assessment

2504743 - Macmillan US ©

A fascinating subject The human brain increasingly has captured the attention of not only neuroscientists

but also the public at large. Here an eighth-grade student holds and examines a brain ever so carefully

than they were in the past, condemning many individuals with such genes to a

near-endless stream of fear and arousal. That is, the very genes that helped their ancestors to survive and reproduce might now leave these individuals particularly prone to fear reactions, anxiety disorders, or related psychological patterns.

The evolutionary perspective is controversial in the clinical field and has been rejected by many theorists. Imprecise and at times impossible to research, scientists often find such explanations unacceptable.

Biological Treatments

Biological practitioners look for

certain kinds of clues when they treat people who are behaving abnormally. Does the person’s family have a history of that behavior, and hence a possible genetic predisposition to it? (Philip Berman’s case history mentions that his mother was once hospitalized for

depression.) Is the behavior produced by events that could have had a physiological effect? (Philip was having a drink when he flew into a jealous rage at the restaurant.) Once the clinicians have pinpointed physical sources of dysfunction, they are in a better position to choose a

biological course of treatment. The

2504743 - Macmillan US ©

during a visit to the psychology department at Indiana University.

three leading kinds of biological treatments used today are drug therapy, brain stimulation, and

psychosurgery. Drug therapy is by far the most common of these approaches.

In the 1950s, researchers discovered several effective psychotropic medications, drugs that mainly affect emotions and thought processes. These drugs have greatly changed the outlook for a number of mental disorders and today are used widely, either alone or with other forms of therapy (see Trending). However, the psychotropic drug revolution has also produced some major

problems. Many people believe, for example, that the drugs are overused. Moreover, while drugs are effective in many cases, they do not help everyone.

…TRENDING TV Drug Ads Come Under Attack

“Ask your doctor about Abilify.” “There is no need to suffer any longer.” Anyone who watches

television or browses the Internet is familiar with phrases such as these. They are at the heart of

direct-to-consumer (DTC) drug advertising — advertisements in which pharmaceutical companies

appeal directly to consumers, coaxing them to ask their physicians to prescribe particular drugs for

them. The United States and New Zealand are the only developed countries in the world that allow

such advertising, but exposure to online DTC ads is worldwide and increasing (Elfassy et al., 2019).

Around 80 percent of American adults have seen these ads, and at least 30 percent ask their doctors

about the specific medications they see advertised (Llamas, 2019b; ProCon, 2018). Psychotropic

drugs, such as antibipolar and antidepressant drugs, are among the leading DTC-advertised

medications (Schwartz & Woloshin, 2019).

DTC ads have flooded the airwaves since 1997 when the U.S. Food and Drug Administration (FDA)

relaxed its restrictions for drug advertising on television, ruling that DTC ads must simply

recommend that consumers speak with a doctor about the drug, mention the drug’s important risks,

and indicate where consumers can get further information about it — o�en a website or phone

number (WHO, 2020a; Aikin et al., 2019). Such ads have received considerable criticism in recent

years, with numerous consumer groups, government leaders, and even the American Medical

Association calling for a ban on them and saying the ads o�en contribute to economic hardships,

patient misinformation, and less-than-optimal treatment (King, 2020; Das, 2019; Zadeh, Robertson,

& Green, 2019).

2504743 - Macmillan US ©

“Ask your doctor if …” This still is taken from a DTC television ad for the antidepressant drug Trintellix

(generic name: vortioxetine).

First, the economic concerns. Altogether, pharmaceutical companies now spend $6.6 billion a year

on American television and some online advertising, an amount that keeps growing (Bulik, 2019;

Lee, 2019). This leads to higher drug prices, at a time when prescription drug costs and insurance

premiums are already skyrocketing (WHO, 2020a). Moreover, the DTC ads typically promote newer

and more expensive drugs, inflating the demand for such drugs even when older, generic, and

cheaper drugs or lifestyle changes such as exercise or better nutrition might be equally or more

appropriate (Das, 2019; Zadeh et al., 2019).

