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10.1146/annurev.clinpsy.1.102803.143758

Annu. Rev. Clin. Psychol. 2005. 1:1–30

doi: 10.1146/annurev.clinpsy.1.102803.143758
Copyright
c 2005 by Annual Reviews. All rights reserved
First published online as a Review in Advance on October 26, 2004

A HISTORY OF CLINICAL PSYCHOLOGY AS A

PROFESSION IN AMERICA (AND A GLIMPSE
AT ITS FUTURE)

Ludy T. Benjamin, Jr.

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Psychology Department, Texas A&M University, College Station,

Texas 77843; email: [email protected]

Key Words assessment, managed care, professional organizations, psychiatry,

psychotherapy
■ Abstract Clinical psychology emerged as a profession in the United States in the
1890s with studies conducted by psychologists with patients in the mental asylums of
that time, and with the founding of Witmer’s psychological clinic, where he treated
children with learning and behavioral problems. This chapter traces the history of
clinical psychology as a profession, from the focus on assessment at the turn of the
twentieth century to the provision of psychotherapy that would come to dominate the
field after World War II. It concludes with a discussion of some of the contemporary
concerns in the profession and how those might impact the future practice of clinical
psychologists.

CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PRECURSORS TO CLINICAL PSYCHOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
WITMER AND THE BEGINNINGS OF CLINICAL PSYCHOLOGY . . . . . . . . . . 4
MENTAL TESTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
EXTERNAL INFLUENCES ON CLINICAL PSYCHOLOGY AT THE
TURN OF THE TWENTIETH CENTURY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SEEKING A PROFESSIONAL IDENTITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A VOICE FOR PROFESSIONAL PSYCHOLOGISTS . . . . . . . . . . . . . . . . . . . . . . . 12
THE RISE OF PERSONALITY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
WORLD WAR II AND THE EMERGENCE OF MODERN CLINICAL
PSYCHOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
NEEDED: A TRAINING MODEL FOR CLINICAL PSYCHOLOGY . . . . . . . . . . . 17
WORLD WAR II AND PSYCHOLOGISTS AS PSYCHOTHERAPISTS . . . . . . . . 19
MARKERS OF A PROFESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CLINICAL PSYCHOLOGY’S GOLDEN AGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CRISES IN CONTEMPORARY CLINICAL PSYCHOLOGY . . . . . . . . . . . . . . . . . 23
WHAT DOES THE FUTURE HOLD? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

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2 BENJAMIN

INTRODUCTION
Since the popularization of psychoanalysis in America, shortly after Sigmund
Freud’s only visit to the United States in 1909, the American public’s stereotype
of a psychologist was a practitioner listening to the woes of a patient reclining
on a couch. It would require another 50 years and the development of clinical
psychology as a profession before that stereotype would become prototype (with
or without the couch). Now, early in the twenty-first century, roughly a century
after Freud’s visit, the profession of clinical psychology is once again undergoing
considerable change. This chapter provides a selective historical account of the
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development of this profession over the past century and offers some speculations
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about what may lie in the future for those individuals who choose to practice as
clinical psychologists.
The Commission for the Recognition of Specialties and Proficiencies (2004)
defined the professional clinical psychologist as follows:
Clinical psychology is a general practice and health service provider specialty
in professional psychology. Clinical psychologists assess, diagnose, predict,
prevent, and treat psychopathology, mental disorders, and other individual or
group problems to improve behavior, adjustment, adaptation, personal effec-
tiveness, and satisfaction. What distinguishes clinical psychology as a general
practice specialty is the breadth of problems addressed and of populations
served. (p. 1)
The multiple roles listed in this definition—assessment, diagnosis, prevention,
treatment—were not all indigenous to the pioneering clinical psychologists. The
assessment role is arguably the beginning of clinical psychology. It emerged from
the research of the new science of psychology at the turn of the twentieth century
and has been maintained as an important feature of clinical practice throughout
its history, although the growth of managed care in the 1980s has diminished its
role in recent years. Among the multiple roles of the psychologist practitioner,
assessment—the crown jewel of clinical psychology for decades—met with the
least resistance from those practitioners, namely psychiatrists, who had already
staked claim to the domain of psychological treatment. The other roles, especially
treatment, would not be won so easily. Clinical psychologists battled psychiatrists
for much of the last half of the twentieth century to win their place in professional
practice on such issues as licensure, insurance reimbursement, hospital privileges,
and the independent practice of psychotherapy. They won some of those battles
because clinical trials research indicated that doctoral-level psychologists could do
the work as well as their medical counterparts in psychiatry. Interestingly, psychol-
ogy’s place of preeminence in the psychotherapeutic world is being challenged to-
day by a number of other practitioner groups, mostly trained at the master’s degree
level, who are calling for professional privileges based on clinical trials research
that shows that they can do the therapeutic work as well as the MD- and PhD-
trained therapists. The practice of psychotherapy is a significant part of this story,
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HISTORY OF CLINICAL PSYCHOLOGY 3

but it is important to remember that psychotherapy was not always the principal
activity of the clinical psychologist, and it is likely that the profession will evolve
further to include a host of other activities, including some of those abandoned in
the 1950s when the lure of psychotherapy proved so seductive in defining modern
clinical psychology.

PRECURSORS TO CLINICAL PSYCHOLOGY

Long before there was a science of psychology, there was a practice of psychol-
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ogy. Indeed the practice of psychology, for example, the giving of aid to persons
in psychological distress, likely existed from the beginning of human history. In
the eighteenth and nineteenth centuries there were many psychological practition-
ers who operated under a variety of labels such as phrenologist, physiognomist,
graphologist, mesmerist, spiritualist, seer, psychic, medium, mental healer, and
psychologist. No certification or licensure laws existed to define the training or
practices of these individuals, and there were few laws to protect the public from
fraudulent practices. Yet, like today, there were persons in centuries past with rela-
tionship difficulties, depression, and questions about vocational choices or about
problem children, and they sought out individuals who were believed to be capable
of rendering aid and answers (Sokal 2001). The profession of clinical psychology
that developed in the twentieth century would join these other practitioner groups
in trying to mark out its domain of expertise.
By the beginning of the nineteenth century, the assessment, diagnosis, and treat-
ment of mental illness (especially serious mental illness) were largely in the hands
of one of the earliest medical specialties, psychiatry. A history of the psychiatric
profession is beyond the scope of this chapter, but some brief coverage is necessary
to set the context for the later conflicts between psychiatry and clinical psychology.
Throughout the nineteenth century, most American psychiatrists worked at one
of the many “lunatic asylums,” later to be known as hospitals for the insane, and
then as state hospitals, mental hospitals, or retreats. These hospitals began in the
late 1700s, following the American Revolution, with three existing by 1800, and
they grew to more than 300 in the 1960s, when federal legislation ended their reign
as America’s solution to the care of the seriously mentally ill.
These asylums began as places of hope, limited to a manageable maximum
of 250 patients, with each asylum headed by a psychiatrist superintendent who
planned the course of moral therapy for each patient. In 1844, in recognition of
common problems facing the asylums, the superintendents organized themselves
into the Association of Medical Superintendents of American Institutions for the
Insane (AMSAII) and in the same year formed a new journal, the American Jour-
nal of Insanity. Seventy-five years later, the optimism of cure had faded as chronic
cases swelled individual hospitals to thousands of patients. Psychiatrists found
their profession suffering from low morale and low prestige. By the 1920s, they
had reinvented themselves with roles outside of the mental hospitals and with
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4 BENJAMIN

new treatment regimes in those hospitals, so-called somatic treatments that would
include the shock treatments of the 1930s that were believed to be more firmly
grounded in medical science. The AMSAII changed its name in 1921 to the Amer-
ican Psychiatric Association and the name of its journal to the American Journal
of Psychiatry (Grob 1994).
Soon the effectiveness of the highly touted somatic treatments came into ques-
tion. The treatments seemed to improve manageability of patients, but long-term
cures were rare, and the patient population continued to grow, making many of
the state hospitals into warehouses of lost humanity, and the subject of govern-
ment investigations, exposé books, and sensationalistic films depicting the alleged
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horrors of the asylums. By the 1960s, there were pressures from many sectors to
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do something about the stigma of the asylums. The solution, based on overcon-
fidence in the new psychotropic medications and a mistaken belief that patients
would be cared for by family members in their home communities, was the Com-
munity Mental Health Centers Act of 1963, signed by President John Kennedy.
The legislation called for the establishment of Community Mental Health Centers
in all communities with populations greater than 30,000, in which most patients
suffering from serious psychological disorders would be handled on an outpa-
tient basis. This federal act established what is known as deinstitutionalization,
marking the release of hundreds of thousands of mental hospital patients, and
defining another chapter in America’s failure to provide for its mentally impaired
citizens.

