History Of Clinical Psychology In Europe Research Paper

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1. Introduction

Europe is characterized by its social, linguistic, and cultural diversity (e.g., Drenth et al. 1990, Poortinga 1996), which is rooted in very diﬀerent histories and traditions of the 48 or so countries. Even the geographical or political extent of Europe is a matter for some debate, though it is assumed that the growth of the European Union (currently 15 states, all of them in western Europe) will clarify this in future years. Although psychology as a discipline originated with Wundt’s laboratory in Leipzig, Germany, in 1879, the profession of clinical psychology was considerably slower to develop in Europe than in the USA (Sexton and Misiak 1976, Eysenck 1990, Sexton and Hogan 1992).

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The major inﬂuence for the development of clinical psychology in many western European countries was the rebuilding of Europe after World War II in the 1940s and 1950s and the development of mental health facilities by European states, as the challenge of mental problems and mental health presented itself to health authorities (Lunt 2000). In eastern European countries clinical psychology developed much later as these countries emerged in the 1980s from political regimes which were critical of the discipline (e.g., Pawlik 1996). It is only relatively recently that these countries have begun to develop a profession of clinical psychology.

2. The Field Of Clinical Psychology

Although there are diﬀerences between countries, it is possible to provide a general deﬁnition of the ﬁeld which would be agreeable to all European countries; clinical psychologists may be deﬁned as psychologists who

apply psychology in a clinical context, usually a hospital, medical or community setting, with people (patients or staﬀ ) who consider themselves to be in need of a psychological perspective on their lives. In practice, the majority of clinical psychologists contribute to the assessment and treatment of people who see themselves as having psychological problems, such as those with mental health diﬃculties, but they also work with the handicapped, families, those with learning diﬃculties, and, more widely, with staﬀ and/organisations (Llewelyn 1994).

There are some diﬀerences in the practice of clinical psychology, from countries where the majority are employed by the state such as the United Kingdom where most clinical psychologists work for the National Health Service (NHS) and there is relatively little private practice, to countries such as Switzerland and Germany where many clinical psychologists work in private practice, with charges reimbursed by medical insurance companies. Furthermore, there are diﬀerences in the dominant activity of clinical psychologists: in many European countries the main activity is psychotherapy, whereas in others there is a broader role which includes assessment and other forms of intervention, and also a role in training and consulting with other staﬀ. While the dominant paradigm informing clinical psychology in the United Kingdom is cognitive behavior therapy, other European countries such as France and Italy historically have been more inﬂuenced by psychoanalytic ideas. Although all European countries have been inﬂuenced by the USA, this inﬂuence has been perhaps most striking in the Scandinavian countries which embraced the ‘scientist practitioner’ approach to practice from an early stage.

2.1 Europe

As mentioned, the political face of Europe is developing and changing rapidly (see Lunt 1998). Many of the central and eastern European countries have applied for membership of the European Union, and are working towards criteria which will enable them to join. This will mean an expanded and changed Europe in the not too distant future, bringing together the early members of the European Union and nonmember states; many of the latter in Eastern Europe and formerly belonging to the Soviet Union. The countries of Europe constitute a very diverse group that may nevertheless be grouped into broad regions with some commonality in their organization and practice of clinical psychology. For these purposes, at a very broad level it is possible to identify a Nordic group of countries with considerable commonalities in their practice (the Scandinavian countries), Great Britain which has much in common with education and training in the USA and other parts of the English-speaking world, the German speaking countries, a southern European group, and an eastern European group. Of course, within these regions, the countries are characterized by their individuality and their diversity, and the diﬀerent histories that have had a profound inﬂuence on the development of clinical psychology.

3. The Early Years Of Clinical Psychology

There are a number of models in the ﬁeld of clinical psychology, a ﬁeld which emerged in European countries substantially after World War II (see above). It emerged as a recognizable profession at diﬀerent times in diﬀerent countries. In the United Kingdom the two World Wars provided a signiﬁcant impetus to the emergence of this profession, initially through the need to develop psychological tests to recruit suitable personnel, and later in 1948 with the formation of the NHS that provided a considerable impetus to the development of this new profession. In these early days, the role of the clinical psychologist was largely one of laboratory technicians administering psychometric and other tests, usually for medical practitioners (Eysenck 1990). However, in the United Kingdom, the development of behavior therapy, in particular under the inﬂuence of Hans Eysenck who established clinical psychology as a profession in England in 1949, led to clinical psychologists developing a therapeutic role, and by the 1960s they had become clinical practitioners in their own right.

