Clinical Psychology: Revisiting the Classic Studies

Graham C.L. Davey, Graham C.L. Davey

• Publisher: SAGE Publications Ltd
• Year: 2019
• ISBN:
  9781526483201
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Clinical Psychology: Revisiting the Classic Studies traces 14 ground-breaking studies by researchers such as Leo Kanner, David T. Lykken and Aaron T. Beck to re-examine and reflect on their findings and engage in a lively discussion of the subsequent work that they have inspired. Revisiting the Classic Studies is a series of texts that introduces readers to the studies in psychology that changed the way we think about core topics in the discipline today. It provokes students to ask more interesting and challenging questions about the field by encouraging a deeper level of engagement, both with the details of the studies themselves and with the nature of their contribution. Written by researchers at the cutting edge of these developments, the chapters in each text provide details of the original works, as well as their theoretical and empirical impact.

1 Defining ‘Insanity’: Building on Rosenhan (1973) Rosenhan, D.L. (1973) On being sane in insane places, Science, 179: 250–8

Richard P. Bentall

Background: Psychiatry’s Perfect Storm

David Rosenhan was not a clinical psychologist and spent most of his academic career at Stanford University working on the interface between psychology and law (he died in 2012; Ross & Kavanagh, 2013). Nonetheless, his 1973 paper ‘On being sane in insane places’, which was published in the prestigious American journal Science, has long been regarded as one of the most controversial studies in the history of psychiatry and clinical psychology, and has been regularly singled out as one of the most influential ever conducted in the field (for example, as one of the 10 greatest psychology experiments ever conducted in Lauren Slater’s (2004) book Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century, about which more later).

In the study Rosenhan claimed to show that psychiatrists at that time were unable to distinguish between severe mental illness (insanity) and normal behaviour, a conclusion that has since been contested by many commentators. Certainly, as we will see, both the methodology of the study and Rosenhan’s interpretation of the findings can be challenged. However, without a doubt, and whatever its merits as an experiment, the study has cast a penetrating light on some of the most intractable disputes in the study of mental illness. It was not only the product of a long history of debate and disagreement about the nature of mental illness, it also shaped the way this debate¹ developed over the following half century until the present day. That debate cannot be understood without considering the history of psychiatry in the modern period.

¹ This debate includes arguments about the term ‘mental illness’, which many commentators have argued reflects the biomedical approach to abnormal behaviour, which was contested in the Rosenhan experiment. However, for ease of communication I will use this term throughout.

The origins of psychiatry and the problem of defining psychiatric disorders

Although all societies make some kind of distinction between mental health (sanity) and mental illness (madness, insanity), and although the idea that the latter should be considered a medical condition can be traced as far back to the pre-Christian era (notably in the writings of Hippocrates in the fourth century BCE), psychiatry as it is understood today was an invention of German-speaking physicians living in the nineteenth century (Bentall, 2003). The term ‘psychiatry’ (from the Greek psyche – soul) – and latros – physician) was coined in the early years of that century by Johann Christian Reil (1759–1813) and the first modern academic psychiatry department was established in Berlin by Wilhelm Griesinger (1817–1868) in 1865. Griesinger, like most other physicians of his era, assumed that mental illness was not fundamentally different from physical illness, arguing in the opening editorial of his journal Archives for Psychiatry and Nervous Disease that:

Psychiatry has undergone a transformation in its relation to the rest of medicine. This transformation rests principally on the realization that patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain. (Cited in Shorter, 1999)

Early psychiatrists naturally focused their attention on the problem of defining psychiatric disorders, mainly by using the clinical method to describe the phenomena they observed in asylum populations. (The earliest asylums long pre-dated the emergence of psychiatry as a medical discipline and were run by lay people. However, throughout the United States and much of Europe, these institutions expanded and came under medical control during this period.) The assumption at the time was that psychiatric disorders are categorical; that is, they fall into a small number of discrete types analogous to the types of illness studied in physical medicine.