DTC ads also may adversely affect patient awareness and clinical treatment (Aikin et al., 2019, 2017;

Elfassy et al., 2019). Three-quarters of surveyed doctors believe that most of the ads overemphasize

a drug’s benefits while leaving out key negative information (ProCon, 2018). Small wonder that many

patients believe their mental or physical health will be put in jeopardy if they do not take advertised

drugs (Zadeh et al., 2019).

Despite these problems, doctors o�en feel pressured to prescribe DTC-advertised drugs, even in

cases in which the drugs are not appropriate for patients (Das, 2019; Elfassy et al., 2019). Over half of

patient requests for such drugs are granted by doctors (WHO, 2020a). This has apparently

contributed to an overuse of psychotropic and other drugs (DeFrank et al., 2019).

So why do DTC ads continue to rise in number? One reason is that this form of advertising has its

supporters. The FDA, for example, believes that the ads may indeed provide a public service,

protecting consumers — although imperfectly — by directly educating them about drugs that are

available in the marketplace (Zadeh et al., 2019). Many doctors also believe that DTC ads get patients

2504743 - Macmillan US ©

more involved in their mental and physical health care, and a number report that they now have

better discussions with their patients about treatment options as a result of DTC advertising

(DeFrank et al., 2019). Finally, not to be overlooked are the profits that DTC advertising helps

generate for pharmaceutical companies. The sales of a prescription drug rise more than 4 dollars for

each dollar spent on advertising it. Moreover, the number of prescriptions written for DTC-advertised

new drugs are a whopping nine times greater than those written for new drugs that do not have DTC

ads (Llamas, 2019b).

What might the popularity of psychotropic drugs suggest about coping styles and problem-solving skills in our society?

Four major psychotropic drug groups are used in therapy. Antianxiety drugs, also called minor tranquilizers or anxiolytics, help reduce tension and anxiety. Antidepressant drugs help improve the functioning of people with depression and certain other disorders. Antibipolar drugs, also called mood stabilizers, help

steady the moods of those with a bipolar disorder, a condition marked by mood swings from mania to depression. And antipsychotic drugs help reduce the confusion, hallucinations, and delusions that often accompany psychosis, a loss of contact with reality found in schizophrenia and other disorders.

Psychotropic drugs, like all medications, reach the marketplace only after systematic research and review. It takes an average of 12 years and hundreds of millions of dollars for a pharmaceutical company in the United States to bring a newly identified chemical compound to market. Along the way, the drug is vigorously tested in study after study — first on animals and then on humans — to determine its efficacy, safety, dosage, and side effects, until finally it receives approval by the U.S. Food and Drug Administration. Only 3 percent of newly discovered chemical compounds make it to animal testing, only 2 percent of

animal-tested compounds reach human testing, and only 21 percent of human- tested drugs are eventually approved (DC, 2019; FDA, 2019a).

2504743 - Macmillan US ©

As the name implies, a second form of biological treatment, brain stimulation, refers to interventions that directly or indirectly stimulate certain areas of the brain. The oldest (and most controversial) such approach, used primarily on severely depressed people, is electroconvulsive therapy (ECT). Two electrodes

are attached to a patient’s forehead, and an electrical current of 65 to 140 volts is passed briefly through the brain. The current causes a brain seizure that lasts up to a few minutes. After seven to nine ECT sessions, spaced two or three days apart, many patients feel considerably less depressed. This treatment is used on tens of thousands of persons annually, particularly those whose depression fails to respond to other treatments (Kellner, Obbels, & Sienaert, 2019).

of NOTE … FDA Approval of Pioneering Drugs

1954 Thorazine (antipsychotic drug)

1955 Ritalin (ADHD drug)

1958 MAO inhibitors (antidepressant drugs)

1960 Librium (antianxiety drug)

1961 Elavil (antidepressant drug)

1963 Valium (antianxiety drug)

1970 Lithium (mood stabilizer/antibipolar drug)

1987 Prozac (antidepressant drug)

1998 Viagra (erectile disorder drug)

As you will see in Chapter 7, several other brain stimulation techniques have increasingly been used over the past decade, particularly in cases of depression. In one, transcranial magnetic stimulation (TMS), an electromagnetic coil is placed

on or above a person’s head, sending a current into certain areas of the brain. In another such technique, vagus nerve stimulation (VNS), a pulse generator is implanted in a person’s neck, helping to stimulate their vagus nerve, a long

2504743 - Macmillan US ©

nerve that extends from the brain down through the neck and on to the abdomen. The stimulated vagus nerve then delivers electrical signals to the brain. As with ECT, research suggests that each of these newer brain stimulation techniques is able to improve the psychological functioning of many people

whose depressive or related disorders have been unresponsive to other forms of treatment (Holtzheimer, 2019a, 2019b).

