assessment

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that had yet been developed. An additional factor contributing to the decline of

moral treatment was the emergence of a new wave of prejudice against people with mental disorders. The public came to view them as strange and dangerous. Moreover, many of the patients entering public mental hospitals in the United States in the late nineteenth century were poor foreign immigrants, whom the public had little interest in helping.

The more things change … The “crib” (le�) was one of many unthinkable devices and techniques used in asylums

several centuries ago. Unfortunately, in some parts of the world today, similar “treatments” are still applied to people with severe mental disorders. The photo on the right, for example, shows a man chained to a wall at a holy

shrine in a local village of Afghanistan, the primary intervention for his psychological disorder.

By the early years of the twentieth century, the moral treatment movement had ground to a halt in both the United States and Europe. Public mental hospitals were providing only custodial care and ineffective medical treatments and were becoming more overcrowded every year. Long-term hospitalization became the rule once again.

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The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives As the moral movement was declining in the late 1800s, two opposing

perspectives emerged and began to compete for the attention of clinicians: the somatogenic perspective, the view that abnormal psychological functioning has physical causes, and the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. These perspectives came into full bloom during the twentieth century.

The Somatogenic Perspective

The somatogenic perspective has at least a 2,400-year history — remember

Hippocrates’ view that abnormal behavior resulted from brain disease and an imbalance of humors? Not until the late nineteenth century, however, did this perspective make a triumphant return and begin to gain wide acceptance.

Two factors were responsible for this rebirth. One was the work of a

distinguished German researcher, Emil Kraepelin (1856–1926). In 1883, Kraepelin published an influential textbook arguing that physical factors, such as fatigue, are responsible for mental dysfunction. In addition, as you will see in Chapter 4, he developed the first modern system for classifying abnormal behavior, listing their physical causes and discussing their expected course (Kendler, 2019; Kendler & Engstrom, 2018).

New biological discoveries also triggered the rise of the somatogenic perspective. One of the most important discoveries was that an organic disease, syphilis, led to general paresis, an irreversible disorder with both mental symptoms such as delusions of grandeur and physical ones like paralysis (Ha, Tadi, & Dubensky, 2019). In 1897, the German neurologist Richard von Krafft- Ebing (1840–1902) injected matter from syphilis sores into patients suffering

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from general paresis and found that none of the patients developed symptoms of syphilis. Their immunity could have been caused only by an earlier case of syphilis. Since all of his patients with general paresis were now immune to syphilis, Krafft-Ebing theorized that syphilis had been the cause of their general

paresis. The work of Kraepelin and the new understanding of general paresis led many researchers and practitioners to suspect that physical factors were responsible for many mental disorders, perhaps all of them.

Despite the general optimism, biological approaches yielded mostly disappointing results throughout the first half of the twentieth century. Although

many medical treatments were developed for patients in mental hospitals during that time, most of the techniques failed to work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy (alternating hot and cold baths), and lobotomy, a surgical cutting of certain nerve fibers in the brain. Even worse, biological views and claims led, in some circles, to proposals for immoral solutions such as eugenic sterilization, the elimination (through medical or other means) of individuals’ ability to reproduce (see Table 1-1). Not until the 1950s, when a number of effective medications were finally discovered, did the

somatogenic perspective truly begin to pay off for patients.

TABLE: 1-1

Eugenics and Mental Disorders

Year Event

1896 Connecticut became the first state in the United States to prohibit persons with mental disorders from marrying.

1896−1933 Every state in the United States passed a law prohibiting marriage by persons with mental disorders.

1907 Indiana became the first state to pass a bill calling for people with mental disorders, as well as criminals and other “defectives,” to undergo sterilization.

1927 The U.S. Supreme Court ruled that eugenic sterilization was constitutional.

1907−1945 Approximately 45,000 Americans were sterilized under eugenic sterilization laws; 21,000 of them were patients in state mental hospitals.

1929−1932 Denmark, Norway, Sweden, Finland, and Iceland passed eugenic sterilization laws.

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1933 Germany passed a eugenic sterilization law, under which 375,000 people were sterilized by 1940.

1940 Nazi Germany began to use “proper gases” to kill people with mental disorders; 70,000 or more people were killed in less than two years.

Information from: Markfield, 2019; Lombardo, 2017; Stern, 2016; Fischer, 2012; Whitaker, 2002.

The Psychogenic Perspective

The late 1800s also saw the emergence of the psychogenic perspective, the view that the chief causes of abnormal functioning are often psychological. This view, too, had a long history, but it did not gain much of a following until studies of hypnotism demonstrated its potential.

Hypnotism is a procedure in which a person is placed in a trancelike mental state during which they become extremely suggestible. It was used to help treat psychological disorders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734–1815) established a clinic in Paris. His patients suffered from hysterical disorders, mysterious bodily ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room filled with music; then he appeared, dressed in a colorful costume, and touched the

troubled area of each patient’s body with a special rod. A surprising number of patients seemed to be helped by this treatment, called mesmerism (Leskowitz, 2019). Their pain, numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients and that this state was causing their symptoms to disappear. The treatment was so controversial, however, that eventually Mesmer was banished from Paris.

It was not until years after Mesmer died that many researchers had the courage to investigate his procedure, later called hypnotism (from hypnos, the Greek word for “sleep”), and its effects on hysterical disorders. The experiments of two physicians practicing in the city of Nancy in France, Hippolyte-Marie Bernheim (1840–1919) and Ambroise-Auguste Liébault (1823–1904), showed that hysterical

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Hypnotism update Hypnotism opened the door for the

psychogenic perspective and continues to influence many areas of modern life. Here, a client is hypnotized

by a clinician with the aid of a pendulum.

disorders could actually be induced in otherwise normal people while they were under the influence of hypnosis. That is, the physicians

could make normal people experience deafness, paralysis, blindness, or numbness by means of hypnotic suggestion — and they could remove these artificial symptoms by the same means. Thus they established that a mental process — hypnotic suggestion —

could both cause and cure even a physical dysfunction. Leading scientists concluded that hysterical disorders were largely psychological in origin, and the psychogenic perspective rose in popularity.

Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer (1842–1925) of Vienna. Breuer, a physician, discovered that his patients sometimes awoke free of hysterical symptoms after speaking candidly under hypnosis about past upsetting events. During the 1890s, Breuer was joined in his work by another Viennese physician, Sigmund Freud (1856–1939). As you will see in Chapter 3, Freud’s work eventually led him to develop the theory of psychoanalysis, which holds that many forms of abnormal and

normal psychological functioning are psychogenic. In particular, Freud believed that unconscious psychological processes are at the root of such functioning.

Freud also developed the technique of psychoanalysis, a form of discussion in which clinicians help troubled people gain insight into their unconscious

psychological processes. He believed that such insight, even without hypnotic procedures, would help the patients overcome their psychological problems.

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Freud and his followers offered psychoanalytic treatment to patients in their offices for sessions of approximately an hour — a format of treatment now known as outpatient therapy. By the early twentieth century, psychoanalytic theory and treatment were widely accepted throughout the Western world.

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Recent Decades and Current Trends

IT WOULD HARDLY BE ACCURATE to say that we now live in a period of great enlightenment about or dependable treatment of mental disorders. In fact, surveys have found that 43 percent of respondents believe that people bring mental disorders on themselves, 31 percent consider such disorders to be a sign

of personal weakness, 35 percent believe the disorders are caused by sinful behavior, and 33 percent are afraid of people with such disorders (APA, 2019a; Yokoya et al., 2018; Roper, 2017). Nevertheless, there have been major changes over the past 70 years in the ways clinicians understand and treat abnormal functioning. There are more theories and types of treatment, more research studies, more information, and — perhaps because of those increases — more disagreements about abnormal functioning today than at any time in the past.

How Are People with Severe Disturbances Cared For? In the 1950s, researchers discovered a number of new psychotropic medications — drugs that primarily affect the brain and reduce many symptoms of mental dysfunction. They included the first antipsychotic drugs, which correct extremely confused and distorted thinking; antidepressant drugs, which lift the mood of depressed people; and antianxiety drugs, which reduce

tension and worry.

When given these drugs, many patients who had spent years in mental hospitals began to show signs of improvement. Hospital administrators, encouraged by

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these results and pressured by a growing public outcry over the terrible conditions in public mental hospitals, began to discharge patients almost immediately.

Since the discovery of these medications, mental health professionals in most of the developed nations of the world have followed a policy of deinstitutionalization, releasing hundreds of thousands of patients from public mental hospitals. On any given day in 1955, close to 600,000 people were confined in public mental institutions across the United States (see Figure 1-1). Today the daily patient population in the same kinds of hospitals is between

38,000 and 75,000 (AHA, 2019a; O’Reilly, Allison, & Bastiampillai, 2019; Amadeo, 2017). In addition, thousands of people receive treatment in private psychiatric hospitals, care that is paid for by the patients themselves and/or their insurance companies. On average, the private facilities offer more pleasant surroundings and more favorable staff–patient ratios than the public ones.

FIGURE 1-1

The Impact of Deinstitutionalization

The number of patients now hospitalized in public mental hospitals in the United States (less than 75,000) is a small fraction of the number hospitalized in 1955.

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From Juilliard to the streets Nathaniel Ayers, subject of the book and movie The Soloist, plays his violin on

the streets of Los Angeles while living as a homeless person in 2005. Once a promising musical student at the Juilliard School in New York, Ayers developed

schizophrenia and eventually found himself without treatment and without a home.

(Information from: AHA, 2019a; O’Reilly et al., 2019; Amadeo, 2017)

Without question, outpatient care has now become the primary mode of treatment for people with severe psychological disturbances as well as for those with more moderate

problems. When severely disturbed people do need institutionalization these days, they are usually hospitalized for a short period of time. Ideally, they are then provided with outpatient psychotherapy and medication in community programs and residences (Ersan, 2019).

Chapters 3 and 14 will look more closely at this recent emphasis on community care for people with severe psychological disturbances —

a philosophy called the community mental health approach. The approach has been helpful for many patients, but too few community programs are available to address current needs in the United States (O’Donnell, Davis, & Mestan, 2019). As a result, hundreds of thousands of persons with severe disturbances fail to

make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets. Around 140,000 people with such disturbances are homeless on any

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given day; another 440,000 are inmates of jails and prisons (MIPO, 2019; NAMI, 2019b). Their abandonment is truly a national disgrace.

How Are People with Less Severe Disturbances Treated? The treatment picture for people with moderate psychological disturbances has been more positive than that for people with severe disorders. Since the 1950s, outpatient care has continued to be the preferred mode of treatment for them, and the number and types of facilities that offer such care have expanded to meet the need.

Before the 1950s, almost all outpatient care took the form of private psychotherapy, in which individuals meet with a self-employed therapist for counseling services. Since the 1950s, most health insurance plans have expanded coverage to include private psychotherapy, so that it is now more widely available to people of all incomes. Today, outpatient therapy is also offered in a number of less expensive settings, such as community mental

health centers, crisis intervention centers, family service centers, and other social service agencies. Surveys suggest that around 43 percent of people with psychological disorders in the United States receive treatment in the course of a year (AHA, 2019b; NIMH, 2019).

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Outpatient treatments are also becoming available for more and more kinds of problems. When Freud and his colleagues first began to practice, most of their patients suffered from anxiety or depression. Almost half of today’s clients

suffer from those same problems, but people with other kinds of disorders are also receiving therapy. In addition, at least 20 percent of clients enter therapy because of milder problems in living — problems with marital, family, job, peer, school, or community relationships (APA, 2019b).

Yet another change in outpatient care since the 1950s has been the

development of programs devoted exclusively to specific psychological problems. We now have, for example, suicide prevention centers, substance abuse programs, eating disorder programs, phobia clinics, and sexual dysfunction programs. Clinicians in these programs have the kind of expertise that can be acquired only by concentration in a single area.

A Growing Emphasis on Preventing Disorders and Promoting Mental Health Although the community mental health approach has often failed to address the needs of people with severe disorders, it has given rise to an important principle of mental health care — prevention (Lewis, 2019). Rather than wait for

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psychological disorders to occur, many of today’s community programs try to correct the social conditions that underlie psychological problems (poverty or violence in the community, for example) and to help individuals who are at risk for developing emotional problems (for example, teenage mothers or the

children of people with severe psychological disorders). As you will see later, community prevention programs are not always successful, but they have grown in number, offering great promise as the ultimate form of intervention.