WITMER AND THE BEGINNINGS OF

CLINICAL PSYCHOLOGY
The American Psychological Association (APA) held its fifth annual meeting in
December 1896 in Boston, where one of the presenters was Lightner Witmer,
then in his fifth year as head of the psychology program at the University of
Pennsylvania. In his remarks, Witmer (1897) urged his audience of academic
colleagues to use their psychology to “throw light upon the problems that confront
humanity” (p. 116). Witmer had followed his own advice earlier that year, in
March, when he had begun to evaluate and treat cases of psychological problems
in what he labeled his psychological clinic, the first such clinic in the United States
and perhaps the first in the world (McReynolds 1997).
Witmer’s first case was that of a 14-year-old boy who had spelling problems.
The boy was brought to Witmer by a schoolteacher who reasoned that if psychology
was the science of mind, then it ought to be able to help the student. Witmer was
successful in treating the problem and, as word of that success spread, other cases
were brought to the clinic. The founding of this clinic is typically marked as the
starting point of clinical psychology and of school psychology. Given the nature
of the cases that Witmer saw, his activities were closer to the latter than the former
when compared to the practice of those two specialties today. In the beginning of
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HISTORY OF CLINICAL PSYCHOLOGY 5

the clinic, Witmer handled most of the cases himself, usually schoolchildren who
had behavioral or learning problems. As the caseload grew, he hired additional
staff and used some of his own doctoral students as clinic staff.
In 1907, Witmer began a new journal, entitled The Psychological Clinic, as
a vehicle for publishing his case studies in which descriptions were provided of
the presenting symptoms, the diagnoses, and the treatments. The lead article in
the inaugural issue of the journal was entitled “Clinical Psychology,” an article in
which Witmer laid out a program for doctoral training in the field that he had named
(Witmer 1907). In his clinic, Witmer made use of an interdisciplinary approach to
both assessment and treatment, as described by O’Donnell (1979):
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Children would be referred to the clinic through the school system. Following
medical diagnosis, subjects would undergo an anthropometric, optometric,
and psychometric examination. . .. Witmer converted such experimental ap-
paratus as the chronoscope, kymograph, ergograph, and plethysmograph into
diagnostic devices by substituting the child for the trained introspectionist.
Similarly, the Seguin form board—formerly used as a pedagogical tool—
was transformed into an instrument for testing a child’s powers of memory,
visual discrimination, and muscular coordination. Complementing psycholo-
gist and physician, the social worker would prepare a case study of the child’s
background. Clinical records were compiled with the threefold purpose of
correlating case histories in order to produce generalizations, of standardiz-
ing tests, and of establishing new diagnostic techniques. Testing completed,
a final diagnosis would be made, followed by attempts at remedial treatment.
(pp. 6–7)
Although Witmer’s clinical work would not mirror the practices in modern
clinical psychology, his importance in a history of clinical psychology should not
be underestimated. He understood that life’s difficulties were often the result of
cognitive and behavioral problems and that psychological science should have
the means to fix those problems. He adapted the research tools of his science to
serve as diagnostic instruments, and he developed innovative treatments to help
his clients. Among American psychologists, he was the first to speak so publicly
and so forcefully for establishing a helping profession. As O’Donnell (1979) has
written, “While others called for an applied psychology, Witmer enacted one”
(p. 14).

MENTAL TESTING
If there is one activity that characterized applied psychology in the first half of
the twentieth century, it is psychological testing, especially intelligence testing.
The clinical assessment work had begun in the 1890s with psychologists, such as
Boris Sidis and William Krohn, who were employed at mental hospitals where
they engaged in research to compare abnormal and normal minds. Yet, both Sidis
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6 BENJAMIN

and Krohn abandoned the work after a few years, and few other psychologists took
up the cause at that time.
Another psychologist active in testing in the 1890s was James McKeen Cattell,
who coined the term “mental test” in 1890. Cattell modeled the largely anthro-
pometric tests he constructed on the work of Francis Galton, with whom Cattell
had studied. Cattell’s mental tests consisted of measures of sensory, motor, and
cognitive functioning, as well as physical measurements of the individual. Cattell
believed that his tests were measures of intelligence and could be used to predict
academic success. Among his measures were tests of head size, reaction time, and
sensory abilities. Head size was supposed to be a measure of brain size, reaction
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time was thought to be an indicator of the speed of neural processing, and be-
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cause the British empiricists had convinced most of the psychological world that
all knowledge comes to the mind via the senses, the tests of sensory acuity were
also believed to be related to intelligence. When the correlation coefficient was
invented, one of Cattell’s graduate students used it to measure the relationship
between Cattell’s measures of “intelligence” and students’ performance in school,
finding, alas, zero correlations (Wissler 1901). Those negative findings ended Cat-
tell’s research program in anthropometric mental testing (Sokal 1982). However,
alternative measures of intelligence were just around the corner, and they would
define the way in which most clinical psychologists would make a living in the
first half of the twentieth century.
Henry Herbert Goddard, one of G. Stanley Hall’s students from Clark Univer-
sity, was hired in 1906 to be the director of psychological research at the New Jersey
School for Feebleminded Boys and Girls in Vineland, New Jersey. His research
was directed at assessment of levels of mental retardation and a determination of
what actions might be taken to aid the development of those children. Goddard
was frustrated to find that extant American psychology offered him little help, so
he journeyed to Europe in 1908, having heard that experts there were more ad-
vanced in their understanding of mental retardation. In Europe, he discovered the
testing work of Alfred Binet and Theodor Simon, and shortly thereafter published
the first version of the Binet intelligence scale in America, labeled the Binet and
Simon Tests of Intellectual Capacity (Goddard 1908). Unlike Cattell’s tests, this
scale emphasized abilities similar to those required for success in school, such as
verbal fluency, imagination, numerical reasoning, and comprehension. Also unlike
Cattell’s tests, the Binet scores correlated positively with school performance. The
popularity of the Binet testing procedure spread throughout psychology, first to
other “feebleminded” populations and then to usage across the intellectual spec-
trum, including studies of the gifted by Lewis Terman of Stanford University.
Terman modified the scale in 1916, creating a revision and extension of the Binet-
Simon Intelligence Scale (Terman 1916) that would become known simply as the
“Stanford-Binet,” the dominant measure of intelligence in America for the next
40 years (see Minton 1988, Zenderland 1998).
When the United States entered the First World War in 1917, psychologists
found themselves hurriedly involved in two assessment activities. One activity
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HISTORY OF CLINICAL PSYCHOLOGY 7

was in the field of personnel work headed by Walter Dill Scott that developed
selection instruments for various military occupations. The second activity was
a program of intellectual assessment headed by Robert Yerkes that was intended
to screen out those individuals who were judged psychologically unfit for mil-
itary service. In the latter effort, Yerkes, Goddard, Terman, and others met at
the Vineland School to plan the test. The immediate problem was to convert
individual testing methods into a group test that could assess hundreds of re-
cruits at a time. They eventually settled on a multiple-choice format, suggested
by Arthur Otis, one of Terman’s graduate students, and created two versions of
a group test, one labeled the Army Alpha (for English speakers) and the other
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the Army Beta (for non-English speakers and those who were illiterate). The
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psychologists—nearly 40 of them—who worked on the test completed the job

by December of 1918, including some pilot testing. The actual testing program
began in early 1918; by its conclusion in 1919, more than 1.7 million soldiers had
been tested (Yerkes 1921). Although the military actually made little use of the
test results, the assessment program was deemed a general success, with the result
that psychologists received considerable favorable publicity for their assessment
skills.
Psychologists were also involved with psychiatric cases at the end of the war,
principally “shell shock” (post-traumatic stress disorder) victims at the Army
hospitals. Harry Hollingworth, who had earned his doctorate in psychology at
Columbia University from Cattell, Edward Thorndike, and Robert Woodworth,
was stationed at the Army hospital in Plattsburg, New York, “where soldiers with
persistent psychoneurotic symptoms were assembled for further observation and
diagnosis, care and treatment” (Hollingworth 1920, p. ix). The military consid-
ered the individuals suffering from shell shock to be psychologically weak, and the
hope had been that they could be identified in a recruitment assessment program
and prevented from enlisting. However, a number of psychologists and psychi-
atrists disputed that diagnosis, arguing that the horribly traumatic conditions of
war could produce that kind of breakdown in almost any soldier under certain
circumstances. Not surprisingly, psychologists found these cases interesting. In
the hospitals, psychologists typically administered a test battery at the time of ad-
mission for all patients. The battery included a measure of intellectual functioning
(Army Alpha), separate tests of reasoning and decision making, tests of vocational
interests and aptitudes (for guidance in occupational therapy), and a measure of
morale.
Hollingworth was also engaged in personality assessment at Plattsburg using
a test developed by one of his mentors. Woodworth’s Personal Data Sheet (1919)
was a test commissioned by the Army in an effort to identify soldiers who would be
susceptible to shell shock, and would today be labeled a measure of neuroticism.
The test was administered not only to the shell shock patients but also to other
patients and a number of army personnel who had not been in combat. Personality
assessment would shortly join intellectual assessment as the two principal tools in
the arsenal of clinical psychologists.
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8 BENJAMIN

EXTERNAL INFLUENCES ON CLINICAL PSYCHOLOGY

AT THE TURN OF THE TWENTIETH CENTURY
For centuries, the etiology of mental illness had been debated, and throughout much
of that history, there was general agreement that the causes were somatic in nature.
There were occasional voices that argued for psychic interpretations but none so
forceful as that of Sigmund Freud. Freud’s emphasis on psychic factors would
validate psychologists’ place in the treatment of the mentally ill. Although Freud’s
influence was paramount among the external forces to affect clinical psychology,
the early twentieth century saw other influences as well, including the Mental
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Hygiene Movement, the Emmanuel Movement, and the support of neurologists

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such as Morton Prince.

