An asocial psychology and a misdirected clinical psychology.

The origins of modern clinical psychology cannot be understood independently of some longstanding, dominant characteristics of American psychology in general. One such characteristic is psychology's emphasis on the individual organism, an emphasis that ill prepared psychology in the post-World War II period for the public arena. One of the consequences for clinical psychology was that it became embroiled in the traditions of American medicine. The adverse effects of this are explored and discussed. In what social-historical context did the major features of modern clinical psychology initially gain expression? How did this context affect the universe of policy alternatives modern clinical psychology could have considered in its early phase? Why did clinical psychology so readily accommodate to a public policy that not only defined what the "mental health problem" was in our society but also outlined how that problem was to be approached? And why did the basis of that approach in an individual psychology go unexamined? It is the last question that interests me the most because I have come to believe that from its inception a hundred years ago, American psychology has been quintessentially a psychology of the individual organism, a characteristic that however it may have been and is productive has severely and adversely affected psychology's contribution to human welfare. I elaborate later on this point, but those who may want to delve more deeply into this question I urge to read the APA publication edited by Hilgard (1978), which contains addresses of presidents of the association, beginning with William James. With one notable exception one would hardly know that psychology existed in a particular society having a distinctive social order deriving from a very distinctive past, that psychologists did not (and do not) represent a random assortment of people, and that by virtue of their socialization into their society, and their social-professional niche in it, the substance of their theories had to reflect these factors. Instead, Vol. 36, No. 8, 827-836 Copyright 1981 by the American Psychological Association, Inc. 0003-066X/81/3608-0827$00.75 one finds a riveting on the individual organism. The one notable exception, and it is a dramatically instructive exception, is a presidential address given in 1899 in New Haven with the title "Psychology and Social Practice. " If psychology (then and now) had been able to understand this address, which was quite critical of the directions psychology was taking, American psychology would not now be suffering the malaise it is. I have recently completed a book, Psychology Misdirected (Sarason, 1981), that is dedicated to the APA president who gave that address: John Dewey. Psychologists think of John Dewey, when they think of him at all, as an educator and philosopher who once was a psychologist. But Dewey saw clearly what psychology still is blind to: The substance of psychology cannot be independent of the social order. It is not that it should not be independent but that it cannot be. But American psychology has never felt comfortable pursuing the nature and consequences of the social order. Let the other social sciences wrestle with such matters! Besides, a true understanding of the social order, as well as efforts to change and improve it, could only come after psychology illuminated human nature, individual human nature. Psychology had it backwards, a fact to which it cannot be sensitive as long as theories are about individuals—as single individuals, as individuals in a dyad or small group, or as individuals in a family. For all practical purposes, social history and the social order were ignored. And this explains why when psychology really entered the "real world" and the arena of public policy in the post-World War II period, it was, from my standpoint, the beginning of a disaster. I must now turn to elaborating on these This article was originally the presidential address to Division 12 (Clinical Psychology), presented at the meeting of the American Psychological Association, Montreal, September 1980. The author gratefully acknowledges the help provided by Michael Klaber during the writing of this article. Requests for reprints should be sent to Seymour B. Sarason, Yale University, Institute for Social and Policy Studies; Box 17A Yale Station, New Haven, Connecticut 06520. AMERICAN PSYCHOLOGIST • AUGUST 1981 • 827 points by reflecting on the history of modern clinical psychology. This introduction has been necessary if only to underline the point that the limitations of clinical psychology inhered in American psychology. Consequences of World War II Modern clinical psychology was a direct outgrowth of World War II. At all levels of federal government during the war, there was recognition that the government would have responsibility for a staggering number of veterans who in one way or another would be physical or mental casualties. That the government "owed" these casualties the best kind of care was clear, and the best kind of care would have to be quite different from that provided veterans in the decades after World War I. To provide this care would require a policy that would facilitate the placement of facilities and services in or near medical centers. That policy was intended to create a partnership between the Veterans Administration (VA) and the medical centers, the bulk of which would be university based. The VA wanted the quality Services the medical centers could provide, and the medical centers needed the new facilities for training and research. No one raised the possibility that given the traditions of medical centers, especially their professional preciousness and imperialistic ambience, partnership would, in practice, mean domination by the medical centers. It was a policy that assumed that self-serving professionalism would not be a problem: It was not a policy rooted in the sociology of professions in general and the medical profession in particular. Indeed (as I discuss later in relation to clinical psychology), one of the characteristics of the policymaking process is the absence of sensitivity to social history. But there was an even more fateful, implicit assumption to the policy: Veterans would get "better" in the hospitals and clinics and then return to their homes and communities. That assumption contains a kernel of truth in relation to physical illness, but if I had the time I would have no difficulty demonstrating that from the standpoint of prevention of personal, family, and 'work problems, this kernel of truth is not all that impressive. In relation to psychological problems there is no kernel of truth. By their very nature these problems are individual-family-workcommunity related. In fact, as the VA learned in subsequent decades, hospitalization and clinic visits that focused on the intrapsychic dynamics of the individual were frequently counterproductive or simply ineffective. Another important stimulus to the formulation of a policy for casualties of the war was an economic one, not only in terms of money for facilities and personnel but in terms of payments to veterans depending on their degree of war-incurred handicap. I am not attributing unworthy motivations to the policymakers when I say they were quite concerned that many veterans would seek to obtain payments from the government disproportionate to their handicaps and that some would manufacture symptoms to be eligible for payments. In short, there was the potential for an adversary relationship between the veterans and the professionals in the medical centers who would have to render judgments about degree of disability. This, of course, raised the question, Whom did the professionals represent? The potential for conflicts of interests, as well as for self-serving actions, was obvious on all sides. If what was obvious was not taken seriously, it was in part because everyone assumed that money would not be a problem, that the VA budget would increase to meet needs. So what if some veterans were getting benefits they did not merit? It may be somewhat unfair to say that the policymakers envisioned an endless gravy train. It is not unfair to say that they were naively ahistorical in the extreme in adopting such a stance toward the future. It took less than a decade for the professionals to learn that they were enmeshed in a system which put serious obstacles in the way of their therapeutic efforts and raised ethicalmoral questions the professionals did not know how to deal with, except by getting out, which many began to do. Unless one lived through those early post-World War II days, it is hard to appreciate the role of money as an incentive to medical center departments to enter the partnership. In the case of psychiatry, which up to World War II was not a strong or prestigef ul part of medical schools and medical centers, the VA presented a fairyland of delights: new facilities, additional personnel, residencies paid for by the government, consulting fees for faculty, research budgets, and all else that makes for gracious living. There are no grounds for ques^ tioning the sincerity of departments of psychiatry insofar as helping veterans was concerned. There are grounds for saying that the VA medical center tie presented psychiatry with the opportunity to become more influential vis-a-vis other specialties. And it is also true that departments of psychiatry did not see this tie as an end in itself but as a means 828 • AUGUST 1981 • AMERICAN PSYCHOLOGIST whereby other non-VA activities were made possible. Noblesse oblige characterized psychiatry's stance, which in practice meant, as it does in some legal partnerships, that there was a general partner and a limited partner. Guess who was the limited partner? The economics of the VA medical center tie reinforced the imperialistic traditions of American medicine, resulting in battles among medical departments and in "forei