Why do you think it has taken psychologists so long to start studying positive behaviors?

Prevention programs have been further energized in the past few decades by the field of psychology’s ever-growing interest in positive psychology (Seligman, 2019). Positive psychology is the study and enhancement of positive feelings such as optimism and happiness, positive traits like hard work and wisdom, and group-directed virtues, including altruism and tolerance (see InfoCentral).

INFOCENTRAL HAPPINESS

Positive psychology is the study of positive feelings, traits, and abilities. A better understanding of

constructive function-ing enables clinicians to better promote psychological wellness. Happiness is

the positive psychology topic currently receiving the most attention. Many, but far from all, people

are happy. In fact, only one-third of adults declare themselves “very happy.” Let’s take a look at

some of today’s leading facts, figures, and notions about happiness.

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While researchers study and learn more about positive psychology in the laboratory, clinical practitioners with this orientation are teaching people coping skills that may help protect them from stress and adversity and encouraging them to become more involved in personally meaningful activities and relationships — thus helping to prevent mental disorders (Comer et al., 2020; Craig et al., 2019).

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Positive psychology in action O�en, positive

psychology and multicultural psychology work together. Here, two young girls come together as one

at the end of a “slave reconciliation” walk by 400 people in Maryland. The walk was intended to promote

racial understanding and to help Americans overcome the lasting psychological effects of slavery.

Multicultural Psychology

We are, without question, a society of multiple cultures, races, and languages. Members of racial and ethnic minority groups in the United States collectively make up 40

percent of the population, a percentage that is expected to grow to 52 percent by the year 2055 (WPR, 2019a). This change is due in part to shifts in age structure, birth rates, and immigration (Poston & Saenz, 2019). For example, only 42 percent of adult non-Hispanic white women

in the United States today are of childbearing age, while 62 percent of adult minority group women fall into this age range. Moreover, on average, non-Hispanic white women in the United States give birth to fewer than two children during their lifetime, while minority group

women give birth to more than two children.

In response to this growing diversity, an area of study called multicultural psychology has emerged. Multicultural psychologists seek to understand how

culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders may differ psychologically (Mio et al., 2020). As you will see throughout this book, the field of multicultural psychology has begun to have a powerful effect on our understanding and treatment of abnormal behavior.

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Preventing an even worse outcome Children attend activities at this psychological

support and education center in Damascus, Syria, in 2016. The center was set up, on the advice of mental health, medical, and education advisers, to help prevent or at

least minimize the psychological and physical problems experienced by millions of Syrian children who have been caught up in the ongoing horrors of the country’s civil

war.

The Increasing Influence of Insurance Coverage According to the U.S. Census Bureau, 67 percent of Americans have private health insurance, purchased directly or through an employer, while the remainder are either uninsured (9 percent of Americans) or enrolled in a public- supplemented insurance program such as Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or military insurance. So many people now seek mental health services that most private and public insurance programs have changed their coverage for these patients in recent decades. The dominant form of insurance now consists of managed care programs — programs in which

the insurance company determines such key issues as which therapists its clients may choose, the cost of sessions, and the number of sessions for which a client may be reimbursed (Enthoven, Fuchs, & Shortell, 2019; Friedman et al., 2019).

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Managed care coverage for mental health treatment follows the same basic principles as coverage for medical treatment, including a limited pool of practitioners from which patients can choose, preapproval of treatment by the insurance company, strict standards for judging whether problems and

treatments qualify for reimbursement, and ongoing reviews. In the mental health realm, both therapists and clients typically dislike managed care programs (Schneiderman, 2018). They fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments whose results are not always lasting (for example, drug therapy), pose a special hardship for those with severe mental disorders, and result in treatments determined by insurance companies rather than by therapists.

of NOTE … Famous Movie Psych Lines

“Is it me, or is it getting crazier out there?” (Joker, 2019)

“If you worry, you suffer twice.” (Fantastic Beasts and Where to Find Them, 2016)

“I suffer from short-term memory loss.” (Finding Dory, 2016)

“I just want to be perfect.” (Black Swan, 2010)

“Take baby steps.” (What About Bob? 1991)

“I love the smell of napalm in the morning.” (Apocalypse Now, 1979)

“Are you talkin’ to me?” (Taxi Driver, 1976)

“Mother’s not herself today.” (Psycho, 1960)

A key problem with insurance coverage — both managed care and other kinds of insurance programs — is that reimbursements for mental disorders tend to be lower than those for physical disorders. This places persons with psychological difficulties at a distinct disadvantage. Thus, in 2008, the U.S.

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Congress passed a federal parity law that directed insurance companies to provide equal coverage for mental and physical problems, and in 2014 the mental health provisions of the Affordable Care Act (the ACA) — referred to colloquially as “Obamacare” — went into effect and extended the reach of the

earlier parity law. Moreover, the ACA designated mental health care as 1 of 10 types of “essential health benefits” that must be provided by all insurers.

The parity laws have brought about some important improvements in mental health insurance coverage. For example, insurance programs can no longer charge their members higher deductibles for mental health services than for

physical health services (Dangor, 2019). Nor can the programs set annual or lifetime limits on the mental health costs they will help pay for.

Despite the parity laws, however, many insurance companies still manage to shortchange the mental health claims of their members. In 2019, for example, a

federal court ruled that United Health, one of the nation’s largest health insurers, discriminates against its members with mental health needs by covering only enough mental health treatment to “stabilize” the patients, “while ignoring [coverage for the] effective treatment of the members’ underlying conditions” (Abelson, 2019; Dangor, 2019). Insurance coverage for physical problems does not typically make such a distinction.

Similarly, a report by the Health Care Cost Institute (2019) revealed that over the past 5 years, out-of-pocket patient expenses for inpatient mental health care (for example, psychiatric hospitalizations and specialized nursing facilities) have actually grown 13 times faster than the out-of-pocket patient expenses for all other kinds of inpatient health care.

Thus, although parity laws have made a difference in certain aspects of mental health coverage, such coverage remains far from equal to that for physical problems. Moreover, it is worth noting that many mental health advocates worry that current efforts in Congress and various state legislatures to change or

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repeal the ACA may, if successful, negatively affect mental health parity, as well as other aspects of mental health insurance coverage.