At the age of 53, Freud was invited by G. Stanley Hall to speak at the twen-
tieth anniversary celebration of Clark University (Rosenzweig 1992). Freud, in
a letter to Carl Jung, found it amusing that Americans would celebrate such an
anniversary—20 years! (McGuire 1974). Freud delivered five lectures on psycho-
analysis at Clark. He likely never envisioned the impact his ideas would have on
this side of the Atlantic. Five years after his visit there was an American psycho-
analytic journal, an American Psychoanalytic Association, and training programs
in psychoanalysis. Although most American psychologists of the 1910s rejected
Freud’s psychoanalytic theory as being outside the bounds of science, the American
public embraced Freudian ideas with great interest. Hornstein (1992) has written
that by the 1920s, psychoanalysis had been accepted by the American public as
the one legitimate science of psychology.
The year before Freud’s visit to America, Beers (1908) published his book,
A Mind That Found Itself. Beers attempted suicide at the age of 24 and subsequently
was confined for two years in a mental asylum. After his release he wrote about his
experiences, detailing the horrible treatment that he witnessed and experienced, and
calling for the reform of mental institutions. Johns Hopkins University psychiatrist
Adolf Meyer took an interest in the book and in Beers, and the two of them found
grounds for common work. Both believed that many cases of mental illness could
be prevented by social reforms in America. Together they established the National
Committee for Mental Hygiene, whose agenda was to bring about societal changes
that would lead to psychologically healthier lives and to improve the conditions
of life and treatment in mental hospitals. Their activities became known as the
Mental Hygiene Movement, a movement that was active in fits and starts until its
eventual demise in the early years of the Great Depression. Meyer and Beers had
disagreements that caused Meyer to leave the movement after only a few years.
Beers persisted with little success and was eventually committed to a private mental
hospital where he died at age 67. Historians are in general agreement that the Mental
Hygiene Movement was wholly ineffective in achieving its goals, and that there
were no reforms in mental hospitals that could be attributed to its efforts. However,
the movement did bring greater public attention to the issues of mental health at a
time when psychiatrists and psychologists were reevaluating their roles regarding
the mentally ill (Grob 1994).
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HISTORY OF CLINICAL PSYCHOLOGY 9

In the same year that Beers’ asylum exposé appeared, Elwood Worcester pub-
lished Religion and Medicine: The Moral Control of Nervous Disorders (Worcester
et al. 1908). Worcester had completed his doctorate with Wundt in 1889 and worked
for a few years as a professor of psychology and chaplain at Lehigh University,
where his interests in clinical psychology originated. In 1906, while serving as
rector of the Emmanuel Church in Boston, Worcester invited those members of
his congregation who had moral or psychological problems to visit him the follow-
ing morning. Worcester expected that a few might come but was astounded when
nearly 200 appeared. The demonstrated need led him to establish a therapeutic
program through the church that consisted of a medical exam by physicians and an
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interview with Worcester. Based on those results, some individuals were selected
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for psychological treatment, which was in effect a program of psychotherapy, with

some use of hypnosis and relaxation training.
Historian Eric Caplan (1998) argued that when psychotherapy emerged in the
beginning of the twentieth century, the medical profession had virtually no inter-
est in it. However, the success of the Emmanuel Movement, which spread quickly
to other churches across the country, made physicians reevaluate their position,
believing that ministers were involved in medical practice. Psychologists joined
their physician colleagues in attacking the Emmanuel Movement. Witmer wrote,
“Whatever Dr. Worcester’s practice may be in his own church clinic, the principles
of psychotherapy to which he and his associates adhere, are based upon neither
sound medicine, sound psychology, nor to our mind, upon sound religion” (quoted
in Caplan 1998, p. 148). In his 1909 book on psychotherapy, Harvard psychologist
and physician Hugo Münsterberg wrote, “The only safe basis of psychotherapy
is a thorough psychological knowledge of the human personality” (p. 9). For
Münsterberg (1909), psychology would provide the knowledge, yet he believed
that the therapy should reside in the hands of the physicians. Concerned about the
Emmanuel Movement, Christian Science, and other mental healing approaches
popular at the time, he wrote, “Scientific medicine should take hold of psychother-
apeutics now or a most deplorable disorganization will set in, the symptoms of
which no one ought to overlook today” (p. x).
By 1910, the Emmanuel Movement was effectively at an end. Medicine took
control of psychotherapy, which became the domain of psychiatry. In the coming
decade, psychologists’ views of psychotherapy would change, especially due to
their experiences in the First World War. But it would require another 40 years and
another world war to wrest control away from psychiatry and add psychotherapy
to the arsenal of clinical psychologists.
As has been shown, the first decade of the twentieth century was a time of
widespread interest in questions of psychopathology, including the psychoanalytic
ideas of Freud, the Mental Hygiene Movement’s encouragement of prevention via
societal change, and Elwood Worcester’s promotion of psychotherapy. Another
major player in this decade was Morton Prince, a neurologist who had close ties
to the new field of psychology. Prince published his best-known book in 1905,
The Dissociation of a Personality, the most complete description to that time of
a case of multiple personality (dissociative identity disorder). He believed that
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10 BENJAMIN

psychologists should be involved in both the study and treatment of mental dis-
orders, and especially encouraged them to bring their science to bear on clinical
questions. In 1906, Prince founded the Journal of Abnormal Psychology (which he
later donated to the American Psychological Association) as an outlet for research
and case studies on psychopathology. A number of prominent psychologists such
as Sidis, Harvey Carr, Joseph Jastrow, Münsterberg, Scott, Yerkes, and Knight
Dunlap published in the journal, adding to psychology’s foothold in the psychi-
atric domain. Each of these forces, along with the work in assessment, especially
intelligence testing, would impact the growth of clinical psychology in the years
following World War I.
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SEEKING A PROFESSIONAL IDENTITY

Prior to World War I, most psychologists were employed in university settings.
However, a small number of psychologists made their living in applied settings—
in schools, hospitals, and businesses. After the war, the applied fields began a
sustained period of growth, in part sparked by psychologists’ experiences during
the war in addressing problems of application but also because of the growing
reputation of the applicability of psychology, stimulated by the perceived success
of the assessment and selection programs of the war. The numbers were great
enough by 1917 for J.E. Wallace Wallin, a psychologist who worked with mentally
retarded children in the schools, and others to found the American Association of
Clinical Psychologists (AACP). Membership in this group was supposed to serve
as a kind of credential, identifying the individual to the public as a legitimate
psychologist, but the public knew nothing of the organization and had no real way
to distinguish among the myriad practitioners who claimed to offer psychological
services.
The growth of clinical psychology did not go unobserved by the psychiatric
community, which issued a report in 1917 calling for an end to clinical psychology.
The psychiatrists were willing for psychologists to apply their assessment skills
in the areas of education and in industry (for example, in advertising and sales),
but psychiatrists were adamantly opposed to the clinical work. The report of a
committee of the New York Psychiatrical Society concluded:
We recommend that the Society express its disapproval of psychologists (or
of those who claim to be psychologists as a result of their ability to apply
any set of psychological tests) undertaking to pass judgment upon the mental
conditions of the sick, defective or otherwise abnormal persons when such
findings involve questions of diagnosis, or affect the future care and career of
such persons. (Hollingworth 1917, p. 224)
Psychologists responded promptly, noting that they had developed many of the
diagnostic instruments in use by clinical psychologists, and that they were thus best
qualified to interpret their results with regard to questions of mental functioning
and abnormality (see Franz 1917).
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HISTORY OF CLINICAL PSYCHOLOGY 11

