Frederic Lyman Wells.

The status of clinical psychology online

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Published in Mc.ital II

[Reprinted from MENTAL HYGIENE, Vol. VI, No. 1, January, 1922, pp. 11-22.]


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.



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.


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-

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.


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.


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.


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.


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.


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.


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 :



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


Online LibraryFrederic Lyman WellsThe status of clinical psychology → online text (page 1 of 2)