Green spaces and mental health Each day, numerous people gather at High Line

Park, a large grassy area built on an unused elevated train track in New York City — just steps away from the glass and steel buildings that otherwise dot the city’s

landscape. Positive psychology research has found that people who live in urban areas feel less distress and report higher life satisfaction if they reside in or near greener areas of their cities (Engemann et al., 2019).

What Are Today’s Leading Theories and Professions? One of the most important developments in the clinical field has been the growth of numerous theoretical perspectives that now coexist in the field.

Before the 1950s, the psychoanalytic perspective, with its emphasis on unconscious psychological problems as the cause of abnormal behavior, was dominant. Since then, additional influential perspectives have emerged, particularly the biological, cognitive-behavioral, humanistic-existential, sociocultural, and developmental psychopathology schools of thought. At present, no single viewpoint dominates the clinical field as the psychoanalytic perspective once did. In fact, the perspectives often conflict and compete with one another.

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of NOTE … Gender Shift

28% Psychologists in 1978 who were female

80% Current psychology graduate students who are female

(Fowler et al., 2018)

In addition, a variety of professionals now offer help to people with psychological problems. Before the 1950s, psychotherapy was offered only by psychiatrists, physicians who complete three to four additional years of training after medical school (a residency) in the treatment of abnormal mental functioning. After World War II, however, with millions of soldiers returning home to countries throughout North America and Europe, the demand for mental health services expanded so rapidly that other professional groups had

to step in to fill the need.

Among those other groups are clinical psychologists — professionals who earn a doctorate in clinical psychology by completing four to five years of graduate training in abnormal functioning and its treatment as well as a one-year

internship in a mental health setting. Psychotherapy and related services are also provided by counseling psychologists, educational and school psychologists, mental health counselors, psychiatric nurses, marriage therapists, family therapists, and — the largest group — clinical social workers (see Table 1-2). Each of these specialties has its own graduate training program. Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the various specialties often use similar techniques.

TABLE: 1-2

Profiles of Mental Health Professionals in the United States

  Degree Began to Practice

Current Number

Average Annual Salary

Percent Female

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Psychiatrists MD, DO 1840s    26,000 $222,000 44%

Psychologists PhD, PsyD, EdD

Late 1940s 182,000    $79,000 74%

Social Workers

MSW, DSW Early 1950s 707,000    $49,000 83%

Counselors Various Early 1950s 424,000    $45,000 74%

Information from: BLS, 2019a, 2019b, 2019c, 2019d, 2019e, 2019f; Kane, 2019; Social Solutions, 2019; Fowler et al., 2018.

A related development in the study and treatment of mental disorders since World War II has been the growth of effective research. Clinical researchers have worked to determine which concepts best explain and predict abnormal behavior, which treatments are most effective, and what kinds of changes may be required. Well-trained clinical researchers conduct studies in universities,

medical schools, laboratories, mental hospitals, mental health centers, and other clinical settings throughout the world. Their work has produced important discoveries and has changed many of our ideas about abnormal psychological functioning.

Technology and Mental Health The breathtaking rate of technological change that characterizes today’s world has begun to have significant effects — both positive and negative — on the mental health field, and it will undoubtedly affect the field even more in the coming years.

of NOTE … Their Words

“I can calculate the motion of heavenly bodies but not the madness of people.”

Sir Isaac Newton

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Our digital world provides new triggers for abnormal behavior (Stronge et al., 2019). As you’ll see in Chapter 11, for example, many individuals who grapple with gambling disorder have found the ready availability of Internet gambling to be all too inviting. Similarly, social media, the Internet, and texting have become

convenient tools for those who wish to stalk or bully others, express sexual exhibitionism, or pursue pedophilic desires. Likewise, some clinicians believe that violent video games may contribute to the development of antisocial behavior. And, in the opinion of many clinicians, constant texting, social media posting, tweeting, and Internet browsing may become an addictive behavior or may help lead to shorter attention spans.

A number of clinicians also worry that social networking can contribute to psychological dysfunction in certain cases (see Figure 1-2). On the positive side, research indicates that, on average, social media users are particularly likely to maintain close relationships, receive social support, be trusting, and lead active lives (Hampton, 2019). But, on the negative side, there is research suggesting that social networking sites may increase peer pressure and social anxiety in some adolescents (Kelly et al., 2019; Twenge, 2019). The sites may, for example,

cause some people to develop fears that others in their network will exclude them socially. Similarly, such sites may facilitate shy or socially anxious people’s withdrawal from valuable face-to-face relationships.

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FIGURE 1-2

The Digital Explosion

Over the past decade, online behavior (emailing, texting, social media activity, gaming, and the like) has increased while other key activities have dropped off. By converting results from various surveys into scores on a common

scale (known as z-scores), researchers have determined that today’s young adolescents spend fewer hours each day socializing in face-to-face interactions and sleeping than adolescents did 10 to 15 years ago. Perhaps not so

coincidentally, today’s teenagers also have lower levels of happiness. (Information from: Twenge, 2019)

In addition, our digital world has greatly expanded the amount of mental health information available to the public. Indeed, countless websites offer such information. When accurate, material of this kind can be very useful to people in search of mental health answers, help, and guidance. Unfortunately, however, along with this wealth of online information comes an enormous amount of misinformation about psychological problems and their treatments, offered by persons and sites that are far from knowledgeable.

What kinds of problems might result from the growing availability and use of mental health apps in today’s world?

The face of clinical treatment is also changing in our fast-moving digital world. For example, computerized intervention programs and Internet-based support groups are now widely available. Moreover, there are hundreds of smartphone apps devoted to relaxing people, cheering them up, giving them feel-good advice, helping them track their shifting moods and thoughts, or otherwise improving their psychological states (Bry et al., 2018). Increasingly, therapists are

even including wearable technologies in their treatment (for example, “smart” watches/bands and “smart” glasses) to help monitor key psychophysiological processes that unfold throughout individuals’ lives, such as sleep quality, physical activity, respiration, and heart rate (Comer, Conroy, & Timmons, 2019).