Leta Hollingworth, a member of the psychology faculty at Teachers College of

Columbia University and one who had worked in clinical services in New York,
was also a member of AACP. She led an effort in 1918 for certification of applied
psychologists by academic departments, arguing that the doctoral degree should be
the minimal standard for clinical work in psychology. She recommended further
that the degree “Doctor of Psychology” be established for clinical psychologists
and that it include a year of “apprenticeship” (Hollingworth 1918, p. 283).
The APA was approached about aiding with the certification effort, but the
Association declined, arguing that its bylaws were specific with regard to advancing
psychology as a science. However, there were voices within APA who worried
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that the growth of AACP could hurt organized psychology. One side argued for
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bringing the group into the fold of APA, whereas the other argued that the goals of
AACP did not fit within the stated goals of APA. AACP was also conflicted about
whether it wanted to be part of APA or continue to be independent. There were
perceived advantages to either situation. Eventually the membership in AACP
agreed to dissolve their organization, and they reestablished themselves in 1919
as the Section on Clinical Psychology within APA (Routh 1994).
The growing public awareness of psychology after the war was accompanied
by a public euphoria in America in the 1920s. America had helped win the Great
War, a war that was supposed to end all wars. Except for a slight recession in
the early 1920s, the American economy appeared particularly strong, whereas
those in Europe were struggling. The long campaign for suffrage was over, and
women finally had the right to vote as of 1920 and the nineteenth amendment
to the U.S. Constitution. The rise of factories of many kinds meant hundreds of
new job descriptions, greatly expanding vocational choices. Unprecedented waves
of immigrants, mostly from Europe and seeking new opportunities in America,
continued to pour through the facilities at Ellis Island. It was a decade of great
optimism, and part of that public optimism was a belief in the value of psychology
for everyday living, a belief reinforced in the books and magazines that Americans
were reading. Journalist Albert Wiggam (1928) was one of many who issued the
call to take advantage of the services that psychologists had to offer:
Men and women never needed psychology so much as they need it to-day.
Young men and women need it in order to measure their own mental traits
and capacities with a view to choosing their careers early and wisely . . .
businessmen need it to help them select employees; parents and educators
need it as an aid in rearing and educating children; all need it in order to secure
the highest effectiveness and happiness. You cannot achieve these things in the
fullest measure without the new knowledge of your own mind and personality
that the psychologists have given us. (p. 13)
H.G. Wells, writing for the American Magazine in 1924, told his readers,
“The advances that have been made in psychology . . . have been enormous. The
coming hundred years or so will be, I believe, essentially a century of applied
psychology. . .. It will mark a revolution in human affairs.” (p. 190)
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12 BENJAMIN

Even psychologists touted their own wares. Writing for the public in 1925,
behaviorist John B. Watson argued for why psychology was so critical for child
rearing:
Give me a dozen healthy infants, and my own specified world to bring them
up in and I’ll guarantee to take any one at random and train him to become
any type of specialist I might select—doctor, lawyer, artist, merchant-chief
and, yes, even beggar-man and thief, regardless of his talents, penchants,
tendencies, abilities, vocations, and race of his ancestors. (p. 82)
Where there is demand, there is usually supply. Americans sought psycholog-
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ical services in unprecedented numbers, and, not surprisingly, there were many
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nonpsychologists who were more than willing to offer their services for a fee. This
situation further alarmed the APA Section on Clinical Psychology, which urged
APA to establish a certification program to identify properly trained psychologists
for the public. The certification program was begun in 1921 but abandoned a few
years later when only 25 psychologists became certified, and because it was clear
that the certification had no impact on the public’s choosing of psychologists.
The Roaring Twenties were not without their problems: Overcrowding in the
cities, poverty, and problems with acculturation for the new immigrants provided
other opportunities for clinical psychologists. Juvenile delinquency was a growing
concern in America in the 1920s and prompted a national reform movement that
led to the establishment of more than 100 child guidance clinics by 1927, each
typically staffed by a psychiatrist, clinical psychologist, and several social workers.
The hallmark of work in these clinics for clinical psychologists was assessment,
both intellectual and personality. The belief was that early detection of problems,
either in intellectual functioning or in conduct, would allow amelioration of the
problems. The staff worked as a team, with social workers carrying out most of
the interventions. These clinics had their maximum impact from their inception in
1921 through the end of the Second World War, but they have persisted in some
locales into the present. They were a major employer of clinical psychologists in
the 1920s and 1930s and stimulated further growth in the field that would prompt
new organizational activities in the 1930s, as clinical psychologists continued to
seek a professional identity (Horn 1989).

A VOICE FOR PROFESSIONAL PSYCHOLOGISTS

During the 1920s, more than a dozen regional and state organizations formed for
applied psychologists. The largest of those was the New York State Association of
Consulting Psychologists founded in 1921. It was reorganized in 1930, extending
its membership boundaries to include all of the United States in an attempt to create
a national organization of professional psychologists under the title “Association
of Consulting Psychologists” (ACP). In 1933, it published a code of ethics for
professional psychologists, something the Clinical Section of APA had been urging
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HISTORY OF CLINICAL PSYCHOLOGY 13

APA to do for years, and in 1937 it founded a new journal entitled the Journal of
Consulting Psychology.
Although ACP tried to develop itself into a national organization, it remained
largely a collection of New Yorkers. In 1935, ACP initiated an effort to organize
all existing professional societies into a federation. The federation proposal was
rejected, and in 1937 a new organization was founded, entitled “American Asso-
ciation for Applied Psychology” (AAAP). Both ACP and the Clinical Section of
APA voluntarily dissolved so that their members could be part of the new organi-
zation, and the Journal of Consulting Psychology became the official organ of the
new society. The organizational structure of the AAAP involved the creation of
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sections, of which there were initially four: clinical, consulting, educational, and
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industrial psychology. A fifth—military psychology—would be added later. Clin-

ical psychology was the largest of the four sections, with a founding membership
of 229 out of a total of about 410 members. Among the early presidents of AAAP
was Carl Rogers.
Professional psychologists, and more specifically, clinical psychologists, finally
had their own organization, one that could be expected to work on behalf of their
interests. But the organization would prove to be short-lived. Only eight years after
its founding, AAAP merged with APA in the emergency of the Second World War to
found a new APA with headquarters in Washington, DC. New bylaws were written
that called for the advancement of psychology as a science and a profession; a new
divisional structure was modeled from the sectional structure of AAAP (clinical
psychology would be Division 12); a new flagship journal was established, the
American Psychologist, which for more than a decade carried the subtitle “The
Professional Journal of the American Psychological Association”; and promises
were made to work on behalf of the interests of professional psychologists as well
as psychologists in academic and research settings. It would soon be evident that
too many of the academics and researchers kept their fingers crossed when they
made all those promises to the practitioners (Benjamin 1996, 1997).

THE RISE OF PERSONALITY ASSESSMENT

The practice of clinical psychology between the two world wars was essentially
about assessment. Initially the assessment role was limited largely to adminis-
tration and scoring of tests. In some settings, clinical psychologists would also
interpret the test results, turning them into diagnoses and maybe even recommen-
dations for treatment. However, that was not always acceptable in situations where
psychiatrists demanded that such extrapolations remain solely in their domain.
That situation would change somewhat with the introduction of projective testing,
especially in the use of the Rorschach test.
Likely the first personality tests used by clinical psychologists were word-
association tests, mostly following the technique that Carl Jung had introduced to
Americans, first in a 1907 article in the Journal of Abnormal Psychology and then
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14 BENJAMIN

in his lectures at Clark University in 1909 (Jung 1910), where he joined Freud as
one of the invited speakers from abroad. Drawing on Jung’s method, Helen Kent,
a psychologist, and Aaron Rosanoff, a psychiatrist, developed a word-association
test of 100 words designed to be a measure of personality for both normal and
abnormal populations. Norms were created from 1000 normal subjects and from
247 patients in mental hospitals. The result was the Kent-Rosanoff Association Test
published in 1910. Clinical judgments of abnormality were made by measuring
the individual’s responses in terms of deviations from the test’s norms (Kent &
Rosanoff 1910).
Probably the first paper-and-pencil personality test to be used in clinical psy-
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chology was Woodworth’s Personal Data Sheet, developed in 1919 and mentioned
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above. As a test designed to measure neurotic symptoms, it was often included

in test batteries. Other similar personality tests were developed in the 1920s and
1930s, one of the most popular by Robert Bernreuter (1931). Yet, for clinical pur-
poses, these tests would be overshadowed by a new projective test brought to the
United States in 1921 by psychiatrist David Levy. The test consisted of a series
of 10 inkblot cards developed by a Swiss psychiatrist, Hermann Rorschach. Al-
though the word-association tests were also projective in design, they were never
seen as having the power or the mystery associated with interpreting the Rorschach
test. By the 1930s, there were few practicing clinical psychologists who were not
familiar with the Rorschach, which was clearly the most important personality in-
strument in clinical work by the beginning of World War II. Ernest Hilgard (1987)
has described the allure of the test as follows:
The appeal of the test to clinical psychologists rested in part on a practical
advantage it gave them. Before World War II, the practice had developed
in child guidance clinics of a weekly staff conference on ongoing cases in
which the “team” of workers met together, usually under the chairmanship
of a psychiatrist, but including the psychologists (who gave the tests) and
the psychiatric social worker. . .. The practice gradually extended to adult
cases as well. In case review conferences, the psychologist was usually called
upon for IQ scores, and perhaps numerical scores on an inventory such as the
Bernreuter test . . . and then was either dismissed or expected to keep quiet.
However, if the psychologist was an expert on the Rorschach, which required
subtle interpretation, the psychologist had secrets to share and was listened to
with some deference because the psychologist now made clinical diagnoses
that had previously been disallowed. To be able to talk of free-floating anxiety
and colorshock based on the patient’s responses commonly caused many heads
about the table to nod in assent as others on the staff recognized something
that had been seen in the patient. This was worth a great deal to the self-image
of the psychologist, even though doubts arose over the accuracy of the test by
statistical standards. (pp. 516–517)
The popularity of the Rorschach as a projective test evidenced the influence of
Freudian ideas in American clinical psychology. Soon other projective tests would
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HISTORY OF CLINICAL PSYCHOLOGY 15

be developed for clinical use as well, notably the Thematic Apperception Test, or
TAT, conceived by Christiana Morgan and Henry Murray in 1935 (Klopfer 1973).
Whereas projective tests dominated clinical personality assessment through the
1940s, objective measures of personality had not wholly disappeared. Indeed, the
status of those tests would change dramatically in 1943 with the publication of a
paper-and-pencil test of 561 items (later 550) known as the Minnesota Multipha-
sic Personality Inventory, or MMPI. The test was developed by two University of
Minnesota faculty members, Starke Hathaway and Charnley McKinley, and was
eventually standardized on a group of normal subjects as well as psychiatric pa-
tients classified into one of nine different diagnostic groups, such as depression,
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hypochondriasis, and schizophrenia. This testing allowed scales to be developed

