A 1 2 1 8 9 8 'J.BAKMJDWI.UJAW [umb Price 20 cents EPRINT AND CIRCULAR SERIES NATIONAL RESEARCH COUNCIL THE STA f i .INI- )LOGY By F. L. WELLS CHIEF OF PSYCHOLOGICAL LABORATORY, BOSTON PSYCHOPATHIC HOSPF L Published in Mc.ital II [Reprinted from MENTAL HYGIENE, Vol. VI, No. 1, January, 1922, pp. 11-22.] THE STATUS OF "CLINICAL" PSYCHOLOGY F. L. WELLS, PH.D. Chief of Psychological Laboratory, Boston Psychopathic Hospital HE problems of civilized human adjustment have long since divided themselves up among certain systems. Medicine has looked after man's body. Law has looked after his social relationships. Religion has assumed the care of his otherworldly relationships. The present discussion con- cerns psychology as a factor in these various disciplines, with special reference to medicine. The lack of coordination between medicine and psychology, in their application to the guidance of conduct, arises from the development of types of work, of a psychological nature, that have an appropriate place in the management of certain clinical and social groups of cases. This work is little covered in medical training, or, save exceptionally, by medical men. It is being covered more and less well by persons more and less competent in psychology or its techniques. With the ambition to be of service goes responsibility for adequate performance of that service. There is a growing sentiment that if psychology is to take its proper share in the guidance of human adaptations, there must be a more responsible organization of its work for this purpose. Under the auspices of the National Research Council, there was held at Washington, in the spring of 1921, a conference of representatives of psychiatry and psychology, to discuss the difficulties of the situation and to promote a better under- standing of the respective points of view. 1 The purpose of this paper is to review some of the nuclear remarks made on this occasion, with particular reference to the medical point 1 The following associations took part in the conference: American Associa- tion for the Study of the Feebleminded ; American Medico-Psychological Associa- tion; American Neurological Association; American Psychological Association; American Psychological Association, Clinical Section ; American Psychopatho- logical Association; National Committee for Mental Hygiene; National Research Council; National Research Council, Division of Medical Sciences; New York State Association of Consulting Psychologists; Southern Society for Psychology. 1 2 THE STATUS OF "CLINICAL" PSYCHOLOGY of view and its indications for action on the part of psycho- logical organizations. It is easy to agree that medicine and psychology should cooperate for the public good, etc. The essential issue is raised in asking whether such cooperation is to be secured through a new professional class, the psychologists, or through an infiltration of psychology into the medical curriculum. Forecast is made of a person "with biological, educational, social, psychological, and medical background; he need not have the various types of training in obstetrics, surgery, and the other varied fields of the conventional medical course." 1 Such a person should work as a highly qualified expert in the field of mental adjustments. To a program like this medicine would accede provided the training were given in a medical school, with enough of general medicine to justify the medical degree, and with the assumption of medical responsibilities. In thinking of back- ground, one should perhaps guard against overloading the informational side of such a program. Most of the informa- tional detail to be insisted on is of a medical character. There is certain information that must be available before any maladjustment case is handled with ordinary safety, and this information is not to be had save through medical training. As medicine sees it, the specialist postulated will have to be a physician. There is, however, a group of "clinical" psychologists large enough and coherent enough for the development of a definite esprit de corps. Certain conditions affecting a pro- fessional class of this kind should not be lost sight of. It belongs with the law and with medicine in dealing with human adjustments, as against engineering, for example, which deals with material things. The practitioners of law and medicine are in great part supported by individuals who seek pro- fessional help from the doctor when they are feeling sick, from the lawyer when they are feeling wronged. The value of a profession for private practice upon human beings de- pends essentially on what it can do to get people out of trouble. If psychology is to develop further as an accom- l Harry L. Hollingworth, PH.D. plishment of private practice in this sense, it must be able to take care of a certain class of individual troubles better than the lawyer or the physician can take care of them. Before predicating the development of a professional class of con- sulting psychologists, one must consider carefully how great is the class of troubles that psychology is distinctively quali- fied to meet. They are not unallied to the type of difficulties that now go to the religious confessor or to systems of healing that have a quasi-religious basis. There are grave difficulties