Clinical Psychology and Bulimia Nervosa: History and Practice

Introduction: The Scope of Clinical Psychology

The beginnings of clinical psychology date back to the year 1492, and the field has changed from the mere treatment of mental illness into an entire discipline of research and experimentation. This evolution has helped individuals affected by mental disorders — including eating disorders such as bulimia nervosa and anorexia nervosa, which are prevalent among adolescent and young adult women worldwide — overcome harmful habits and lead more productive lives. Some of the most important names in the history of clinical psychology, who can be regarded as the founding fathers of the field, are Lightner Witmer and Wilhelm Wundt. Their theories and methods paved the way for the clinical psychologists of today, who are now trained to encompass a broader range of healthcare concerns for the individuals who come to them for treatment. The future of clinical psychology may see it come under the wider umbrella of general healthcare, moving beyond its earlier narrow focus on mental disorders alone.

The actual beginnings of clinical psychology can be attributed to Luis Vives, who lived from 1492 to 1540. He can be called the precursor of modern psychology, but the official founding date of clinical psychology is generally considered to be 1879, when Wilhelm Wundt established his experimental laboratory at the University of Leipzig.

History and Definitions of Clinical Psychology

Today, clinical psychology can be defined as the application of psychology to mental illnesses, abnormal behavior, or behavioral problems in the human mind. It is also defined as the branch of psychology that focuses on the treatment of mental disorders of any kind, as well as abnormal thinking and abnormal behavior. The actual term "clinical psychology" was introduced by the American psychologist Lightner Witmer in a paper published in 1907.

There has been widespread criticism of the contemporary definition of clinical psychology, with critics arguing that the definition is too broad and all-encompassing, incorporating many non-pathological behaviors and conditions within its scope. As a result, several alternative definitions have been proposed. One well-known alternative was put forward by Wakefield in 1992, who termed mental disorder as "harmful dysfunction." Bergner, in 1997, endorsed a definition proposed earlier by Ossorio in 1985, which stated that psychopathology is best defined as a "significant restriction" on an individual's abilities and faculties, whereby the person cannot engage in deliberate actions; that is, they are not in control of their behavior and therefore cannot participate effectively in the prevalent social practices of their time. (Stricker, Widiger, & Weiner, 2002)

In other words, clinical psychology can be understood as a broad field of research within psychology that applies psychological principles to the assessment, prevention, amelioration, and rehabilitation of individuals experiencing psychological distress or trauma of any kind, with the ultimate aim of enhancing both mental and physical well-being.

The original definition of clinical psychology did not necessarily include all these elements. The field developed in ways that its founder, Lightner Witmer, may not have anticipated when he opened the very first psychology clinic in 1896 and founded the first scholarly academic journal related to psychology, named The Psychological Clinic, which was responsible for training some of the world's first generation of clinical psychologists. One of the first cases treated, as is widely known today, was that of Charles Gilman, a school-going child with certain spelling difficulties. (Routh, 1996)

After treating visual difficulties in this case, Witmer became convinced that psychology could meaningfully help such individuals. His primary emphasis was on the academic treatment of children who were "retarded" in their normal mental development — using "retarded" in the sense of delayed, for whatever reason. This emphasis on children's academic problems contributed to the development of school psychology and was a major stepping stone in the early definition of clinical psychology. (Routh, 1996)

The beginnings of clinical psychology are again attributed to Lightner Witmer. It was in his first publication in The Psychological Clinic, in an article entitled "Clinical Psychology," that Witmer explained the clinical method he had been using in treating his subjects — or "cases," as he called them. This method involved performing small experiments on subjects so that the attending psychologist could better understand the basic nature of the patient's difficulties. Over time, Witmer also began to conduct educational experiments, in which he advocated a strategy of "teaching to weaknesses." Although both Witmer's clinic and his journal no longer exist, the conception of clinical psychology that he developed must be attributed to this pioneering figure. (Lightner Witmer and the Beginning of Clinical Psychology)

The Scientist-Practitioner Model, also known as the Boulder Model of clinical psychology, is widely acknowledged as one of the first formal models for training in clinical psychology. It emerged from a conference at which more than seventy-three educators and professionals discussed the best educational program for doctoral psychology training — a conference prompted by the explosive growth of clinical psychology following the Second World War. The professionals attending noted that existing traditional graduate training programs for doctoral psychology were insufficient, and that both clinicians and faculty were being inadequately prepared. (Hodgson, Johnson, Ketring, Wampler, & Lamson, 2005)