Finally, telemental health, the use of remote technologies (such as long- distance videoconferencing) to provide real-time therapy sessions without the

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therapist being physically present, is growing by leaps and bounds (Lal, 2019; Wade et al., 2019). Enthusiasm for telemental health services had been gaining momentum among clinicians and clients for over a decade, but it was the COVID-19 pandemic and related social distancing that truly propelled such

services into the clinical mainstream. Prior to the pandemic, certain barriers were preventing telemental health from being practiced on a large scale. For example, a number of insurance providers were refusing to reimburse this form of treatment, rendering it unaffordable for many individuals. Moreover, in the years prior to the pandemic many clinicians were reluctant to offer telemental health, fearing that technology-related confidentiality breaches, such as hacking incidents, could result in significant personal or professional penalties.

When the United States took steps to reduce the spread of COVID-19 in March 2020 by shutting down business activities and issuing stay-at-home orders, traditional office-based mental health care became abruptly out-of-reach for most individuals. To counter this negative impact and ensure continuity of care for persons with mental health problems, federal and state policymakers acted to remove the previous barriers to telemental health care. They immediately

mandated that all insurance plans provide coverage for telemental health services (APA, 2020a; Wicklund, 2020). In addition, they waived all penalties against clinicians for unintended confidentiality violations that might arise from the use of remote communication technologies (Conrad et al., 2020). These policy changes empowered therapists to practice telemental health without concern for personal or professional consequences.

Within weeks of these mandates, the vast majority of mental health services in the United States were being conducted online (Schroeder, 2020). As the advantages of online mental health services unfolded over the ensuing months — greater affordability, accessibility, convenience, and outreach — it became clear that telemental health would, to one degree or another, remain a permanent part of the clinical field, extending well beyond the COVID-19

pandemic.

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of NOTE … Myth Buster

Although it is popularly believed that a full moon is accompanied by significant increases in crime,

strange and abnormal behaviors, and admissions to mental hospitals, decades of research have

failed to support this notion.

(Demler, Lysogorski, & Trigoboff, 2019)

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SUMMING UP

What Is Psychological Abnormality?

Abnormal functioning is generally considered to be deviant, distressful, dysfunctional, and dangerous. Behavior must also be considered in the context in which it occurs, however, and the concept of abnormality depends on the norms and values of the society in question. pp. 2–6

What Is Treatment?

Therapy is a systematic process for helping people overcome their psychological difficulties. It typically requires a patient, a therapist, and a series of therapeutic contacts. pp. 6–7

How Was Abnormality Viewed and Treated in the Past?

The history of psychological disorders stretches back to ancient times. Prehistoric societies apparently viewed abnormal behavior as the work of evil spirits. There is evidence that Stone Age cultures used trephination, a primitive form of brain surgery, to treat abnormal behavior. People of early societies also sought to drive out evil spirits by exorcism. pp. 7–8

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GREEKS AND ROMANS

Physicians of the Greek and Roman empires offered more enlightened explanations of mental disorders. Hippocrates believed that abnormal behavior was caused by an imbalance of the four bodily fluids, or humors. p. 8

THE MIDDLE AGES

In the Middle Ages, Europeans returned to demonological explanations of abnormal behavior. The clergy was very influential and held that mental disorders were the work of the devil. As the Middle Ages drew to a close, such explanations and treatments began to decline, and people with mental disorders were increasingly treated in hospitals instead of by the clergy. pp. 8–10

THE RENAISSANCE

Care of people with mental disorders continued to improve during the early part of the Renaissance. Certain religious shrines became dedicated to the humane

treatment of such individuals. By the middle of the sixteenth century, however, persons with mental disorders were being warehoused in asylums. p. 10

THE NINETEENTH CENTURY

Care of those with mental disorders started to improve again in the nineteenth century. In Paris, Philippe Pinel started the movement toward moral treatment. In the United States, Dorothea Dix spearheaded a movement to ensure legal rights and protection for people with mental disorders and to establish state hospitals

for their care. However, the moral treatment movement disintegrated by the late nineteenth century, and mental hospitals again became warehouses where inmates received minimal care. pp. 10–12

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THE EARLY TWENTIETH CENTURY

The turn of the twentieth century saw the return of the somatogenic perspective, the view that abnormal psychological functioning is caused primarily by physical factors. The same period saw the rise of the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. Sigmund Freud’s psychogenic approach, psychoanalysis, eventually gained wide

acceptance and influenced future generations of clinicians. pp. 12–14

Recent Decades and Current Trends

There have been major changes over the past 70 years in the understanding and

treatment of abnormal functioning. In the 1950s, researchers discovered a number of new psychotropic medications, drugs that mainly affect the brain and reduce many symptoms of mental dysfunction. Their success contributed to a policy of deinstitutionalization, under which hundreds of thousands of patients were released from public mental hospitals. In addition, outpatient treatment has become the primary approach for most people with mental disorders, both mild and severe; prevention programs are growing in number and influence; the field of multicultural psychology has begun to influence how clinicians view and treat

abnormality; and insurance coverage is having a significant impact on the way treatment is conducted.

It is also the case that a variety of perspectives and professionals have come to operate in the field of abnormal psychology, and many well-trained clinical researchers now investigate the field’s theories and treatments. And finally, the remarkable technological advances of recent times have affected the mental health field. pp. 14–22

Visit LaunchPad to access the e-book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards, FAQs, and research exercises.

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C H A P T E R 2

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Research in Abnormal Psychology

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TOPIC OVERVIEW

What Do Clinical Researchers Do? The Case Study

How Are Case Studies Helpful? What Are the Limitations of Case Studies?

The Correlational Method Describing a Correlation When Can Correlations Be Trusted? What Are the Merits of the Correlational Method?

The Experimental Method The Control Group Random Assignment Masked Design

Alternative Research Designs Matched Designs Natural Experiments Analogue Experiments Single-Case Experiments Longitudinal Studies Epidemiological Studies

Protecting Human Participants Keeping an Eye on Research Methods

“Woman may be said to be an inferior man.”

— Aristotle, 350 �.�.�.

“The ‘telephone’ has too many shortcomings to be seriously considered as a means of communication.”

— Western Union, 1876

“The horse is here to stay but the automobile is only a novelty — a fad.”

— Horace Rackham, Michigan Savings Bank, 1903

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“There is no reason for any individual to have a computer in their home.”

— Ken Olsen, Digital Equipment Corp., 1977

“The cloning of mammals … is biologically impossible.”

— James McGrath and Davor Solter, genetic researchers, 1984

“Websites will never replace newspapers.”

