Army Beta tests in years to come. TheArmy Alpha and Beta tests were standardized measures for screening largenumbers of people to optimize recruit placement. These tests identified apti-tudes and skills to determine which positions in the military would be suitablefor an able recruit. Each test served the same purpose, but the Beta test couldbe administered to individuals who did not speak English as a primary lan-guage. The fact that all individuals could be examined with these assessmentsbecame significant not only for military recruiting purposes at the time but alsofor clinical applications after the war.

Hold on. We leave again and head for England. It is 1938 and we are ob-serving an old man speaking into an early wire recording machine. He speaksslowly and deliberately because of the prosthesis in his mouth. His speech issomewhat muffled but we can make out his English. It is Sigmund Freudspeaking of his career:

The History, Politics, and Social Environment of Clinical Psychology 9

I started my professional activities as a neurologist trying to bring relief to my neu-rotic patients. Under the influence of an older friend [Josef Breuer] and by my ownefforts I discovered some important new facts about the unconscious, insight, therole of instinctual urges, and so on. Using these new findings, I developed a newscience, psychoanalysis, a branch of psychology as a new method for the treatmentof the neurosis. I had to pay heavily for this bit of good luck. People did not believein my facts and thought my theories unsavory. In the end I succeeded in acquiringpupils and bringing up an international psychoanalytic association. But the strug-gle is not yet over.

He stops for a moment and then says, “Sigmund Freud.” We know thathe died of cancer the following year. It must make us thoughtful that by hisown words, Freud saw psychoanalysis as part of what we would call clinicalpsychology.

Next we travel to the United States. It is 1944, and we are looking in on amilitary strategy meeting at the Pentagon in Washington, DC. The Army is pon-dering what to do about World War II soldiers suffering from combat fatigue.(In World War I, it was called shellshock.) “We need to be able to do somethingwith these boys,” declares a colonel. Wearing the insignia of the medical corps,he argues for more psychiatrists for both field hospital work and behind thelines. The brigadier general asserts, “If they are doctors, we need them to becutting and patching these kids up to save their lives. I am less worried abouttheir mental health if they have shrapnel in their gut.” A major tentativelyraises his hand. “What about the possibility of using psychologists to deal withthe psychological problems? They are not physicians but they have studiedabout helping people with psychological problems.” “Where would we findthem?” asked the colonel. “I can contact several universities and see who mightbe available,” replied the major. “Do it,” commands the general.

Our next stop is at a coffeehouse in Witwatersrand, South Africa. It is theearly 1950s. A young psychiatrist is discussing an idea with another colleague.“It seems obvious. If patients are anxious, they have great difficulty being re-laxed. If they are relaxed it is hard to be anxious. What if we can teach anxiouspatients to relax? Wouldn’t that ease their problem?” His colleague shook hishead. “Dr. Wolpe, don’t be foolish! You are a trained psychoanalyst. You knowthat the anxiety is a symptom of the underlying conflicts. Sure, we can removethe anxiety for a moment or two, but it will return. Even if we help to removethe anxiety about one situation, it will only return in another symptom. Be-sides, the complexity of the anxiety disorders cannot be explained in so simple aparadigm.” We can only smile knowing the enormous impact that Joseph Wolpehad on his generations of students and thereby on millions of anxious patients.

Back to the Future

At this point, we come back and land our magic carpet. The rest of the history ofclinical psychology belongs in today’s world. The associations, organizations, divi-sions, meetings, certifying bodies, and philosophies of practice are contemporary.

10 Introduction

Yet in the practices, publications, and missions of these institutions, we see thehistorical influence of the people, events, and scientific eras that have shaped thefield of clinical psychology.

Major Organizations Concerned with Scientific Practice

Major organizational bodies relevant to the professional culture of clinical psy-chology include the American Board of Professional Psychology (ABPP), theAmerican Psychological Association (APA), and the Association for Behavioraland Cognitive Therapies (ABCT). Each of these organizations has specialty sub-divisions that reflect the growing complexity of clinical psychology. Establishedin 1948, the American Board of Examiners in Professional Psychology (nowshortened to American Board of Professional Psychology), offers advanced cer-tification of competency in a subspecialty of clinical psychology. These special-ties include clinical psychology, clinical child and adolescent psychology, andclinical neuropsychology.

Founded in 1892, the American Psychological Association (APA) is thelargest worldwide association of psychologists. With approximately 150,000members, the APA offers a vast number of programs and initiatives, including56 numbered divisions or special interest groups that focus on particular top-ics. Clinical psychologists are often affiliated with the following APA divisions:Clinical Psychology (12), Psychotherapy (29), Psychoanalysis (39), Psycholo-gists in Independent Practice (42), and Society of Clinical Child and AdolescentPsychology (53). There are many other divisions that the clinical psychologistmight be interested in joining. For additional information, see www.apa.org.

APA Division 12—Clinical Psychology

APA members who belong to this division are active in practice, research,teaching, administration, and study in the field of clinical psychology. Graduatestudents in APA approved or regionally accredited doctoral programs may be-come student affiliates. Members and student affiliates may also join one ormore sections of the division: Section II: Clinical Geropsychology; Section III:The Society for a Science of Clinical Psychology; Section IV: Clinical Psychologyof Women; Section VI: Clinical Psychology of Ethnic Minorities; Section VII:Emergencies and Crises; Section VIII: Association of Psychologists in AcademicHealth Centers (APAHC); Section IX: Assessment; and Section X: Graduate Stu-dents and Early Career Psychologists.

APA Division 29—Psychotherapy

APA members who also belong to this division share in fostering collegial rela-tions among APA members who are interested in psychotherapy. This divisionstimulates the exchange of information about psychotherapy, encourages theevaluation and development of the practice of psychotherapy, educates thepublic about the service of psychotherapists, and promotes the general objec-tives of the APA.