in the way of meeting this type of troubles with the setting of scientific psychology that is now available. This is not out of harmony with the fact that individuals of good personality and exceptional insight have been able to make of themselves a Vaterersatz in the psychoanalytic sense, to guide less stable personalities among life's pitfalls, and earn material reward therefor, all in the name of scientific psychology. Such things are done in the name of medicine or law also, not to mention systems of far less standing. It is on these individual grounds that the few conspicuous successes in private work that psy- chology records seem best understood. They are not pro- tagonists of a professional class of the same standing that they, as individuals, represent. A professional class of a less pretentious order, the expert in mental measurement, or psychometrist, is already a part of the educational, and to some extent the psychiatric, system. Medical education here seems of rather less relevance than in the case of the dental practitioner. Few psychologists, however, would see in this development a solution of the problem, or consider that it adequately represented the contribution of psychology to medical or educational science. On the medical side, an approach to the adjustment already suggested is made through a three-year graduate medical course, at the end of which "one might be more or less authoritatively designated as a psychiatrist or neuropsychia- trist". 1 With such training one should come as close as is practicable to the ideal of the "psychobiologist". In con- sidering the substance of psychology's contribution to such a course, it should not be forgotten that practical, if not psy- IHugh T. Patrick, M.D. 4 THE STATUS OF "CLINICAL" PSYCHOLOGY chologically systematic, study of human behavior pervades the whole atmosphere of medical training to an extent approached in no other discipline save perhaps the law. The program suggested in the above paragraph is clarified by a proposal for "the development of medical education along the lines of extending the responsibilities and corre- spondingly the educational and practical equipment of the physician. . . . The physiologist would have been compelled to undertake certain practical work for mankind had not medicine adopted physiology ... as a basic science. Now if the medical profession is prepared to take over psychology . . . either as an independent science or as an extension of physiology, it seems that we have one possible solution of our present practical difficulty. ' n In view of such considerations, it is not surprising to find argument from the side of psychology for the introduction of psychobiology into medical education as a basic science. It is said of psychology and psychiatry that "one is very obviously a branch of science, the other a particular applica- tion of scientific knowledge. " 2 The term psychology is like chemistry in denoting both pure and applied science, but psychology has in psychiatry a term whose etymology denotes application. Actually, also, "clinical" psychology is non- medical psychiatry. 3 So soon as psychology, the science, is applied to human difficulties, it falls within the definition of psychiatry. The present teaching of psychiatry involves not a little teaching of psychology, whose fragmentary character is somewhat offset by its concreteness. The suggestion is offered that a saving of time when it is of particular value would be effected if the student had a carefully designed course in psychology early in the curriculum, or pre-medic- ally. The nearest alternative to the gradual incorporation of the medical phases of psychology into medical education is for "the psychologist to continue his present efforts to establish definite standards for psychological work, to lay down high 1 Robert M. Yerkes, PH.D. 2 Robert M. Yerkes, PH.D. 3 A psychologist has recently been appointed psychiatrist to the Bureau of Public Welfare in one of the Southern states. THE STATUS OF "CLINICAL" PSYCHOLOGY 5 definitions of what it is to be a psychologist, and to get these on record. ... On the other hand, psychiatry must continue to educate the medical profession to look upon itself as a distinct specialty dealing with mental disease in a strict sense." 1 The first of these proposals may and should be carried out irrespective of other developments. It happens that the medical phase of psychology where standards can be most objectively formulated is in the field of psychometrics. It should be a matter for official concern that the popular or medical conception of "psychologist" does not come to rep- resent something confined to the psychometric level. While "high definitions" must be less objective, these considerations make them probably as urgent. Any standards now prac- ticable should be formulated with the expectation of making them progressively more exacting. Ultimately they should embody medical requirements. The physician's disposition to concede the second point does not appear. It is contended that "the whole progress of clinical medicine is toward dealing with minor and rela- tively insignificant departures from health, where there is opportunity for prevention and early treatment." 