— Newsweek, 1995

“There’s no chance that the iPhone is going to get any significant market share.”

— USA Today, 2007

Each of these statements was once accepted as gospel. Had their accuracy not been tested, had they been judged on the basis of conventional wisdom alone, had new ideas not been proposed and investigated, human knowledge and progress would have been severely limited. What enabled thinkers to move beyond such misperceptions? The answer, quite simply, is research, the systematic search for facts through the use of careful observations and

investigations.

Research is the key to accuracy in all fields of study; it is particularly important in abnormal psychology because a wrong belief in this field can lead to great suffering. Consider, for example, schizophrenia and the treatment procedure

known as the lobotomy. Schizophrenia is a severe disorder that causes people to lose contact with reality. Their thoughts, perceptions, and emotions become distorted and disorganized, and their behavior may be bizarre and withdrawn. For the first half of the twentieth century, this condition was attributed to schizophrenogenic (“schizophrenia-causing”) mothers — women described as cold, domineering, and unresponsive to their children’s needs. As you will see in Chapter 13, this widely held belief turned out to be wrong.

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During the same era, practitioners developed a surgical procedure that supposedly cured schizophrenia. In this procedure, called a lobotomy, a pointed instrument was inserted into the frontal lobe of the brain and rotated, destroying much brain tissue (Staudt et al., 2019). Early clinical reports described

lobotomized patients as showing near-miraculous improvement. This impression, too, turned out to be wrong, although the mistake wasn’t discovered until tens of thousands of people had been lobotomized. Far from curing schizophrenia, lobotomies caused irreversible brain damage that left many patients withdrawn and even stuporous.

Can you think of beliefs that were once widely accepted as true but, as a result of scientific research, eventually were proven false?

These errors underscore the importance of scientific research in abnormal psychology. Only by fully testing a theory or technique on representative groups of individuals can clinicians evaluate the accuracy, effectiveness, and safety of their ideas and techniques. Until clinical researchers conducted properly designed studies, millions of parents, already heartbroken by their children’s schizophrenia, were additionally labeled as the primary cause of the disorder, and countless people with schizophrenia, already debilitated by their symptoms, were made permanently apathetic and spiritless by a lobotomy.

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What Do Clinical Researchers Do?

CLINICAL RESEARCHERS, also called clinical scientists, try to discover broad laws, or principles, of abnormal psychological functioning. They search for a general, or nomothetic, understanding of the nature, causes, and treatments of abnormality across individuals. Except for research purposes, they do not assess, diagnose, or treat individual clients; that is the job of clinical practitioners, who seek an idiographic, or individualistic, understanding of abnormal behavior. You will read about the work of practitioners in later chapters.

To gain nomothetic insights, clinical researchers, like scientists in other fields, use the scientific method — that is, they collect and evaluate information through careful observations. These observations in turn enable them to pinpoint and explain relationships between variables. Simply stated, a variable is

any characteristic or event that can vary, whether from time to time, from place to place, or from person to person. Age, sex, and race are human variables. So are eye color, occupation, and social status. Clinical researchers are interested in variables such as childhood upsets, present life experiences, moods, social functioning, and responses to treatment. They try to determine whether two or more such variables change together and whether a change in one variable causes a change in another. Will the death of a parent cause a child to become depressed? If so, will a given treatment reduce that depression?

Such questions cannot be answered by logic alone because scientists, like all human beings, frequently make errors in thinking. Thus, clinical researchers depend mainly on three methods of investigation: the case study, which typically focuses on one individual, and the correlational method and experimental method,

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approaches that are usually used to gather information about many individuals. Each is best suited to certain kinds of circumstances and questions. As a group, these methods enable scientists to form and test hypotheses — hunches or predictions that certain variables are related in certain ways — and to draw

broad conclusions as to why. More properly, a hypothesis is a tentative explanation offered to provide a basis for an investigation.

Flawed study, gigantic impact Dan Reynolds, the frontman for the rock group

Imagine Dragons, drapes himself in a pride flag as he speaks out against conversion therapy and the psychological harm it has inflicted on the LGBTQ community.

Conversion therapy, a now widely discredited psychological treatment, purports to help gay persons change their sexual orientation. In 2012, Robert Spitzer, one of the world’s most respected psychiatric researchers, offered an extraordinary public

apology to the gay community for his influential and supportive 2003 study on this therapy. Spitzer called his earlier study both fatally flawed and morally wrong.

As you read about the methods used by clinical researchers, it is important to keep in mind that these scientists face certain challenges that make their work

particularly difficult. They must, for example, figure out how to measure such elusive concepts as unconscious motives, private thoughts, mood changes, and human potential. They must consider the different cultural backgrounds, races,

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and genders of the people they choose to study. And, as we are reminded in PsychWatch, they must always ensure that the rights of their research participants, both human and animal, are not violated (Vardigans, Malloy, & Meynell, 2019).

PSYCHWATCH Animals Have Rights

For years, researchers have learned much about human functioning, including abnormal

human functioning, from experiments with animals. It is estimated that between 12 and 27 million

animals are used as subjects in research studies in the United States each year (SR, 2019a). Close to

500,000 of them are guinea pigs, rabbits, monkeys, dogs, and cats. Most of the remainder are mice

and rats.

Over time, research animals have been shocked, prematurely separated from their parents, and

starved. They have had their brains surgically changed and have even been killed, or “sacrificed,” so

that researchers could autopsy them. It is estimated that medical animal research (for example,

cardiovascular research) has helped increase the life expectancy of humans by almost 24 years.

Similarly, animal research has been key to the development of many medications, leading to a

savings of hundreds of billions of dollars every year in the United States alone (Clark et al., 2019; SR,

2019a, 2019b). Nevertheless, concerns remain: Are such actions always ethically acceptable?

Animal rights activists say no (DeGrazia & Beauchamp, 2019; Hvitved, 2019). They have called such

undertakings cruel and unnecessary and have fought many forms of animal research with legal

protests and demonstrations. Some have even harassed scientists and vandalized their labs (Clark et

al., 2019). In turn, certain researchers have accused activists of caring more about animals than

about human beings. In response to this controversy, various state courts, government agencies, and

the American Psychological Association have issued rules and guidelines for animal research. The

U.S. Public Health Service, for example, requires that all animal research facilities must have an

“institutional animal care and use committee” (IACUC) to oversee the proper treatment of animals

(Mohan & Huneke, 2019). Partly because of this increase in regulatory bodies and the growth of

public activism, the number of monkeys, cats, and dogs used in research today has fallen to one-

third the number of 30 years ago (SR, 2019b).