A third kind of biological treatment is psychosurgery, brain surgery for mental disorders. It has roots as far back as trephining, the prehistoric practice of chipping a hole in the skull of a person who behaved strangely. Modern

procedures are derived from a notorious technique developed in the late 1930s by a Portuguese neuropsychiatrist, António Egas Moniz. In that procedure, known as a lobotomy, a surgeon would cut the connections between the brain’s frontal lobes and the lower regions of the brain. Today’s psychosurgery procedures are much more precise and safe than the lobotomies of the past. Even so, they are typically used only after certain severe disorders have continued for years without responding to any other treatment. In one current form of psychosurgery, called deep brain stimulation, electrodes are implanted in

specific areas of a person’s brain and connected to a battery (“pacemaker”) in the chest. The pacemaker proceeds to power the electrodes, sending a steady stream of low-voltage electricity to the targeted brain areas. This procedure, actually a combination of psychosurgical and brain stimulation techniques, has proved quite helpful for many individuals with severe, hard-to-treat depression (Holtzheimer, 2019b).

Assessing the Biological Model Today the biological model enjoys considerable respect. Biological research constantly produces valuable new information, and biological treatments often

bring great relief when other approaches have failed. At the same time, this model has its shortcomings. Some of its proponents seem to expect that all human behavior can be explained in biological terms and treated with biological methods. This view can limit rather than enhance our understanding of

2504743 - Macmillan US ©

abnormal functioning. Our mental life is an interplay of biological and nonbiological factors, and it is important to understand that interplay rather than to focus on biological variables alone.

Another shortcoming is that several of today’s biological treatments are capable of producing significant undesirable effects. Certain antipsychotic drugs, for example, may produce movement problems such as severe shaking, bizarre- looking contractions of the face and body, and extreme restlessness. Clearly such costs must be addressed and weighed against the drug’s benefits.

2504743 - Macmillan US ©

The Psychodynamic Model

THE PSYCHODYNAMIC MODEL is the oldest and most famous of the modern psychological models. Psychodynamic theorists believe that a person’s behavior, whether normal or abnormal, is determined largely by underlying psychological forces of which the individual is not consciously aware. These internal forces are described as dynamic — that is, they interact with one another — and their interaction gives rise to behavior, thoughts, and emotions. Abnormal symptoms are viewed as the result of conflicts between these forces.

Psychodynamic theorists would view Philip Berman as a person in conflict. They would want to explore his past experiences because, in their view, psychological conflicts are tied to early relationships and to traumatic experiences that occurred during childhood. Psychodynamic theories rest on the deterministic assumption that no symptom or behavior is “accidental”: all behavior is

determined by past experiences. Thus Philip’s hatred for his mother, his memories of her as cruel and overbearing, the apparent weakness of his father, and the birth of a younger brother when Philip was 10 may all be important to the understanding of his current problems.

The psychodynamic model was first formulated by Viennese neurologist

Sigmund Freud (1856–1939) at the turn of the twentieth century. After studying hypnosis, Freud developed the theory of psychoanalysis to explain both normal and abnormal psychological functioning as well as a corresponding method of treatment, a conversational approach also called psychoanalysis. During the early 1900s, Freud and several of his colleagues in the Vienna Psychoanalytic Society — including Carl Gustav Jung (1875–1961) — became the most influential clinical theorists in the Western world.

2504743 - Macmillan US ©

How Did Freud Explain Normal and Abnormal Functioning? Freud believed that three central forces shape the personality — instinctual needs, rational thinking, and moral standards. All of these forces, he believed, operate at the unconscious level, unavailable to immediate awareness; he further believed these forces to be dynamic, or interactive. Freud called the forces the id, the ego, and the superego.