2 Con- templation of the number and type of problems referred to psychiatry in out-patient services, or in contact with school systems, offers little prospect that this extension of medical activities will be limited by developments within psychology. The imponderabilia of medical discipline receive from the conference not more than their due weight. No class that does not pass through a comparable discipline should expect to enter into the privileged relationship of the physician toward his patient or the attorney toward his client. The old saying that one should always tell the whole truth to one 's doctor, one's lawyer, and oneself, expresses the almost equal privileges of the two relationships. "The doctor has devel- oped, during his medical course and hospital interneship and. practice, a protective and responsible relationship towards sick persons that no other profession has. ... Tn every civilized country women and children are entrusted in the 1 Harry L. Hollingworth, PH.D. 2 Thomas W. Salmon, M.D. 6 THE STATUS OF "CLINICAL" PSYCHOLOGY most confidential relations to physicians with hardly any casualties/' 1 In the varied and scattered training, sometimes one of sophistication rather than of experience, that now con- notes the psychologist, there is nothing comparable to this medical training. There is a rather strong feeling among medical men, not unshared in psychology, that the discipline of medical train- ing is a proper prerequisite to certain types of psychological research. These are exemplified as * ' the mental aspects of the sex life in children, people who are feebleminded, diseased, prevented from exercising a normal choice as to the extent of the investigation or the method." It is largely felt that matters thus touching on intimate and emotionally charged topics should be studied by medical men or under medical direction. Interest in such studies is by no means a criterion of qualification for them it may be quite the reverse. Their significance as a sexual Partialtrieb, the rationalization for them derivable from psychoanalysis, with the easy abuse of laboratory license, make it important in medical eyes that such avenues of research should be carefully guarded. That the discipline of the medical course does contribute to a more objective attitude toward such topics is hardly to be ques- tioned. Stress is also laid on the responsible nature of the physician's relationship, now far from established in the case of the psychologist. It is thought that these points are often passed over too casually. "The training of the medical man is not merely the question of giving him a certain amount of information ... he is brought into very special and somewhat privileged relation with sick people in regard to very vital issues. . . . This training enables the physician to put aside a great num- ber of conventional prejudices and personal feelings." 8 It is argued, and again with reason, that "medical training does not include the whole range of human behavior, nor does it concern itself with all problems of adaptation. There appear to be problems that have a wider significance than those which the medical training so far offered has enabled l Thomas W. Salmon, M.D. 3 Thomas W. Salmon, M.D. 3 C. Macfie Campbell, M.D. THE STATUS OF "CLINICAL" PSYCHOLOGY 7 one to handle well." This returns to the vital part of the issue. Granted that there is such a lack in medical training, is it to be supplied through psychology or through psycholo- gists? Is the question that of a professional class seeking to establish a standing as such, or is the contention for the place of a certain discipline in that system of training which is historically responsible for the organism's well-being? Medicine should not be expected to look with favor upon the management of an ailment independently of medical authority. It is said that some people will go to a psycholo- gist before they will to a physician, nor can the psychologist, without sacrifice of the patient's interest, at once send them to a physician. The physician replies that such cases are insignificant in number. It must not be lost sight of that very similar considerations would apply to persons who have first recourse to various systems of faith healing. The point is made that one does not fulfill one's duty to the patient without the best practicable control of objective factors with which the physician alone is trained to deal. Recognition of this is not lacking in psychological quarters. "There would be no hesitation on the part of all psychologists to feel that medical examination was desirable and essential, even if the findings were negative. . . . The question of sequence will arise. Which examination is to precede the other!" 