Table Of ContentREADINGS 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
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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