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for various psychiatric diagnoses. The test became enormously popular, stimulated
in part by the surge in clinical psychology training after the Second World War.
The test was widely used as a diagnostic device, where various subscales were
created to increase the accuracy of those diagnoses, but it also became an impor-
tant instrument for research on studies of both normal and abnormal personalities
(Buchanan 1994).
From the time Cattell coined the term “mental test” in 1890, psychologists had
looked for behavioral correlates to the tests they constructed. Clinical psychol-
ogists relied heavily on both intelligence tests and personality tests, but also on
other kinds of tests such as tests of aptitude, interests, and achievement, in order
to practice their trade. As has been shown, this assessment work defined their con-
tributions, with more occasional forays into diagnostic work as the field matured.
Yet, clinical psychologists never doubted their second-class status in the field of
mental health. Buchanan (1994) has written about their work prior to World War
II, noting that “clinical psychologists were largely relegated to subservient roles
and remained dependent in the final instance on the benevolence of psychiatrists”
(p. 149). For 50 years, clinical psychologists had been observers to psychother-
apy. Psychiatry had worked hard to ensure that psychologists were kept in their
place, that psychotherapy would remain the exclusive domain of those with medi-
cal degrees. But in the 1940s there was a war raging across several continents that
would exact a heavy psychological toll on the survivors. The most sacred turf of
psychiatry was about to be invaded.

WORLD WAR II AND THE EMERGENCE OF

MODERN CLINICAL PSYCHOLOGY
There was not supposed to be a Second World War, but when it happened it required
that a number be assigned retrospectively to the Great War of the 1910s. The war
was a crushing blow of reality for many intellectuals who had to reassess their
assumptions about the rationality of human beings in the mid-twentieth century,
individuals who had believed that the horrors of the Great War had convinced all
sane people that future differences would have to be solved in nonviolent ways.
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16 BENJAMIN

The depth of their despair is evidenced in stories of individuals committing suicide

because the new world war had caused them to give up any hope for the human race.
As the United States prepared for war in 1941, the National Research Council
instructed its Emergency Committee on Psychology to explore ways of organizing
psychology for the national good, especially emphasizing psychological services.
The divide between practitioners in AAAP and academics in APA was of special
concern if psychology was to act with one voice. It was particularly clear that to
meet the psychological demands of the war would require cooperation between
those who trained clinical psychologists and those who would deliver services as
practitioners. Robert Yerkes was selected once again for an important wartime
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role, to chair the Subcommittee on Survey and Planning of Psychology. The sub-
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committee met in June 1942 at the Vineland School where a similar group had
gathered 25 years earlier to plan the Army Alpha and Beta tests. The group was
given two charges: (a) to make recommendations for the use of psychology in the
war, and (b) to plan for the development of the science and profession of psychol-
ogy after the war. It is the second charge that proved critical for the emergence
of modern clinical psychology. The subcommittee recommended a new national
organization in psychology that would unify scientists, teachers, and practitioners,
and suggested the name “The American Institute of Psychology.” What they got
was a newly remodeled APA (Benjamin 1997).
Capshew (1999) has written:
As late as 1940 it was impossible to obtain a formal Ph.D. in clinical psy-
chology. . .. The war had created the conditions necessary for the full institu-
tionalization of clinical psychology. Before then, despite several attempts to
create a graduate-level clinical track in the standard psychology curriculum,
clinical psychologists, like other practitioners, developed most of their skills
through informal internships and on-the-job training. (p. 172)
That situation would change dramatically by 1950 through the creation of an
APA accrediting system for clinical psychology in 1946, the spending of massive
federal dollars for clinical research and training, the creation of hundreds of jobs in
the Veterans Administration (VA) for clinical psychologists, and the establishment
of training guidelines for the new profession at a national conference.
In 1942, aware of the pending and likely overwhelming need for psychological
services for veterans, the federal government called on the VA and the United States
Public Health Service (USPHS) to expand the pool of mental health professionals.
Because it was unlikely that medical schools could attract many more students to
psychiatry, the federal directive was translated as a mandate for increasing the pool
of clinical psychologists. The VA and USPHS worked with the newly organized
APA to encourage development of doctoral programs in clinical psychology and
to establish a program that would be able to assess the quality of those programs.
As a result, APA began to lobby doctoral programs that were involved in clinical
training to enhance their programs, whereas doctoral programs that offered no
such training were encouraged to establish such programs.
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HISTORY OF CLINICAL PSYCHOLOGY 17

The USPHS provided funds to psychology departments that trained clinical

psychologists, and the VA established funded practica and internship experiences.
Indeed, it can be argued that the modern profession of clinical psychology was
established not by the psychological community, at least not by organized psy-
chology, but by federal government agencies seeking to meet a wartime and post-
wartime need. In support of that claim, Capshew (1999) has written, “. . . The
Veterans Administration practically created a new mental health specialty by pro-
viding training funds as well as hospital internships and permanent jobs for clinical
psychologists. The massive infusion of funds for research and training transformed
university psychology departments, causing a rapid rise in the number of faculty
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members, students, and support staff as well as major changes in curriculum”

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(pp. 171–172). In 1946–1947, the initial year of the new VA psychology pro-
gram, the VA provided training funds to more than 200 doctoral trainees at 22
universities. Three years later, the VA funded more than 1500 psychology students
at 50 universities (Capshew 1999). These early clinical programs also enrolled
a number of returning veterans whose wartime experiences perhaps drew them
to clinical psychology and who were able to pursue their education (including
graduate education) under the provisions of the new GI Bill.
University psychology departments were not wholly enamored with the changes
wrought by the VA and USPHS. Whereas departments recognized the advantages
of the federal dollars, both for research and student support, they often resented
the changes in their departments brought on by the applied focus. In addition,
some departments resented what they viewed as external control of their admis-
sions process, curriculum, and research agenda. Those concerns notwithstanding,
many of the better psychology departments in the country joined the call to train
clinical psychologists, and many of that first generation of the late 1940s would
find permanent employment in the VA.
It turned out that the federal government had been accurate in its estimates of
needed psychological services. A survey on April 1, 1946, less than one year after
the end of the war, showed that of the 74,000 patients being cared for by the VA,
44,000 of them (nearly 60%) were classified as neuropsychiatric patients (Miller
1946).

NEEDED: A TRAINING MODEL FOR

CLINICAL PSYCHOLOGY
In 1946, even though APA’s accreditation program for clinical psychology was in
place, and even though many universities offered training in clinical psychology
supported by VA practica and internships, there was no agreed-upon training model
for clinical psychology. The issue of a training model was not a new one. Leta
Hollingworth had called for one in 1918, arguing that specifying such a model
would be the first step in developing a profession of clinical psychology. In 1941,
David Shakow provided a report to AAAP that outlined a clinical curriculum.
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18 BENJAMIN