2 To some extent this question answers itself in terms of the type of examination to which the individual first comes. As to synthesis, undoubtedly there are cases in which psychology provides a better synthesis than does medicine in its ordinary sense. Also, there are psychologists who can synthesize such cases better than the average physician. The best equipment for synthesis now available seems to be a genius for certain aspects of psychology plus a medical education. A physician states the ethics of the situation to the effect that "in the community where there is a well-trained body of medical men who have spent years in studying these disorders, it would be the natural thing, the desirable thing, for the psychologist to refer these cases to these individuals. In a community where such people are not available, then it might 1 David Mitchell, PH.D. 2 Francis N. Maxfield, PH.D. 8 THE STATUS OF "CLINICAL" PSYCHOLOGY be proper for the psychologist to deal with the cases in the light of his special training. The psychiatrist living in other communities would not resent this. One would like to have in every community the possibility of the individual getting help of a rather advanced nature." 1 Attention is directed to complications that may arise in the cross-reference between psychologist and physician. "Suppose the patient originally goes to the psychologist, who refers him to a physician, who finds him physically all right. . . . There is no assurance that the patient will remain that sort of patient. The question of diagnosis cannot be disposed of once and for all. ... If the psychologist is not familiar with psychoses, he is not in a position to decide either at the beginning or at any other stage when the individual needs medical help." 2 It will probably be approved by all physicians, and by many psychologists, "that the terms 'clinic' and especially 'clin- ical' be eliminated from the psychologist's technical vocabu- lary. The introduction of these terms has, to be sure, been innocent enough, but it now proves to have been unfortunate. Clinical psychology as it exists to-day is something entirely different." 3 The most forcible objection is the implication of a medical setting where none exists. The clinical psychologist also finds a large part of his work in educational rather than in pathological fields. As indicative of something the psy- chologist does not do, and not indicative of what he does, there is no term whose tabu at the hands of the psychologist is more advisable. A prominent medical school lists a course in "clinical physiology". In such a setting, it is not impos- sible for clinical psychology, as that portion of clinical prac- tice concerned with the mental processes of the patient, to find a more descriptive application. However extensive its boundaries, it is surely clear that the explored territory of psychology and the degree of organiza- tion within it do not constitute it a discipline coordinate to medicine or law or religion. Psychology is one of those sciences that have particularly to do with human health 1C. Macfie Campbell, M.D. 2 Hugh T. Patrick, M.D. 3 Communication from Robert 8. Woodworth, PH.D. THE STATUS OF "CLINICAL" PSYCHOLOGY 9 through human adjustment. The other sciences of this char- acter have developed naturally as medical sciences. Dis- tinguished names attest that the early days of psychology did not lack points of contact with medicine. Overlapping has been more recent. Neither anatomy nor pathology nor physiology nor psy- chology is so constituted as to carry the whole weight of a human-adjustment problem. Psychology is the latest of these to bring forward knowledge of particular value in such prob- lems. As such, it has a similar, but not greater, place as an autonomous profession than belongs to other medical sciences or to different branches of the law. All of psychology, indeed, is not a medical science, any more than is all of chemistry, from which medicine takes over its biological aspect. The * ' men- tal age" of psychology is that of chemistry fifty years ago, yet to take over psychology might be a larger order than could profitably be disposed of. If medicine does attempt to take over psychology, it is right to ask the taking over of not less than is relevant to medical problems in the broad sense in which medicine now conceives them. In one field of psy- chology namely, psychoanalysis principles and methods were both developed by physicians. 1 To this should be added the simpler, but more objective field of psychometrics, while granting that much routine work in this field requires no more psychological than medical background. Psychometrics should be covered up to the point where the cases in hand cease to be medical problems, wherever this line be drawn. The general course in psychology should be based on genetic study of the personality, giving more attention to affective and instinctive life than does psychometrics, but having a more objective foundation than psychoanalysis. If medicine is to dominate the field of human-adjustment problems, it should incorporate as much of psychology, as of other science, as is relevant thereto. This seems to be the best solution both for medicine and for psychology. Should one expect the standing of non-medical psychologists to be unfavorably affected by such a development? While medical education will un- i It cannot be too clearly realized that psychoanalysis is not a medical applica- tion of principles discovered by others, but grows out of principles and methods developed for strictly medical purposes by men with that type of training. 