In the Nordic countries, also, clinical psychology emerged substantially after World War II, in the 1940s and early 1950s; the Norwegian Psychological Association was founded in 1934, the Danish Psycho-logical Association in 1947, the Swedish Psychological Association in 1955, and the Finnish Union of Psychologists in 1957. The formation of these Psycho-logical Associations reﬂected the emergence in these countries of a profession of psychology, mainly clinical psychology, which progressed through similar broad major phases as the UK; that is, a phase focusing on diagnostic examination and testing of individual patients, a phase focusing on therapeutic work involving mainly psychotherapy, and a phase focusing on indirect work with other professional groups through techniques such as consultation and training.

In Spain, on the other hand, clinical psychology has had a shorter history (Belloch and Olabarria 1994) and is said to have emerged in the 1970s along with fundamental changes in Spanish society. Similarly in Italy, clinical psychology as a professional application emerged substantially in the 1960s and there remain some tensions over the autonomy and role of clinical psychologists and their relationship with medical practitioners, especially psychiatrists. The Association of Greek Psychologists, founded in 1963, reﬂects the existence of professional psychology in Greece, al-though at that time and until very recently, all clinical psychologists received their training overseas, and the profession was very much dominated by the medical profession.

As mentioned above, clinical psychology emerged much later in Eastern European countries, and it was not until the 1980s that psychotherapy was fully recognized as a profession (Pawlik 1996). Until recently, nearly all psychologists were employed in state institutions, though in recent years there has been a growth in demand which has resulted in a growth in private practice.

In all European countries, clinical psychologists represent the largest group of psychologists, and experienced a rapid growth in their number between the 1960s and the 1990s with the expansion of mental health provision and the growing awareness of the contribution of clinical psychology to a wide and diverse range of areas of work (EFPPA 1997). Indeed, the 31 Member Associations of EFPPA (see below) represent 150,000 psychologists, the majority of whom are clinical psychologists.

Since the 1990s, in many European countries the emergence of the specialty of health psychology, with a focus on prevention rather than treatment, and the promotion of health rather than a more therapeutic or curative function, has led to attempts to deﬁne and diﬀerentiate a new ﬁeld of psychological activity within the mental health ﬁeld. This has been supported by the WHO commitment to Health for All by the Year 2000; EFPPA has had three Task Forces, focusing respectively on clinical psychology, health psychology, and psychotherapy, which have drawn up a model deﬁning overlap and separate areas of activity within the health ﬁeld, with corresponding commonalities and diﬀerences in education and training (EFPPA 1997).

4. Training Of Clinical Psychologists

Education and training of clinical psychologists varies in European countries though, again, there are major regional groupings. Across Europe, as in other regions of the world, the education and training period has increased, with moves in some European countries for doctorate training for clinical psychologists, and more demanding requirements in all countries for the internship period. In the United Kingdom, there is a strong commitment to a scientist–practitioner model: ‘the clinical psychologist is ﬁrst and foremost an ‘‘applied scientist’’ or ‘‘scientist–practitioner’’ who seeks to use scientiﬁc knowledge to a beneﬁcial end’ (Marzillier and Hall 1990). This commitment also characterizes the Nordic countries which have been inﬂuenced substantially by the USA, and also by the UK. These countries would sign up to the deﬁnition that:

clinical psychologists share several common attributes. They are psychologists because they have been trained to use the guidelines of knowledge of psychology in their professional work. They are clinicians because they attempt to understand people in their natural complexity and in their continuous adaptive transformations … they are scientists because they utilize the scientiﬁc methods to achieve objectivity and precision in their professional work. Finally, they are professionals because they render important human services by helping individuals, social groups, and communities to solve psychological problems and improve the quality of life (Kendall and Norton-Ford 1982, p. 4).

This model is also espoused by Spanish clinical psychology where Belloch and Olabarria (1994) state that clinical psychology training is ‘very similar to that proposed in the 1940s, in the famous Boulder Conference, organised by the APA.’ In France, where there is a strong clinical psychoanalytic tradition, there is less of a commitment to the ‘Boulder’ model, and more of a philosophical or hermeneutic tradition in relation to education and practice.

However, since 1957 when the Treaty of Rome provided the foundation for the European Com-munity (later Union), there have been requirements on individual countries (‘states’) to provide procedures for the mutual recognition of psychologists’ qualiﬁcations across national boundaries (see McPherson 1988). Wider moves within the European Union such as the Bologna Agreement, which was signed by 29 Ministers in 1999 and commits them to greater convergence in terms of university degree structures, mean that even within Europe there is likely to be greater similarity in terms of structures of education and training for clinical psychologists.