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Making a point With his body painted as a monkey, an activist from the organization PETA (People for the Ethical Treatment of Animals) sits in a cage to protest the use of animals in research at a medical science

institute in India.

Precisely where does the public stand on this issue? In surveys, a slight majority of respondents say

that they dislike animal research and are greatly concerned about the morality of such investigations

— a level of concern that keeps rising each year (Clark et al., 2019; Pew Research Center, 2018). At the

same time, as many as two-thirds of respondents say they can “accept” animal research as long as it

is for scientific purposes, avoids inflicting unnecessary suffering on animals, and is the only way of

gathering medical or other needed knowledge (IM, 2019; Tyler, 2019). People in such surveys

approve of experiments that use mice or rats much more than those using monkeys, dogs, cats, or

other kinds of animals.

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The Case Study

A CASE STUDY is a detailed description of a person’s life and psychological problems. It describes the person’s history, present circumstances, and symptoms. It may also include speculation about why the problems developed, and it may describe the person’s treatment (Alpi & Evans, 2019; Ylikoski & Zahle, 2019).

In his famous case study of Little Hans (1909), Sigmund Freud discusses a 4- year-old boy who developed a fear of horses. Freud gathered his material from detailed letters sent to him by Hans’ father, a physician who had attended lectures on psychoanalysis, and from his own limited interviews with the child. Freud’s case study runs 140 pages in his Collected Papers, so only a few excerpts are presented here.

One day while Hans was in the street he was seized with an attack of morbid anxiety…. On the way

back from Schönbrunn he said to his mother, … “I was afraid a horse would bite me.”

But the beginnings of this psychological situation go back [to] a period when he was not quite three

years old. At that time, by means of various remarks and questions, he was showing a quite peculiarly

lively interest in that portion of his body which he used to describe as his “widdler” [his word for penis].

When he was three and a half his mother found him with his hand to his penis. She threatened him in

these words: “If you do that, I shall send for Dr. A. to cut off your widdler. And then what’ll you widdle

with?” … This was the occasion of his acquiring [a] “castration complex.” …

[At the age of four, Hans entered] a state of intensified sexual excitement, the object of which was his

mother. [For example, one] morning Hans was given his usual daily bath by his mother and a�erwards

dried and powdered. As his mother was powdering round his penis and taking care not to touch it, Hans

said: ‘Why don’t you put your finger there?’ …”

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… The father and son visited me during my consulting hours. [They revealed that Hans] was

particularly bothered by what horses wear in front of their eyes and by the black round their mouths….

[I asked Hans] whether his father wore eyeglasses [and] whether by “the black round the mouth” he

meant a moustache [like his father’s]; and I then disclosed to him that he was afraid of his father,

precisely because he was so fond of his mother. It must be, I told him, that he thought his father was

angry with him on that account; but this was not so, his father was fond of him in spite of it….

By enlightening Hans on this subject I had cleared away his most powerful resistance…. It was at this

stage of the analysis that he recalled the event … which [had] immediately preceded the outbreak of

the illness …. He went for a walk with his mother, and saw a bus-horse fall down and kick about with its

feet. This made a great impression on him. He was terrified, and thought the horse was dead; and from

that time on he thought that all horses would fall down. [In our session, his] father pointed out to him

that when he saw the horse fall down he must have thought of him, his father, and have wished that he

might fall down in the same way and be dead. Hans did not dispute this interpretation….

It is especially interesting … to observe the way in which the transformation of Hans’s libido into

anxiety was projected on to the principal object of his phobia, on to horses. Horses interested him the

most of all the large animals; playing at horses was his favorite game with the older children. I had a

suspicion — and this was confirmed by Hans’s father when I asked him — that the first person who had

served Hans as a horse must have been his father…. When repression [of his desire for his mother and

his fear of retribution by his father] had set in and brought a revulsion of feeling along with it, horses,

which had till then been associated with so much pleasure, were necessarily turned into objects of

fear…. With this [and subsequent insights] the analysis came to an appropriate end.

(Freud, 1909)

Most clinicians take notes and keep records in the course of treating their patients, and some, like Freud, further organize such notes into a formal case study to be shared with other professionals. The clues offered by a case study may help a clinician better understand or treat the person under discussion. In

addition, case studies may play nomothetic roles that go far beyond the individual clinical case.

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Case studies and the arts Case studies o�en find their way into the arts or media and capture the public’s

attention. In a widely acclaimed 1985 book, The Man

Who Mistook His Wife for a Hat, the famous neurologist

Oliver Sacks presented 24 cases featuring clinical problems such as amnesia, autism, intellectual

disability, and amphetamine and cocaine addiction. Over time, the cases in this book were also portrayed

in a theatrical production, an opera, and a music album.

How Are Case Studies Helpful? Case studies are useful to researchers in many ways (Morgan, 2019; Schoch, 2019). They can, for example, be a source of new ideas about behavior and “open the way for discoveries.” Freud’s theory of psychoanalysis was based mainly on the patients he saw in private practice. He pored over their case studies, such as the one he wrote about Little Hans, to find what he believed to be broad

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psychological processes and principles of development. In addition, a case study may offer tentative support for a theory. Freud used case studies in this way as well, regarding them as evidence for the accuracy of his ideas. Conversely, case studies may serve to challenge a theory’s assumptions.

Case studies may also show the value of new therapeutic techniques. For example, Freud believed that the case study of Little Hans demonstrated the therapeutic potential of a verbal approach for children as well as for adults.

Finally, case studies may offer opportunities to study unusual problems that do not occur often enough to permit a large number of observations. For years, information about dissociative identity disorder (previously called multiple personality disorder) was based almost entirely on case studies, such as a famous case popularly referred to as The Three Faces of Eve, a clinical account of a woman who displayed three alternating personalities, each having a separate

set of memories, preferences, and personal habits.

Does psychological abnormality run in families? One of the most celebrated case studies in abnormal psychology is a study of identical quadruplets dubbed the

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“Genain” sisters by researchers (a�er the Greek term for “dire birth”). All of the sisters developed schizophrenia in their twenties.