10 THE STATUS OF "CLINICAL" PSYCHOLOGY doubtedly become a more and more frequent and advantageous part of the consulting psychologist's equipment, this need not prejudice the standing of the consulting psychologist with com- petence already established on grounds of research, teaching, and personality. Persons being trained to-day in psychology have an advantage over their fellows of twenty years ago not incomparable with the advantage that medical education offers to the psychologists of the future. How seriously has this affected the standing of those who made this better train- ing possible ? The psychology of to-day is a species of myriapod with feet in the camps not only of medicine, but of religion, law, educa- tion, sociology, and industry. In these relationships it occu- pies a distinctive position and one with unusual possibilities. As Peter the Great labored in foreign shipyards for the ad- vancement of his undeveloped country, psychology should not hesitate to incorporate itself with better organized disciplines, in which its own progress is the sole limit to its influence, and some of which it may in time come to dominate. Law and education have perhaps not fewer natural affiliations with psychology than has medicine, but these disciplines are less markedly under scientific influence, and there is in them no hierarchy of sciences capable of assimilating the subject matter of psychology. It is hardly to be claimed that one can acquire sound train- ing in medicine and psychology within the space of four years. A graduate course in psychiatry, such as that before men- tioned, would have to carry the greater part of such psychol- ogical training as was given. This would be that part of psychology which could be made a graduate medical subject, assuming certain fundamentals pre-medically and in the medical course. The American Psychological Association recently conducted an inquiry as to what psychological subjects were considered of greatest importance from the standpoint of faulty mental adjustments. A composite of ratings by 81 persons profes- sionally concerned with this class of work rated various course titles as follows, a maximum score for practical purposes being 486 : THE STATUS OP "CLINICAL" PSYCHOLOGY 11 Mental measurement (first year) . 483 Exceptional children 482 Techniques applied psychology. . . 463 Mental diseases 432 Mental measurement (second year) 427 Educational psychology (first year) 390 Mental hygiene 382 Juvenile delinquency 371 Physiological psychology 368 Neurology: diseases of nervous system 363 Genetic (dynamic) psychology. . 353 Genetics (heredity) 344 Child hygiene 332 Psychology of learning 329 Sociology, pathological 315 Developmental psychology 313 Statistics, advanced 307 Social psychology 300 Higher mental processes 300 Physiology 297 Speech defects 288 Vocational psychology 286 Educational psychology (second year) 285 Biology 277 Sociology, general 257 Biometric methods. . . 229 Systematic psychology 228 Industrial psychology (first year) 223 Social service (methods) 222 Practice of psychology 198 Anthropology 196 Clinical physiology 196 Class experiments 188 General pathology 178 Industrial hygiene 168 Animal psychology 162 Zoology 148 Education, seminar 147 Personnel administration 145 Industrial psychology (second year) 133 History of psychology 127 Educational systems 120 Embryology 112 Psychological ethics 106 Economics 92 Business administration (first year) 86 Physiological chemistry 77 Advertising and selling 65 Bacteriology 65 Business administration (second year) 50 Business ethics 23 Epistemology 3 Subjects of medical bearing rank somewhat conspicuously in this classification. A graduate course in neuropsychiatry might make out its curriculum from the ten subjects heading the above list. The topics that psychologists regard as most important are pretty much those that medicine would under- take to provide. Some of them, indeed, depend on medical resources and cannot be had without medical cooperation. The main conclusions that seem to emerge are that psycho- metrics is the task of technical experts who often are not and seldom need to be psychologists in the broad sense that ought to attach to the term. It is doubtful if the problems of clinical or pathological psychology are such as to support an important professional group independently of medical foun- dation. Medical discipline gives the best background, and an all but requisite type of background, for inquiries involving the major affective life of individuals. There is no funda- 12 THE STATUS OF "CLINICAL" PSYCHOLOGY mental conflict between psychology and medicine; it arises among physicians, on the one hand, and psychologists who are masters of certain medical techniques and occupied with certain medical problems that medicine has not assimilated. Medicine should assume greater responsibility for them, when the conflict will disappear. Meanwhile the administrative duty of psychology is to develop progressively higher standards in training and accomplishment and, within those limits where reasonably accurate judgment is possible, means of attesting those who meet these standards. That this can and should be done on the psychometric level seems clear. On the level of the independent consultant, one must distinguish carefully between measures that further the services of psychology to society and those that seem primarily for the interest of a professional group. The latter policy would certainly be without value, and might be disastrous, to the standing of the profession as a whole.