The Id

Freud used the term id to denote instinctual needs, drives, and impulses. The id operates in accordance with the pleasure principle; that is, it always seeks gratification. Freud also believed that all id instincts tend to be sexual, noting that from the very earliest stages of life a child’s pleasure is obtained from nursing, defecating, masturbating, or engaging in other activities that he considered to have sexual ties. He further suggested that a person’s libido, or

sexual energy, fuels the id.

The Ego

During our early years we come to recognize that our environment will not meet every instinctual need. Our parents, for example, are not always available to do our bidding. A part of the id separates off and becomes the ego. Like the id, the ego unconsciously seeks gratification, but it does so in accordance with the reality principle, the knowledge we acquire through experience that it can be

unacceptable to express our id impulses outright. The ego, employing reason, guides us to know when we can and cannot express those impulses.

The ego develops basic strategies, called ego defense mechanisms, to control unacceptable id impulses and avoid or reduce the anxiety they arouse. The

notion of defense mechanisms was actually stated most clearly and elaborated upon by Freud’s daughter Anna Freud, a prolific and highly influential

2504743 - Macmillan US ©

psychoanalyst in her own right. The most basic defense mechanism, repression, prevents unacceptable impulses from ever reaching consciousness. There are many other ego defense mechanisms, and each of us tends to favor some over others (see Table 3-1).

TABLE: 3-1

The Defense Never Rests

Defense Mechanism

Operation Example

Repression Person avoids anxiety by simply not allowing painful or dangerous thoughts to become conscious.

An executive’s desire to run amok and attack their boss and colleagues at a board meeting is denied access to their awareness.

Denial Person simply refuses to acknowledge the existence of an external source of anxiety.

You are not prepared for tomorrow’s final exam, but you tell yourself that it’s not actually an important exam and that there’s no good reason not to go to a movie tonight.

Projection Person attributes their own unacceptable impulses, motives, or desires to other individuals.

The executive who repressed their destructive desires may project their anger onto their boss and claim that it is actually the boss who is hostile.

Rationalization Person creates a socially acceptable reason for an action that actually reflects unacceptable motives.

A student explains away poor grades by citing the importance of the “total experience” of going to college and claiming that too much emphasis on grades would actually interfere with a well- rounded education.

Displacement Person displaces hostility away from a dangerous object and onto a safer substitute.

A�er a perfect parking spot is taken by a person who cuts in front of your car, you release your pent-up anger by starting an argument with your roommate.

Intellectualization Person represses emotional reactions in favor of overly logical responses to a problem.

A woman who has been beaten and raped gives a detached, methodical description of the effects that such attacks may have on victims.

Regression Person retreats from an upsetting conflict to an early developmental stage in which no one is expected to behave maturely or responsibly.

A child who cannot cope with the anger they feel toward a rejecting mother regresses to infantile behavior, soiling their clothes and no longer taking care of basic needs.

2504743 - Macmillan US ©

“Luke … I am your father.” This lightsaber fight between Luke Skywalker and Darth Vader highlights the most famous, and contentious, father−son relationship in movie

history. According to Sigmund Freud, however, all fathers and sons have significant tensions and conflicts that they must work through, even in the absence of the

special pressures faced by Luke and his father in the Star Wars series.

The Superego

The superego is the personality force that operates by the morality principle, a sense of what is right and what is wrong. As we learn from our parents that

many of our id impulses are unacceptable, we unconsciously adopt our parents’ values. Judging ourselves by their standards, we feel good when we uphold their values; conversely, when we go against them, we feel guilty. In short, we develop a conscience.

According to Freud, these three parts of the personality — the id, the ego, and the superego — are often in some degree of conflict. A healthy personality is one in which an effective working relationship, an acceptable compromise, has formed among the three forces. If the id, ego, and superego are in excessive conflict, the person’s behavior may show signs of dysfunction.

Freudians would therefore view Philip Berman as someone whose personality forces have a poor working relationship. His ego and superego are unable to

2504743 - Macmillan US ©

control his id impulses, which lead him repeatedly to act in impulsive and often dangerous ways — suicide gestures, jealous rages, job resignations, outbursts of temper, and frequent arguments.

