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VA Psychologists and Clinical Science in the 1950s
By Wade E. Pickren
Many WWII veterans were interested in psychology as a result of their wartime experiences and the GI Bill (Soldiers' Readjustment Act of 1944) provided financial subsistence for both undergraduate and graduate education of these veterans. Concurrently, the large number of World War II veterans who needed continued medical and psychological care after military discharge prompted the VA to initiate large scale training programs in four mental health disciplines: psychiatry, psychiatric nursing, clinical social work, and clinical psychology. The impact of this program on clinical psychology was enormous and can hardly be overstated. The VA, with consultation from prominent psychologists such as George A. Kelly and in agreement with APA, made the doctorate the entry-level degree for clinical psychology. This decision, in conjunction with the desire of the recently created National Institute of Mental Health to foster mental health research and increase the number of mental health professionals, led to the adoption of the scientist-practitioner (Boulder) model of clinical psychology in 1949.
Of more immediate practical value to graduate students, the VA provided training stipends in return for a set number of work hours in a VA setting. The VA benefitted by having an increasingly well-trained professional work force that more nearly approximated its needs for patient care. Although the VA did not require clinical psychology trainees to commit to postdoctoral service, many trainees did remain with the VA. It is in this context that VA psychologists parlayed their training as scientists into meaningful clinical research.
I use 1953 as the reference year, because by this time the first wave of VA clinical psychology trainees had completed their training. In 1953, the VA had 109 general hospitals, 21 tuberculosis hospitals, 38 neuropsychiatric hospitals, and 63 mental hygiene clinics. In addition, the VA operated 17 domiciliaries, or old soldiers homes. The patient population was large, with neuropsychiatric cases taking approximately 60 percent of the hospital beds. Psychologists were expected to provide some aspects of patient care, especially group psychotherapy. More typically, psychologists provided diagnostic and assessment services. While their results were useful in sorting patients, psychologists also used the collected data as research resources. An example of this can be found in the extensive publication record of Maurice Lorr, then chief of neuropsychiatric research in the VA central office. Lorr was a sophisticated psychometrician who developed the POMS (Profile of Mood States), the IMPS (Inpatient Multidimensional Psychiatric Scale), the Multidimensional Scale for Rating Psychiatric Patients (MSRPP), and many others. Patient management was often the target of this kind of research.
One of the major research innovations of the VA was the "cooperative study". In cooperative studies, a common research protocol was shared by as many hospitals as wished to collaborate. The advantages were a very large patient pool, huge data sets, and a fair amount of statistical power in the analysis. Like all large studies, there were problems, including some inconsistency in following the protocol. The first cooperative studies were among the tuberculosis hospitals. A chief medical concern was what was called, "irregular discharge," which referred to patients leaving the hospital before they were completely well. Psychologists like Robert Barrell and Claire Vernier were among the leaders of this research. A cooperative study on prefrontal lobotomy was conducted in the 1950s among a small group of VA hospitals. The study was later transferred to the Central Neuropsychiatric Research Laboratory at Perry Point, Maryland.
It was at the Perry Point laboratory that the most ambitious of the cooperative studies was coordinated. Begun in 1956, the VA Cooperative Studies in Psychiatry were large scale studies of what was then called chemotherapy, now termed pharmacotherapy or psychopharmacology. Numerous projects on the psychological effects of various drug treatments were conducted, all using a common protocol devised by the study's Executive Committee. Psychologists Jack Lasky and James Klett were the early research directors and numerous psychologists at many VA hospitals were involved. Typically, the main research questions were devised by the Executive Committee, made up of psychiatrists and psychologists. The research design and methodology were the responsibility of the psychologists. Utilizing their scientific training in the Boulder model, psychologists were expert at these tasks and the statistics necessary to analyze the massive data sets.
The Psychiatric Evaluation Project, headed by psychologist Lee Gurel, evaluated the effects of different types of treatment settings on patient outcomes. The initial PEP project was to measure hospital effectiveness. Patients were followed for several years, with the intent that treatment outcomes would provide guidance on how to make VA hospitals more effective. This led to more complex cooperative studies over the years and evolved into an in-house evaluation program. In all of these cooperative studies, psychologists were allowed to pursue spin-off projects. The contributions of VA psychologists added greatly to the clinical science literature of the 1950s and 1960s.