An important contribution to this area of research was made by Karl Ludwig Kahlbaum (1824–1899), a psychiatrist who owned a private hospital in the town of Görlitz, and whose writings on the classification of psychiatric disorders emphasized the importance of the course of mental illness (whether symptoms persisted, remitted or waxed and waned over time). This idea was taken further by Emil Kraepelin (1856–1926), a psychiatrist whose most important work was conducted at the University of Heidelberg and then later at the Kaiser Wilhelm German Psychiatric Research Institute in Munich, which he directed. Kraepelin, who is considered by many to be the ‘father’ of modern psychiatry, is particularly credited with the development of the standard diagnostic approach to classifying psychiatric problems (Engstrom & Weber, 2007), based on the identification of clusters of symptoms that tend to co-occur (known as syndromes) and which have a common course.

Many diagnoses in current usage originated with Kraepelin’s observations of clusters of symptoms in large numbers of patients, outlined in a textbook that, over many editions, influenced the practice of psychiatry not only in the German-speaking world but also abroad (Kraepelin, 1990[1899]). For example, he came to believe that he could identify two major classes of severe mental illness (psychosis): dementia praecox and manic depression. The former was characterized by hallucinations, delusions (abnormal beliefs) and progressive cognitive decline with little chance of recovery, and was later renamed schizophrenia by the Swiss psychiatrist Eugene Bleuler (1950[1911]). The latter was characterized by extreme mood states and thought to have a more benign outcome; later researchers divided it into two separate disorders of major depression and bipolar disorder in which the patient experiences not only recurrent episodes of severe depression but also episodes of mania (periods of extreme positive mood, excitement, impulsivity and agitation) (Healy, 2011).

By the early years of the twentieth century, it had become widely recognized that these kinds of clinical concepts needed to be codified in diagnostic manuals, which could be used for statistical purposes (during this period there was a dramatic rise in the asylum populations of the developed countries – Pilgrim State Hospital located in New York’s Long Island eventually became the largest in the world, with a population of 14,000 patients) and also to guide physicians when making decisions about treatment. The effort to develop such manuals was largely an American endeavour, but a plethora of proposals by different authorities and the consequent lack of a widely agreed system meant that this process was largely unsuccessful. For example, by the end of the Second World War (during which about one in ten American military casualties suffered from a psychiatric condition) separate and often incompatible diagnostic systems were employed by each of the US armed forces and by the civilian hospitals scattered throughout the country which distressed soldiers were evacuated to. The American Psychiatric Association’s response to this problem was to publish the first edition of their Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1951. A similar manual was also developed by the World Health Organization, which took on the responsibility of revising a previously published French government classification of diseases; the resulting sixth edition of the International Classification of Diseases (ICD) was published in 1949.

The challenge from within mainstream psychiatry

However, by this time, the value of conventional psychiatric diagnoses was being contested both within and outside mainstream psychiatry. Within the American psychiatric establishment, the work of Adolf Meyer (1866–1950) had become highly influential. Originally trained in neurology, Meyer had moved to America from Switzerland in the last years of the nineteenth century and had been reluctantly recruited into psychiatry after observing the appalling conditions at an asylum in the small town of Kankakee, near Chicago, where he at first worked as a pathologist. Although largely responsible for introducing Kraepelin’s ideas to North America, he became sceptical about the importance of diagnoses, arguing that ‘We should classify plants not people’. An integrationalist who was inspired by both psychoanalysis and the psychological doctrine of behaviourism (leading the psychiatric historian Edward Shorter (1999) to make the unfair quip that Meyer was ‘A second-rate thinker and verbose writer, [who] was never, in his own mind, able to disentangle schools that were absolutely incompatible, and ended up embracing whatever new came along’), he advocated understanding each patient within his or her social context and history of stressful life events (what clinical psychologists now term a ‘case formulation’). In a nod to this approach, the DSM-I de...