Developmental Stages

Freud proposed that at each stage of development, from infancy to maturity, new events challenge individuals and require adjustments in their id, ego, and superego. If the adjustments are successful, they lead to personal growth. If not, the person may become fixated, or stuck, at an early stage of development. Then all subsequent development suffers, and the individual may well be headed for abnormal functioning in the future. Because parents are the key figures during the early years of life, they are often seen as the cause of

improper development.

Freud named each stage of development after the body area that he considered most important to the child at that time. For example, he referred to the first 18 months of life as the oral stage. Freud believed that during this stage children fear that the mother who feeds and comforts them will disappear. Children

whose mothers consistently fail to gratify their oral needs may become fixated at the oral stage and display an “oral character” throughout their lives, one marked by extreme dependence or extreme mistrust. Such persons are particularly prone to develop depression. As you will see in later chapters, Freud linked fixations at the other stages of development — anal (18 months to 3 years of age), phallic (3 to 5 years), latency (5 to 12 years), and genital (12 years to adulthood) — to yet other kinds of psychological dysfunction.

2504743 - Macmillan US ©

Freud takes a closer look at Freud Sigmund Freud, founder of psychoanalytic theory and therapy, contemplates a sculptured bust of himself in 1931 at his village home in

Potzlein, near Vienna. As Freud and the bust go eyeball to eyeball, one can only imagine what conclusions each is drawing about the other.

How Do Other Psychodynamic Explanations Differ from Freud’s? Personal and professional differences between Freud and his colleagues led to a split in the Vienna Psychoanalytic Society early in the twentieth century. Carl Jung and others developed new theories. Although the new theories departed

from Freud’s ideas in important ways, each held on to Freud’s belief that human functioning is shaped by dynamic (interacting) psychological forces. Thus all such theories, including Freud’s, are referred to as psychodynamic.

Two of today’s most influential psychodynamic theories are self theory and object relations theory. Self theorists emphasize the role of the self — the

unified personality. They believe that the basic human motive is to strengthen the wholeness of the self (Afek, 2019; Kohut, 2014, 1977). Object relations theorists, on the other hand, propose that people are motivated mainly by a need to have relationships with others and that severe problems in the relationships between children and their caregivers may lead to abnormal development (Siegel, 2019; Kernberg, 2018, 2005).

2504743 - Macmillan US ©

Psychodynamic Therapies Psychodynamic therapies range from Freudian psychoanalysis to modern

therapies based on self theory or object relations theory. Psychodynamic therapists seek to uncover past traumas and the inner conflicts that have resulted from them (Wolitzky, 2020; Safran, Kriss, & Foley, 2019). They try to help clients resolve, or settle, those conflicts and to resume personal development.

According to most psychodynamic therapists, therapists must subtly guide therapy discussions so that the patients discover their underlying problems for themselves. To aid in the process, the therapists rely on such techniques as free association, therapist interpretation, catharsis, and working through.

of NOTE … Their Words

“You may be done with the past, but the past may not be done with you.”

Jennifer Dwight, The Tolling of Mercedes Bell

Free Association

In psychodynamic therapies, the patient is responsible for starting and leading each discussion. The therapist tells the patient to describe any thought, feeling, or image that comes to mind, even if it seems unimportant. This practice is

known as free association. The therapist expects that the patient’s associations will eventually uncover unconscious events. In the following excerpts from a famous psychodynamic case, notice how free association helps a woman to discover threatening impulses and conflicts within herself:

2504743 - Macmillan US ©

Patient: So I started walking, and walking, and decided to go behind the museum and walk through

[New York’s] Central Park…. I saw a park bench next to a clump of bushes and sat down. There was a

rustle behind me and I got frightened. I thought of men concealing themselves in the bushes. I thought

of the sex perverts I read about in Central Park. I wondered if there was someone behind me exposing

himself. The idea is repulsive, but exciting too. I think of father now and feel excited…. There is

something about this pushing in my mind. I don’t know what it is, like on the border of my memory.

(Pause)

Therapist: Mm-hmm. (Pause) On the border of your memory?