Action on that report was stalled by the intersociety negotiations that focused
on planning for a new all-encompassing psychological organization. This new
organization, the new APA, appointed Shakow to a committee in 1946 whose
charge was to develop a recommended training program in clinical psychology. The
committee report was published in 1947 (APA Committee on Training in Clinical
Psychology 1947). Two years later that report would become the framework for a
conference in Boulder, Colorado.
In the hurry-up strategy of training many clinical psychologists and training
them quickly, it is not surprising that there was considerable variation in how
students were being trained. That fact worried the VA and the USPHS, and they
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put pressure on APA to do something about it. It should be noted that in the
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roughly 70-year history of American psychology prior to 1949, representatives of

doctoral programs had never sat down together to work out a prescribed curriculum
in psychology. The conference in Boulder would be the first such prescriptive
meeting, and it was clear to psychology departments that it was only to be about
clinical training (Benjamin 2001).
The newly established National Institute of Mental Health (NIMH) provided
the funding for the two-week summer conference at the University of Colorado in
1949. Seventy-three individuals, mostly psychologists, but a few representatives
from psychiatry, social work, and nursing, were invited to attend. The task could
not have been more daunting. The agenda for the participants included discussions
of
the core curriculum; clinical specialties, private practice, master’s-level psy-
chologists; postdoctoral training; undergraduate student access to clinical
courses; standards for agencies beyond the university that offered practicum
and internship work; student characteristics for selection; financial aid for
clinical students; training in ethics; the relationship of clinical psychology to
other fields, such as medicine, social work, and vocational guidance; licensing
and certification; accreditation of programs; federal government involvement
with clinical training; training of clinical faculty; placement of the internship
(predoctoral or postdoctoral, in the university or outside of it); society’s needs
for clinical services; training in psychotherapy and other skills; and training
for research. (Benjamin & Baker 2000, p. 233)
It was nothing short of amazing, given the diversity of representatives at the
conference and the complexity of the issues, that general agreement was reached
on a single model of training that would train clinical psychologists to be compe-
tent in the conduct of research as well as in the delivery of psychological services.
The model specified core clinical skills; required practicum work, usually in mul-
tiple settings; required a full-year internship; and mandated research training and
a research dissertation (Baker & Benjamin 2000, Raimy 1950). The scientist-
practitioner model, or Boulder model as it came to be known, would become the
dominant mode of training in professional psychology (including clinical, coun-
seling, and school psychology programs), a dominance that continues today if
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HISTORY OF CLINICAL PSYCHOLOGY 19

one accepts the claims of current programs, most of which describe themselves as
Boulder-model programs.

WORLD WAR II AND PSYCHOLOGISTS

AS PSYCHOTHERAPISTS
When scientific psychology migrated to American shores from Germany in the
1880s, psychiatry already had a 100-year history of treatment of the mentally ill.
Most psychologists in the early days of the discipline had no interest in abnormality.
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It was the normal mind that held the secrets they were after. But a few adventurers,
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such as Lightner Witmer and Henry Herbert Goddard, were interested in taking
their psychological curiosity to another place. It was a place where they were not
always welcome. Psychological expertise was accepted reluctantly in the medical
community and was likely tolerated in assessment only because psychologists
had designed the instruments they were using. In addition, as noted above, for
the clinical psychologist the testing was to end with assessment, not diagnosis.
Psychologists, however, were not content to remain in the role of psychometrician.
They saw themselves as scientists, with better scientific training than psychiatrists,
and they believed that their science provided them insights into diagnosis and
treatment that were beyond the capabilities of most psychiatrists.
During the Second World War, the military joined psychologists and psychi-
atrists into what were called psychiatric teams. It was natural that professional
jealousies would occur. However, war is a crisis situation, and crises often bring
out the best and the worst in people. In the case of psychology and psychiatry,
the accounts of their interactions were generally positive. Psychologist William
A. Hunt was in charge of the clinical psychology program in the U.S. Navy in
1944–1945 and described the clinical work as follows: “We learned by doing. The
job was bigger than we were and we needed all the help we could get, from what-
ever professional or personal sources were available. Professional distinctions and
professional politics were confined largely to the Washington level. In the field
they faded before the immensity of the task” (Hunt 1975, p. 174).
More than 400 clinical psychologists (by title, not always by training) served
in the military’s neuropsychiatric service during the war. The majority of them
had some experience in providing psychotherapy, and most of them received their
training in that regard on the job. By the war’s end, they had seen Paris and they were
not going back to the assessment farm. Clinical psychologists had been around
psychotherapy for years in mental hospitals and in child guidance clinics, and in
college counseling centers since the 1920s. A few clinical psychologists, typically
with psychoanalytic training, even had been in private practice as psychotherapists
as early as the 1920s.
The psychotherapy work of clinical psychologists in the war was well known in
the military and federal agencies interested in fostering the development of clinical
psychology. The VA, in particular, was adamant that psychologists working in the
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20 BENJAMIN

VA would be able to deliver psychotherapy. The need within the VA hospitals was
simply too great. As a result, psychotherapy courses became standard practice
in clinical psychology training programs in the late 1940s, and doctoral students
were expected to have completed them before beginning their practicum work in
the VA. One of psychology’s champions within the VA was James G. Miller, who
was the chief psychologist with the VA Central Office in Washington, DC. Miller
had a doctorate in psychology but also an MD. He was able to establish parity for
psychologists and psychiatrists within the VA with regard to government service
rating and thus salary (although changes would be made later to provide larger
salaries to psychiatrists).
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In the decades that followed, psychotherapy would become the dominant tool
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of clinical psychologists, available in many flavors from psychoanalytic to be-

havioristic and from humanistic to cognitive. Assessment, especially personality
assessment, remained an important activity for clinicians because the results of
such tests were believed to lead to a better plan of therapy, and thus a marketable
advantage for psychologists. By the mid to late 1970s, most of the major bat-
tles with psychiatry had been won; clinical psychologists had become the chief
dispensers of psychotherapy (Buchanan 2003).

MARKERS OF A PROFESSION
The markers of a profession include certification or licensure, an ethical code,
national organizations, journals for communication of professional concerns, and
standardized training programs (usually in professional schools). As mentioned,
there were professional organizations for clinical psychologists as early as 1917,
although they were of marginal effectiveness until the establishment of AAAP in
1937. When AAAP and APA merged into the new APA in 1945, APA was supposed
to be an organization that advocated for professional concerns, but it did not really
play that role until the mid 1970s, when Charles Kiesler became the chief executive
officer of APA and the membership in APA shifted such that the practitioners were
in control. Instead, state associations became the advocacy groups for professional
psychologists, a situation mandated by the fact that licensure was an issue to be
settled at that level. Connecticut was the first state to license psychologists in 1945,
and in 1977, Missouri was the last state to pass such a law. The state associations
lobbied not only for licensure laws but for other professional issues such as freedom
of choice laws, which mandated that psychologists be included with psychiatrists
in mental health insurance coverage, and that the insured have a right to choose
their practitioners. Today these associations continue their advocacy, for example,
in pursuit of prescription privileges for psychologists. As of 2004, such privileges
had been granted in New Mexico and Louisiana, and bills were pending in other
state legislatures.
Whereas ACP published a code of professional ethics in 1933, it would be 20
years before APA issued such a document, publishing its Ethical Standards of
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HISTORY OF CLINICAL PSYCHOLOGY 21

Psychologists in 1953, a code that has been updated many times since. To manage
such concerns, APA also established an Ethics Office in its central office and an
Ethics Committee.
The first professional journal, the Journal of Consulting Psychology, was also
established by the ACP, as noted above. It continues publication today as the Jour-
nal of Consulting and Clinical Psychology; however, it has long since ceased to be
a professional issues journal, and focuses today exclusively on research. When the
APA-AAAP merger occurred, the American Psychologist was established in 1946
as a new journal that was supposed to cover professional issues. But its record in
that regard was spotty at best, and in 1957 it dropped the word “professional” from
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its subtitle, “The Professional Journal of the American Psychological Association,”

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a title that had never accurately reflected the journal content (Benjamin 1996). In-
stead, state association newsletters and journals and APA division newsletters (such
as the one for Division 12) carried the news of professional issues to interested
parties. Finally, in 1969 APA and Division 12 began joint publication of a journal
entitled Professional Psychology, continued today as Professional Psychology:
Research and Practice, which publishes articles on professional issues of interest
to practitioners in all specialty areas, but especially in the health care fields. Other
APA divisions also publish journals dealing with issues for practicing clinical
psychologists, such as the Division on Psychotherapy’s journal, Psychotherapy:
Theory/Research/Practice/Training.
The first standardized training program model for clinical psychology to have
widespread endorsement was the Boulder model, as described above. However,
it would not be long before there was dissatisfaction among clinical psycholo-
gists both with that model and with the control of clinical training by traditional
academic departments that too often seemed unwilling to train their clinical psy-
chology students adequately for jobs in practice. The professional schools move-
ment emerged as an alternative, with the first such school established at Adelphi
University in 1951 by Gordon Derner. The first freestanding school of profes-
sional psychology was the California School of Professional Psychology, founded
largely through the efforts of Nicholas Cummings. It opened its first two cam-
puses in 1970 in Los Angeles and San Francisco. These schools were founded,
in part, to meet a growing demand for mental health professionals that was not
being met by the limited enrollments of the university-based training programs,
and because there was a growing concern that the university programs had bought
into the scientist part of the Boulder model but were shortchanging students in
terms of clinical skills. These concerns led to a new national training conference
to consider alternative models, this time in Vail, Colorado, in the summer of 1973.
The principal recommendation from that conference was the establishment of the
Doctor of Psychology degree (PsyD) that would place greater emphasis on clini-
cal training and diminished training in research. Leta Hollingworth had called for
that degree in 1918, and it finally became a reality exactly 50 years later in the
professional school clinical psychology program of the University of Illinois in
1968. The growth of the professional schools was such that by 1997 they were
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22 BENJAMIN

graduating twice as many students in clinical psychology as the university-based

programs.