What Are the Limitations of Case Studies? Case studies also have limitations (Alpi & Evans, 2019; Ylikoski & Zahle, 2019). First, they are reported by biased observers, that is, by therapists who have a personal stake in seeing their treatments succeed. These therapists must choose what to include in a case study, and their choices may at times be self- serving. Second, case studies rely on subjective evidence. Is a client’s problem

really caused by the events that the therapist or client says are responsible? After all, those are only a fraction of the events that may be contributing to the situation. When investigators are able to rule out all possible causes except one, a study is said to have internal accuracy, or internal validity (Lavrakas et al., 2019). Obviously, case studies rate low in this respect.

Another problem with case studies is that they provide little basis for generalization. Even if we agree that Little Hans developed a dread of horses because he was terrified of castration and feared his father, how can we be confident that other people’s phobias are rooted in the same kinds of causes? Events or treatments that seem important in one case may be of no help at all in efforts to understand or treat others. When the findings of an investigation can be generalized beyond the immediate study, the investigation is said to have external accuracy, or external validity. Case studies rate low on external

validity, too.

The limitations of the case study are largely addressed by two other leading methods of investigation: the correlational method and the experimental method. These methods do not offer the rich detail that makes case studies so

interesting, but they do help investigators draw broad conclusions about abnormality in the population at large. Thus most clinical investigators prefer these methods over the case study.

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Why do case studies and other anecdotal offerings influence people so much, o�en more than systematic research does?

Three features of the correlational and experimental methods enable clinical investigators to gain general, or nomothetic, insights: (1) The researchers typically observe many individuals. (2) The researchers apply procedures uniformly. Other researchers can thus repeat, or replicate, a particular study to see whether it consistently gives the same findings. (3) The researchers use

statistical tests to analyze the results of a study and determine whether broad conclusions are justified.

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The Correlational Method

CORRELATION IS THE DEGREE to which events or characteristics vary with each other. The correlational method is a research procedure used to determine this “co-relationship” between variables (Cherry, 2019a). This method can be used, for example, to answer the question “Is there a correlation between the amount of stress in people’s lives and the degree of depression they experience?” That is, as people keep experiencing stressful events, are they increasingly likely to become depressed?

To test this question, researchers have collected life stress scores (for example, the number of threatening events experienced during a certain period of time) and depression scores (for example, scores on a depression survey) from individuals and have correlated these scores. The people who are chosen for a study are its subjects, or participants, the term preferred by today’s investigators.

The participants in a given study are collectively called its sample. A sample should be representative of the larger population that the researchers wish to understand. Otherwise the relationship found in the study may not apply elsewhere in the real world — it may not have external validity. If researchers were to find a correlation between life stress and depression in a sample consisting entirely of children, for example, they could not draw clear conclusions about what, if any, correlation exists among adults.

Describing a Correlation Suppose you were to use the correlational method to conduct a study of depression. You would collect life stress scores and depression scores for 10

people and plot the scores on a graph, as shown in Figure 2-1. As you can see,

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the participant named José has a recent life stress score of 7, meaning seven threatening events occurred over the past three months; he also has a depression score of 25. Thus he is “located” at the point on the graph where these two scores meet. The graph provides a visual representation of your data.

Here, notice that the data points all fall roughly along a straight line that slopes upward. You would draw the line so that the data points are as close to it as possible. This line is called the line of best fit.

FIGURE 2-1

Positive Correlation

The relationship between amount of recent stress and

feelings of depression shown by this hypothetical sample of 10 participants is a near-perfect “positive”

correlation.

of NOTE … Their Words

“The temptation to form premature theories upon insufficient data is the bane of our profession.”

Sherlock Holmes in The Valley of Fear, 1914

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The line of best fit in Figure 2-1 slopes upward and to the right, indicating that the variables under examination are increasing or decreasing together. That is, the greater someone’s life stress score, the higher their score on the depression scale. When variables change the same way, their correlation is said to have a

positive direction and is referred to as a positive correlation. Most studies of life stress and depression have indeed found a positive correlation between those two variables (Comer et al., 2020; Ding & Dai, 2019).

Correlations can have a negative rather than a positive direction. In a negative correlation, the value of one variable increases as the value of the other variable

decreases. Researchers have found, for example, a negative correlation between depression and activity level. The greater one’s depression, the lower the number of one’s activities. When the scores of a negative correlation are plotted, they produce a downward-sloping graph, like the one shown in Figure 2-2.

FIGURE 2-2

Negative Correlation

The relationship between number of activities and

feelings of depression shown by this hypothetical sample is a near-perfect “negative” correlation.

There is yet a third possible outcome for a correlational study. The variables under study may be unrelated, meaning that there is no consistent relationship

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between them. As the measures of one variable increase, those of the other variable sometimes increase and sometimes decrease. The graph of this outcome looks like Figure 2-3. Here the line of best fit is horizontal, with no slope at all. Studies have found that depression and intelligence are unrelated,

for example.

FIGURE 2-3

No Correlation

The relationship between intelligence and feelings of depression shown by this hypothetical sample is a

“near-zero” correlation.

In addition to knowing the direction of a correlation, researchers need to know

its magnitude, or strength. That is, how closely do the two variables correspond? Does an increase in one correspond to a large increase in the other, or does an increase in one correspond to a smaller increase in the other? When changes in one variable correspond to large changes in the other variable in person after person, the correlation is said to be high, or strong.

Look back again at Figure 2-1. In this graph of a positive correlation between depression and life stress, increases in life stress correspond to large increases in depression scores. And so here, the line of best fit is quite steep. But what if the graph of the correlation between depression and life stress looked more like

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that shown in Figure 2-4? There we see a pattern in which increases in life stress correspond to more modest increases in depression scores, and so the line of best fit is less steep. The correlation in Figure 2-1 is stronger, or greater, in magnitude than that in Figure 2-4.

FIGURE 2-4

Magnitude of Correlation

The relationship between amount of recent stress and feelings of depression shown by this hypothetical

sample is a “moderately positive” correlation.

of NOTE … Range of Motives

Why do nonstudents volunteer for medical and psychological research studies? Around 27% say they do it to advance medical science and 22% to improve the lives of others. Approximately 15%

volunteer to earn extra money (CISCRP, 2019).