Patient: (The patient breathes rapidly and seems to be under great tension.) As a little girl, I slept with

my father. I get a funny feeling. I get a funny feeling over my skin, tingly-like. It’s a strange feeling, like a

blindness, like not seeing something. My mind blurs and spreads over anything I look at. I’ve had this

feeling off and on since I walked in the park.

(Wolberg, 2005, 1967, p. 662)

Therapist Interpretation

Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative conclusions, and sharing interpretations when they think the patient is ready to hear them. Interpretations of three phenomena are particularly important — resistance, transference, and dreams.

Patients are showing resistance, an unconscious refusal to participate fully in therapy, when they suddenly cannot free associate or when they change a subject to avoid a painful discussion. They demonstrate transference when they act and feel toward the therapist as they did or do toward important persons in their lives, especially their parents, siblings, and spouses. Consider again the woman who walked in Central Park. As she continues talking, the

therapist helps her to explore her transference:

2504743 - Macmillan US ©

Patient: I get so excited by what is happening here. I feel I’m being held back by needing to be nice….

The worst thing would be that you wouldn’t like me. You wouldn’t speak to me friendly … you’d feel you

can’t treat me and discharge me from treatment….

Therapist: Where do you think these attitudes come from?

Patient: When I was nine years old, … Mother would scold me. Don’t frown, don’t talk so much. Sit on

your hands, over and over again. I did all kinds of things. I was a naughty child. She told me I’d be hurt.

(Wolberg, 2005, 1967, p. 662)

Why do most people try to interpret and make sense of their own dreams? Are such interpretations of value?

Finally, a number of psychodynamic therapists try to help patients interpret their dreams (Ridall, 2019; Leonard & Dawson, 2018) (see Figure 3-3). Freud (1924) called dreams the “royal road to the unconscious.” He believed that

repression and other defense mechanisms operate less completely during sleep, and that dreams, if correctly interpreted, can reveal unconscious instincts, needs, and wishes. Freud identified two kinds of dream content — manifest and latent. Manifest content is the consciously remembered dream; latent content is its symbolic meaning. To interpret a dream, therapists must translate its manifest content into its latent content.

2504743 - Macmillan US ©

Figure 3-3

Top Dreams

Some dream themes are particularly common among people. According to surveys, more than half of adults in the United States have recurrent dreams of “falling” and

of “being chased.” (Information from: Hyde, 2020.)

Catharsis

Insight must be an emotional as well as an intellectual process. Psychodynamic therapists believe that patients must experience catharsis, a reliving of past repressed feelings, if they are to settle internal conflicts and overcome their

problems.

Working Through

A single episode of interpretation and catharsis will not change the way a person functions. The patient and therapist must examine the same issues over and over in the course of many sessions, each time with greater clarity. This process, called working through, usually takes a long time, often years.

2504743 - Macmillan US ©

Current Trends in Psychodynamic Therapy

The past 40 years have witnessed significant changes in the way many psychodynamic therapists conduct sessions. An increased demand for focused, time-limited psychotherapies has resulted in efforts to make psychodynamic therapy more efficient and affordable. Two current psychodynamic approaches that illustrate this trend are short-term psychodynamic therapies and relational psychoanalytic therapy.

SHORT-TERM PSYCHODYNAMIC THERAPIES

In several short versions of psychodynamic therapy, patients choose a single problem — a dynamic focus — to work on, such as difficulty getting along with other people. The therapist and patient focus on this problem throughout the treatment and work only on the psychodynamic issues that relate to it (such as unresolved oral needs). Only a limited number of studies have tested the effectiveness of these short-term psychodynamic therapies, but their findings do suggest that these more focused approaches are sometimes quite helpful to

patients (Farber, 2020; Rosso et al., 2019).

2504743 - Macmillan US ©

RELATIONAL PSYCHOANALYTIC THERAPY

Whereas Freud believed that psychodynamic therapists should take on the role of a neutral, distant expert during a treatment session, a contemporary school of psychodynamic therapy referred to as relational psychoanalytic therapy argues that therapists are key figures in the lives of patients — figures whose reactions and beliefs should be included in the therapy process (Curtis, 2020; Govrin,

2019). Thus, a key principle of relational therapy is that therapists should also disclose things about themselves, particularly their own reactions to patients, and try to establish more equal relationships with patients.