CLINICAL PSYCHOLOGY’S GOLDEN AGE

Historian James Capshew (1999) has written that “The notion that Americans
lived in a ‘psychological society’ took hold rapidly in the 1950s and had become
commonplace by the 1960s” (p. 241). The 1960s were a time of great social turmoil
in America and everywhere there was evidence of America’s enhanced interest in
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psychological questions. The establishment of community mental health centers

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across the nation was the latest government answer to treatment of the mentally
ill. Job opportunities expanded for clinical psychologists in these centers. By the
1960s, clinical psychologists were moving into private practices. In 1969, Robert
M. Hughes helped to organize Psychologists in Private Practice, which published
a newsletter entitled The Private Practitioner. The name of the group was changed
in 1974 to the American Society of Psychologists in Private Practice. It remained
small, around 600 members, until 1982 when it became Division 42 of APA,
Psychologists in Independent Practice. In its initial year as a division, it had 650
members. Two years later its membership numbered 5000, and by 1995, it had
topped 10,000 members (Hill 1999).
The successes of the 1960s and 1970s marked the culmination of a dream for
clinical psychologists who, with the exception of prescribing psychotropic med-
ications and the obvious annual income differences, found themselves enjoying
near parity with their psychiatrist colleagues in the mental health field. Psychol-
ogists now dominated the practice of psychotherapy; the golden age of clinical
psychology had arrived. Alas, it would be over all too quickly; the culprit would
be known as managed care. Nicholas Cummings (1995) described the dismay of
those psychologists who had fought the good fight: “It has not been easy for psy-
chology, which struggled for many years to attain autonomy only to see the rules
of the game change just as it became the preeminent psychotherapy profession”
(p. 12).
Managed care began in the 1950s, but its impact on the practice of clinical
psychologists was not felt until the 1980s. Established in the beginning as a way
to provide uniform medical care to employee groups, it became a system whose
principal goal was cost containment. Managed care greatly reduced patient access
to mental health services, substantially reduced the number of therapy sessions for
which psychotherapists would be reimbursed (which meant assessment was often
omitted), and reduced the fees for services charged by therapists (DeLeon et al.
1991, Karon 1995, Rupert & Baird 2004). As the reality of the changes sunk in,
clinical psychologists were forced to reinvent themselves once more; for example,
they adopted briefer therapy methods. As the opportunities for psychotherapy have
diminished, clinical psychologists have broadened their practices into other areas
such as health psychology and forensics.
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HISTORY OF CLINICAL PSYCHOLOGY 23

CRISES IN CONTEMPORARY CLINICAL PSYCHOLOGY

The impacts of managed care—the dramatic reduction in insurance funds for reim-
bursement of mental health services and the increased competition from master’s-
level providers of psychological services—are external forces that have caused
individuals to make predictions of gloom and doom about the future practice of
psychology. There is, however, conflict within the discipline itself.
By the late 1970s, practitioners, largely clinical psychologists, had gained power
in governance of the affairs of the American Psychological Association. More and
more the issues in which APA was involved were clearly guild issues, whereas the
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concerns of the academics and scientists seemed too often ignored. For ten years the
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academics and researchers called for a reorganization of APA that would distribute
power more evenly between scientists and practitioners, something that they had
not viewed as a problem in the 70 years of APA history when the power differential
was reversed. In 1988, when it was clear that the practitioners were not going to
share their newfound power, the outgroup formed a new organization, the American
Psychological Society (APS), an organization dedicated solely to the advancement
of scientific psychology in research, teaching, application, and the improvement
of human welfare. The APS today has approximately 15,000 members compared
to APA’s 150,000 members (which includes student members).
Practicing clinicians have faced heavy criticism from their academic/research
colleagues regarding the scientific basis of their practice. The most strident critics
(e.g., Dawes 1994) have argued that psychotherapy rarely, if ever, is based on sci-
entific evidence. Others have faulted practitioners for failing to adhere exclusively
to empirically supported treatments or at least to make use of such treatments
when the evidence does not support the efficacy of other treatments for specific
disorders (McFall 1991, 2000; Nathan et al. 2000). The debate on this issue, which
in essence divides the scientists and practitioners in psychology, often revolves
around arguments about whether therapy is more art than science, the claim that
much of psychological science is not applicable to practice, and the fact that using
manualized treatments does not take into account client and, especially, thera-
pist variables that are crucial to therapeutic outcome (Deegear & Lawson 2003,
Nathan & Gorman 2002, Norcross 2001, Westen et al. 2004). The pressure for em-
pirically supported treatments, and the practice guidelines built on them, continues,
in part, stimulated by external forces (e.g., insurance companies) that are demand-
ing demonstrations of treatment effectiveness. The subject continues to be hotly
debated. Supporters of empirically supported treatments and practice guidelines
have argued that their development is crucial for the effective practice of clinical
psychology and for the reputation of the field. Critics argue that such guidelines
are limiting and represent a misunderstanding of the therapeutic process.
One of the principal voices in this controversy is Indiana University clinical
psychologist Richard McFall, whose “Manifesto for a Science of Clinical Psy-
chology” (1991) was a call to arms to those who shared his belief that “scien-
tific clinical psychology is the only legitimate and acceptable form of clinical
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24 BENJAMIN

psychology” (p. 76). McFall argued against the label “scientist-practitioner” for
its implication that there were two kinds of clinical psychology, one involving
science, and the other practice. He criticized training programs that watered down
their science training for clinical psychologists and lamented the fact that students
too often eagerly sought out training that was substandard in its scientific rigor.
McFall’s manifesto drew a number of critics who argued that his views were naı̈ve
with regard to the nature of clinical practice, that they illustrated a devaluing of
the worth of practice, and that, if followed, they would ensure that professional
psychologists would do little of value in helping clients (Peterson 1996).
Those in agreement with McFall joined with him in 1994 in founding the
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Academy of Psychological Clinical Science (APCS), an organization of doctoral

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training programs in clinical and health psychology that are “strongly committed
to research training and the integration of such training with clinical training”
(APCS 2004). In 2004, there were 43 doctoral program members of APCS. The
organization has sought to impact clinical training by increased involvement with
the APA accreditation process, and by consultation with federal agencies and other
entities that are involved with clinical science.
In relation to the application of the science of psychology to its practice, train-
ing in clinical psychology has especially been questioned within the professional
schools. Some of the concerns voiced are that because freestanding professional
schools are “for-profit” enterprises, they may be admitting too many students
of marginal ability. Coupled with the reduced education in the science of psy-
chology provided by those schools, the professional-school graduates may be
poorly equipped to apply the science of their field in their work. The evidence
on these claims appears inconclusive at this time (Kenkel et al. 2003, Peterson
2003).

WHAT DOES THE FUTURE HOLD?

Those who wonder if there is a future for clinical psychology must ask themselves
this question: Is the world becoming a saner place? If one constructs a list of the
principal problems facing the world today, there is one inescapable conclusion:
Most of those problems have a behavioral component. The leading killers at the
beginning of the twentieth century—all viral and bacterial illnesses, namely pneu-
monia, tuberculosis, and influenza—have been replaced in many sections of the
world today by cancer, heart disease, and stroke, all disease processes that are
heavily influenced by behavioral factors, such as smoking, poor eating habits, lack
of exercise, and stress. Some of the critically important problems that face the
world include conflict, be it domestic, in the school yard, or international; pollu-
tion and overuse of environmental resources; poor parenting; divorce; addictions; a
growing elderly population; school dropouts and other educational issues; sexually
transmitted diseases; crime; racism; obesity; worker satisfaction; and patient com-
pliance with medical directives. The science and practice of psychology, especially
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HISTORY OF CLINICAL PSYCHOLOGY 25

clinical psychology, should be a key player in the development and application of