Training Models in Clinical Psychology

The Boulder Model was therefore created with the intention of teaching both clinical and research skills to students and practitioners of clinical psychology. It was described as a "mid-point in a continuum" that placed emphasis on the integration of both research and practice. An article published by the American Psychological Association's Committee on Training in Clinical Psychology in 1947 provided the foundational starting point for this model, stipulating that research, theory, and practice must be integrated throughout the candidate's training period. (Hodgson et al., 2005)

The Practitioner-Scholar Model, also called the Reflective Practitioner Model, lays emphasis on providing students with the skills necessary to think and analyze issues critically, and to evaluate research-based findings in light of their own clinical experience. Interns are expected, throughout their year of study, to both develop and apply their analytical thinking skills and their knowledge of scientific literature in order to evaluate research findings as a basis for clinical interventions. Methods used to support this approach include case assignments, individual and group supervisions, training seminars, mentoring, monitoring, and in-service training procedures. (Practitioner-Scholar Model: The Counseling Centre for Human Development)

The widespread belief is that this model encourages students to develop "reflective" skills that will better equip them as clinical practitioners. In the view of Hoshmand and Polkinghorne (1992), professional education must always be grounded in the development of reflective judgment, enabling students to effectively manage the various biases that might otherwise hinder their full comprehension of clinical issues and reduce their effectiveness as practitioners. (Practitioner-Scholar Model: The Counseling Centre for Human Development)

Psychoanalysis can be defined as a family of psychological theories and psychotherapeutic methods that aim to clarify the connections between the unconscious components of an individual's mental processes by tracing the various associations in the patient's mind. In classical psychoanalysis, the basic subject matter is the unconscious pattern of the individual's life, which may become revealed through what is known as "free association." Once the analyst understands these unconscious patterns, he or she can begin to help the patient and liberate them from unconscious barriers — often referred to as "transference" and "resistance" — that are no longer serviceable. Essentially, psychoanalysis seeks to restore to the patient their self-esteem and self-confidence so that they may overcome rational and irrational fears held in the subconscious. (Psychoanalysis: Wikipedia)

It is important to distinguish between psychiatry and psychology. A psychiatrist is a physician who has attended medical school and received specialized training in psychiatry and psychoanalysis, while a psychologist holds a doctoral degree, is in clinical practice, and has conducted extensive research in the field. When an individual wishes to become a psychoanalyst, they must train under a recognized psychoanalytic institute. (Psychology and Psychiatry: A Guide to Psychology and Its Practice)

The theory of life span development and its effect on clinical psychology merits attention as well. In this approach, human development from infancy through adolescence, early adulthood, and the ageing process is analyzed, and these developmental stages inform psychoanalytic and clinical work. According to the School of Psychological Sciences at the University of Indianapolis, which follows the scientist-practitioner method, students are encouraged to build solid core knowledge of assessment, evaluation, intervention, and research skills through structured coursework. The qualified student may then adopt whichever approach is most appropriate for the treatment of a given patient. (Psy.D. Program in Clinical Psychology)

Bulimia Nervosa: Definition, Diagnosis, and Treatment

William James and Wilhelm Wundt are generally regarded as the "Fathers of Psychology" of their era, and the founders of the first great schools of psychology. Wundt was born in 1832, and in 1867 he began a course he called "physiological psychology," which focused on the border area between physiology and psychology — specifically the senses and their reactions. His lecture notes would later become his major work, Principles of Physiological Psychology. The method Wundt created involved experimental introspection, whereby the researcher was required to carefully observe a simple event whose quality, intensity, and duration could be accurately measured, record their responses, and note their reactions to variations of that event. (Wilhelm Wundt and William James)

Wundt also established the world's first laboratory dedicated to experimental psychology, which proved to be a landmark development in the history of the field. All subsequent psychological laboratories in which philosophers and psychology students could gather and share findings were modeled on this initial laboratory. (Wilhelm Wundt, German Philosopher and Psychologist)

There are two types of individuals affected by the disorder known as bulimia nervosa: the "purging type" and the "non-purging type." Any individual with bulimia nervosa engages in a cyclical pattern of behavior: on one hand, discrete episodes of excessive eating, and on the other, compensatory behaviors intended to counteract perceived weight gain from those episodes. A typical episode of overeating in an individual with bulimia nervosa involves consuming an amount of food that would generally be considered excessive by most standards. (Bulimia Nervosa: International Eating Disorder Referral)