5. Professionalization Of Clinical Psychology

The period since the 1950s has seen a greater professionalization of clinical psychology in all European countries, with the development of codes of ethics (Lindsay 1996) and increased regulation and laws for clinical psychologists (Lunt 2000) across European countries. These political and professional developments have been supported by EFPPA which has brought together clinical psychologists from all over Europe to work on the professional aspects of practice at a European level and to support individual European countries seeking to develop their ethical codes, laws protecting the title of psychologist, and education and training in clinical psychology.

6. Organization Of Clinical Psychology

It is also possible to trace the history of clinical psychology through its organization in Europe (Gilgen and Gilgen 1987, Lunt 1998). Many European countries founded scientiﬁc societies for psychologists in the early twentieth century whose purpose was to foster research and psychological science. At the time of World War II, separate professional associations to meet the needs of professional psychologists, often mainly clinical psychologists, were founded in a number of European countries. These associations had, as a focus, issues concerning professional practice and emerged in some countries as Trade Unions, negotiating salaries and terms and conditions of work for clinical psychologists as well as wider professional issues such as regulation, legislation, and ethical codes. In 1981, at a time when the provisions of the European Community demanded that European member states encourage mobility of professionals across Europe, the European Federation of Professional Psychologists Associations was formed to bring together professional associations in Europe and to collaborate on matters of common professional concern.

EFPPA currently has 31 member associations representing all the countries of the EU, all other countries in western Europe, and a growing number of member associations from central and eastern Europe. The federation provides a unique opportunity for comparison between the practices of diﬀerent European countries and a forum for discussion and debate of important issues. The formation of EFPPA in 1981, when matters of mobility and mutual recognition were becoming more pressing, was due to a realization by psychologists and psychology associations of member states that a federation would provide a professionally and politically useful way to move forward and to begin to develop common policies in this area. Clinical psychologists, in particular, were faced with the growing prospects of mobility between countries in the European Union, and the implications of the Treaty of Rome that provided the foundation for the European Community in 1957.

As a federation of Professional Psychology Associations representing around 150,000 professional psychologists in Europe, EFPPA spends most of its eﬀorts on clinical psychology and clinical psychologists, also the largest group of psychologists within Europe (as in the rest of the world). In many countries psychology has become one of, if not the, most popular subjects to study at university. The majority of students studying psychology aspire to become clinical psychologists, and for this reason, in many European countries, there is an oversupply of qualiﬁed practitioners. Many countries now operate a so-called numerus clausus, either at the start of the psychology study, or during the study. This controls the numbers in training. In the United Kingdom, where specialist training in clinical psychology is funded by the NHS— where the vast majority of clinical psychologists work— the number of ‘trainee’ posts is strictly limited and is planned according to staﬃng needs in the diﬀerent regions of the country. In other countries, where there is a tradition of predominantly private practice in clinical psychology, there are large numbers of qualiﬁed psychologists unable to ﬁnd work. In all European countries, the ratio of female to male students is between 6:1 and 3:1, leaving the profession in danger of becoming an almost feminized profession in the future (Schorr and Saari 1995). There has also been some diﬃculty in many countries in recruiting students from the range of ethnic groups represented in Europe’s increasingly multiethnic population. This clearly has implications for the clinical treatment of diﬀerent client groups.

7. The Future

As new ﬁelds of practice in the health ﬁeld evolve, in particular health psychology, there are pressures on clinical psychology. For example, in some countries it has been said that there may no longer be a ﬁeld of clinical psychology, since there are strong moves towards a broader ﬁeld of health psychology and a greater focus on preventive work. These newer areas, such as health psychology, neuropsychology, and forensic psychology, are leading to greater specialization within and outside clinical psychology. Although European countries diﬀer in the extent and nature of their specialisms within the health ﬁeld, there is an increasing trend for specialization and demands for higher qualiﬁcations. In one respect, psychologists working within the health system could be said to be becoming more generic, while on the other hand there are increasing specializations within this ﬁeld of work.

8. Summary

The brief 50-year history of clinical psychology in Europe has seen an enormous increase in numbers both of students and of practitioners, such that the majority of psychologists are now clinical psychologists. This rapid professionalization has been accompanied by higher qualiﬁcations, greater regulation, the development of ethical codes, and all the characteristics of traditional professions. However, as the number of clinical psychologists increases, and the question of mobility across Europe becomes more pressing, there will be increasing attempts to develop more common frameworks and standards for education and practice; the challenge will be to achieve a balance between allowing individual countries their own autonomy which reﬂects their diﬀering history and culture (‘subsidiarity’ as it is called), and developing more common agreed frameworks of practice which reﬂect a possible future ‘federalization’ of Europe.

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