solutions to those problems.
One of the traditional strengths of doctoral education in psychology has been
that students were trained as problem solvers, and were taught the methodological
skills, including in critical thinking, to know how to conceptualize problems so that
they could be solved. Evidence for this flexibility comes from the myriad places
in which psychologists are found. They are in virtually any industry one can name
(motion pictures, space exploration, police work, communications) and they hold
a plethora of jobs that almost no one would have imagined a psychologist might
pursue.
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The times, they are indeed changing. Psychotherapy, the brass ring for clinical
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psychologists, is not likely to disappear from their job description, but there seems
little doubt that the position of preeminence in that arena is gone and will not return.
Master’s-level practitioners, under a variety of labels (e.g., licensed professional
counselors, mental health counselors, marriage and family therapists), will become
the dominant providers of psychotherapy. They have earned their place at the
table in the same way psychologists did in clinical trials in the 1940s when they
demonstrated they were as competent as psychiatrists in doing psychotherapy.
It is clear that neither managed care nor the threat of competition from other
providers has caused clinical psychologists to run from their profession. A survey
of private practitioners in 1997 showed that only 6% had abandoned their practice
or contemplated doing so in the near future (Murphy et al. 1998).
In the press of managed care and other changes, clinical psychologists have al-
ready begun to change the way they practice. Group practices have formed as a way
to provide more comprehensive services and to be more appealing as providers.
Some clinicians believe that their practice options will be widened with the privi-
lege of prescribing medications (DeLeon et al. 1995), whereas others fear that such
privileges will harm the practice of psychology (DeNelsky 1996, Hays & Heiby
1996). Some clinicians have moved into other growing areas, such as evaluations
in child custody cases and other practices in forensic psychology (Otto & Heilbrun
2002). Some have sought to change fields, for example, developing a practice in
sport psychology, a rapidly growing enterprise (see Hays 1995, Meyers et al. 2001).
The fastest growing field in psychology is health psychology, a field for which
clinical psychologists typically are well trained. The opportunities in this field seem
unlimited when one considers the percentage of the gross national product that is
spent annually on health care. Further evidence of the growth of health psychology
is that the fastest-growing employment setting for clinical psychologists in the past
decade has been hospitals (Williams & Kohout 1999). Other employment growth
areas have been in medical schools and academic health care centers (Sheridan
1999), and DeLeon et al. (2003) predict the growth of clinical psychology jobs in
community health centers that serve individuals who are uninsured and typically
underserved.
The concerns about the viability of clinical psychological practice, especially
with regard to the delivery of psychotherapy, have spawned what could be termed
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26 BENJAMIN

an industry of prognosticators whose articles have been plentiful in psycholog-

ical journals in the past ten years. Some of that work is cited above. Although
these articles have been diverse in their predicted scenarios, one theme is espe-
cially provocative. It was voiced quite eloquently by clinical psychologist Keith
Humphreys (1996) who, in looking at his field historically, concluded that in the
rush to psychotherapy after the Second World War, clinical psychologists fore-
closed on much of their training and their opportunities. He wrote:
Clinical psychology’s choice to make psychotherapy a central focus helped
some portion of society and brought significant resources to the field, but a
different central focus might have offered more effective ways of applying
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psychological knowledge to human problems. It is interesting to speculate

what clinical psychology’s contribution to society might have been if it had
kept psychotherapy as a sidelight and elevated one of the many other activities
of clinical psychologists before or after World War II to a central position.
Forensic psychology? Public policy consultation and analysis? Rehabilitation
psychology? Prevention program development and evaluation? Such specu-
lation is not an idle activity . . . it appears to be time again to evaluate the
importance clinical psychology should give to psychotherapy. (p. 193)
Humphreys and others have raised the argument: If master’s-level providers
can be as competent in the delivery of psychotherapy as PhD.-level providers, then
what extra skills should one expect from the latter? Psychotherapy, in most cases,
provides help for a single person at a time. It is a noble and useful and life-changing
service. But is there more that someone trained with a PhD can offer? Are there
services that a clinical psychologist could provide that could affect an entire com-
munity, for example, by reducing bullying in the schools, by reducing spousal
abuse, by getting people to wear seat belts when they are traveling in a car, by
developing more effective programs for treating addictions and developing better
evaluative strategies for extant treatment programs, and so on? The opportunities
are endless. It should be obvious that, as Humphreys (1996) noted, “psycholo-
gists can more effectively benefit society by making long-term commitments to
improving social institutions (e.g., public schools) and social policy than they can
by doing psychotherapy” (p. 195). In a similar vein, Nicholas Cummings (2003)
has expressed dismay that “we keep training doctoral psychologists to dig ditches”
(p. 19), that is, there is so much more that a psychologist should be able to offer,
other than the master’s-level work of psychotherapy.
Realizing that some doors open when others close, some psychologists have
commented on the opportunities presented by managed care for which psycholo-
gists are perhaps uniquely qualified. Sanchez & Turner (2003) have written:
The scientist-practitioner may be best prepared to function in the managed
care environment because this model, with its focus on integrating scien-
tific and clinical knowledge, best prepares the doctoral-level clinician to ed-
ucate utilization reviewers, evaluate effectiveness and efficiency of treatment
through outcome research, design and manage integrated networks, develop
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HISTORY OF CLINICAL PSYCHOLOGY 27

and evaluate clinical practice guidelines, supervise nondoctoral providers, and

deliver empirically based treatments. (p. 127)
And the clinical psychologist providing such services would not be doing so at
ditchdiggers’ wages.
Throughout the 125-year history of psychology in North America, psychol-
ogists have found many niches where they could do interesting and important
work. That is certainly true of the profession of clinical psychology. There seems
little doubt that the clinical psychology of the 1970s or 1990s (as described in
the definition that opened this chapter) will not be the clinical psychology of the
next 25 years. That is far too limiting a picture. The clinical psychologists trained
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as scientist-practitioners should have no difficulty finding interesting work in the

future. They are trained to solve behavioral problems, and the world promises to
provide no shortage of those.

ACKNOWLEDGMENT
Portions of this chapter were adapted from Benjamin & Baker (2004).

The Annual Review of Clinical Psychology is online at

http://clinpsy.annualreviews.org

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P1: JRX
February 26, 2005 19:35 Annual Reviews AR240-FM

Annual Review of Clinical Psychology

Volume 1, 2005

CONTENTS
A HISTORY OF CLINICAL PSYCHOLOGY AS A PROFESSION IN AMERICA
(AND A GLIMPSE AT ITS FUTURE), Ludy T. Benjamin, Jr. 1
Access provided by Pontificia Universidad Javeriana on 08/08/22. For personal use only.
Annu. Rev. Clin. Psychol. 2005.1:1-30. Downloaded from www.annualreviews.org

STRUCTURAL EQUATION MODELING: STRENGTHS, LIMITATIONS,

AND MISCONCEPTIONS, Andrew J. Tomarken and Niels G. Waller 31
CLINICAL JUDGMENT AND DECISION MAKING, Howard N. Garb 67
MOTIVATIONAL INTERVIEWING, Jennifer Hettema, Julie Steele,
and William R. Miller 91
STATE OF THE SCIENCE ON PSYCHOSOCIAL INTERVENTIONS FOR
ETHNIC MINORITIES, Jeanne Miranda, Guillermo Bernal, Anna Lau,
Laura Kohn, Wei-Chin Hwang, and Teresa La Fromboise 113
CULTURAL DIFFERENCES IN ACCESS TO CARE, Lonnie R. Snowden
and Ann-Marie Yamada 143
COGNITIVE VULNERABILITY TO EMOTIONAL DISORDERS,
Andrew Mathews and Colin MacLeod 167
PANIC DISORDER, PHOBIAS, AND GENERALIZED ANXIETY DISORDER,
Michelle G. Craske and Allison M. Waters 197
DISSOCIATIVE DISORDERS, John F. Kihlstrom 227
THE PSYCHOBIOLOGY OF DEPRESSION AND RESILIENCE TO STRESS:
IMPLICATIONS FOR PREVENTION AND TREATMENT,
Steven M. Southwick, Meena Vythilingam, and Dennis S. Charney 255
STRESS AND DEPRESSION, Constance Hammen 293
THE COGNITIVE NEUROSCIENCE OF SCHIZOPHRENIA, Deanna M. Barch 321
CATEGORICAL AND DIMENSIONAL MODELS OF PERSONALITY
DISORDER, Timothy J. Trull and Christine A. Durrett 355
THE DEVELOPMENT OF PSYCHOPATHY, Donald R. Lynam
and Lauren Gudonis 381
CHILD MALTREATMENT, Dante Cicchetti and Sheree L. Toth 409
PSYCHOLOGICAL TREATMENT OF EATING DISORDERS, G. Terence Wilson 439
GENDER IDENTITY DISORDER IN CHILDREN AND ADOLESCENTS,
Kenneth J. Zucker 467

vii
P1: JRX
February 26, 2005 19:35 Annual Reviews AR240-FM

viii CONTENTS

THE DEVELOPMENT OF ALCOHOL USE DISORDERS, Kenneth J. Sher,

Emily R. Grekin, and Natalie A. Williams 493
DECISION MAKING IN MEDICINE AND HEALTH CARE, Robert M. Kaplan
and Dominick L. Frosch 525
PSYCHOLOGY, PSYCHOLOGISTS, AND PUBLIC POLICY,
Katherine M. McKnight, Lee Sechrest, and Patrick E. McKnight 557
COGNITIVE APPROACHES TO SCHIZOPHRENIA: THEORY AND THERAPY,
Aaron T. Beck and Neil A. Rector 577
STRESS AND HEALTH: PSYCHOLOGICAL, BEHAVIORAL, AND
Access provided by Pontificia Universidad Javeriana on 08/08/22. For personal use only.

BIOLOGICAL DETERMINANTS, Neil Schneiderman, Gail Ironson,

Annu. Rev. Clin. Psychol. 2005.1:1-30. Downloaded from www.annualreviews.org

and Scott D. Siegel 607

POSITIVE PSYCHOLOGY IN CLINICAL PRACTICE, Angela Lee Duckworth,
Tracy A. Steen, and Martin E. P. Seligman 629

INDEX
Subject Index 653