The central psychological feature in a bulimic individual is a perceived lack of control over eating. While the person may engage in excessive or binge eating, they will invariably attempt to compensate by self-induced vomiting, misuse of laxatives, caloric restriction through dieting, or use of enemas, diuretics, or excessive exercise. The bulimic individual typically bases their self-evaluation on their perception of their own body image and is obsessively concerned with shape, size, and weight. (Bulimia Nervosa: International Eating Disorder Referral)

Bulimia nervosa can therefore be defined as an eating disorder in which the affected individual repeatedly consumes large quantities of food in a single sitting (binging) and then compensates by vomiting or purging, both typically self-induced. The vomiting is generally triggered by fear of weight gain, and the individual may experience stomach pain as well as intense guilt following overeating. In most cases, the individual also misuses laxatives, diuretics, enemas, or other medications designed to eliminate recently consumed food. Self-condemnation, depression, and guilt are all hallmarks of bulimia nervosa. For a clinical diagnosis to be made, the individual must engage in such episodes of overeating followed by compensatory behavior at least twice a week for a period of three months. (Definitions of Bulimia Nervosa on the Web)

Bulimia is often described as a "social epidemic" that has reached significant proportions not only in the United States but in most other parts of the world as well. The American Psychiatric Association's practice guidelines indicate that this eating disorder has been diagnosed predominantly in a female population, with approximately 1 to 10% of middle and upper class females in the adolescent and college-going age groups affected. On average, it is estimated that about 1 out of every 200 teenage girls suffers from some form of eating disorder, whether bingeing or starvation. (Beach, 1996)

One of the most important diagnostic criteria for bulimia nervosa is the presence of recurrent episodes of binge eating. A second criterion is the presence of "extremely compensatory behavior" undertaken to maintain or control body shape and weight. The third diagnostic criterion is that the person bases their sense of self-worth and self-confidence entirely on body weight and shape. According to a study conducted by Fairburn et al. in 1996, the prevalence rate of bulimia nervosa was generally between 1 and 2%, though it is widely acknowledged that most cases go either unreported or undiagnosed. (The Prevalence of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder)

Bulimia nervosa may have a lifetime prevalence of approximately 1.1% among women aged 16 to 65. However, this does not mean that men are unaffected. Studies have revealed that although rates of bulimia nervosa and anorexia nervosa are significantly lower among men, men do suffer from eating disorders, at rates of approximately 0.1% and 0.5% respectively on average. Many cases of eating disorders in men go unreported or undetected, suggesting the true prevalence may be higher. (The Prevalence of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder)

Most men and women who suffer from bulimia nervosa are individuals who feel overwhelmed in their efforts to cope with their emotions, and who feel compelled to blame themselves for circumstances that may not realistically be their fault. The disorder may stem from a need for self-punishment, with overeating and purging serving as ways of coping with emotions such as anger, stress, anxiety, or depression. (Bulimia Nervosa: something-fishy.org)

Because all harmful habits become harder to break the longer they persist, the recognition and addressing of bulimia as soon as it becomes evident is critically important. Since bulimia involves both mind and body, a team of professionals — including medical doctors, mental health professionals, and dieticians — must be involved in treatment. The fundamental goals of treatment include psychoeducation about the medical implications of the eating disorder, self-identification of the "triggers" that precede bingeing or purging behavior, and the interruption of the ritualized patterns of bulimic episodes. (Bulimia: Signs, Symptoms, Effects, and Treatments)

Treatment should also challenge the distorted weight and body image beliefs the individual holds, and move toward building the patient's self-esteem and self-confidence so that they can begin to define themselves by more than body shape or size alone. A successful treatment plan provides a basic support system for the bulimic, helping to end the isolation that is frequently experienced by those with bulimia nervosa. Common treatment programs include Overeaters Anonymous, the 12-Step Program, and self-help groups run by organizations such as the Eating Disorders Association. (Bulimia: Signs, Symptoms, Effects, and Treatments)

Several theories have been proposed regarding the real causes of bulimia nervosa. Some theorists argue that individuals with the disorder are attempting to redeem their self-esteem through the cycle of bingeing and purging, while others suggest that the highly distorted body image prevalent in Western culture is an important contributing factor. (Eating Disorders Overview) Other theorists lay stress on "guided imagery," through which bulimics can regularly soothe themselves by developing an external source of comfort, while simultaneously enhancing their capacity for internal self-soothing. Winnicott, one of the proponents of the guided imagery method, described "good enough mothering" and the "holding environment," which emphasized the bonding between mother and child. If this experience were to be internalized, Winnicott explained, the bulimic would find comfort from within. (Esplen & Garfinkel, 1998)