2504743 - Macmillan US ©

Assessing the Psychodynamic Model Freud and his followers have helped change the way abnormal functioning is

understood. Largely because of their work, a wide range of theorists today look for answers outside of biological processes. Psychodynamic theorists have also helped us to understand that abnormal functioning may be rooted in the same processes as normal functioning. Psychological conflict is a common experience; it leads to abnormal functioning only if the conflict becomes excessive.

What are some of the ways that Freud’s theories have affected literature, film and television, philosophy, child rearing, and education in Western society?

Freud and his many followers have also had a monumental impact on treatment. They were the first to apply theory systematically to treatment. They were also the first to demonstrate the potential of psychological, as opposed to biological, treatment, and their ideas have served as starting points for many other psychological treatments.

At the same time, the psychodynamic model has its shortcomings. Its concepts are hard to research (Safran et al., 2019). Because processes such as id drives, ego defenses, and fixation are abstract and supposedly operate at an unconscious level, there is no way of knowing for certain if they are occurring. Not surprisingly, then, psychodynamic explanations and treatments have received relatively limited research support over the years, and psychodynamic theorists rely largely on evidence from individual case studies. Nevertheless,

recent research evidence suggests that long-term psychodynamic therapy may be helpful for many persons with long-term complex disorders (Wolitzky, 2020; Lindfors et al., 2019), and 18 percent of today’s clinical psychologists identify themselves as psychodynamic therapists (Prochaska & Norcross, 2018).

of NOTE …

2504743 - Macmillan US ©

Freud Facts Freud’s fee for one session of therapy was $20. For almost 40 years, Freud treated patients 10 hours per day, 5 or 6 days per week. Freud was nominated for the Nobel Prize in 12 different years, but never won.

(Information from: Cherry, 2019c; Cohen, 2009; Gay, 2006, 1999)

2504743 - Macmillan US ©

The Cognitive-Behavioral Model

THE COGNITIVE-BEHAVIORAL MODEL of abnormality focuses on the behaviors people display and the thoughts they have. The model is also interested in the interplay between behaviors and thoughts — how behavior affects thinking and how thinking affects behavior. In addition, the model is concerned with the impact the behavior–cognition interplay often has on feelings and emotions.

Whereas the psychodynamic model had its beginnings in the clinical work of physicians, the cognitive-behavioral model began in laboratories where psychology researchers had been studying behaviors, the responses an organism makes to its environment, since the late 1800s. Such researchers believed that behaviors can be external (going to work, say) or internal (having a feeling), and they ran experiments on conditioning, simple forms of learning, in order to better understand how behaviors are acquired. In these experiments,

researchers would manipulate stimuli and rewards, then observe how such manipulations affect the behaviors of animal and human subjects.

of NOTE … Their Words

“We cannot solve our problems with the same thinking we used when we created them.”

Albert Einstein

During the 1950s, a number of clinicians, frustrated with what they viewed as the vagueness and slowness of the psychodynamic model, began to explain and treat psychological abnormality by applying principles derived from those

2504743 - Macmillan US ©

laboratory conditioning studies. Consistent with the laboratory studies, the clinicians viewed severe human anxiety, depression, and the like as maladaptive behaviors, and they focused their work on how such behaviors might be learned and changed.

A decade or so later, more clinicians came to believe that a focus on behaviors alone, while moving in the right direction, was too simplistic, that behavioral conditioning principles failed to account fully for the complexity of human functioning and dysfunction. They recognized that human beings also engage in cognitive processes, such as anticipating or interpreting — ways of thinking that

until then had been largely ignored in the behavior-focused explanations and therapies. These clinicians developed cognitive-behavioral theories of abnormality that took both behaviors and cognitive processes into account, and cognitive-behavioral therapies that sought to change both counterproductive behaviors and dysfunctional ways of thinking (Cattie, Buchholz, & Abramowitz, 2020; Lebow, 2019).

Some of today’s theorists and therapists still focus exclusively on the behavioral aspects of abnormal functioning, while others focus only on cognitive processes. However, most clinicians with such orientations include both behavioral and cognitive principles in their work. To best appreciate the cognitive-behavioral model, let us look first at its behavioral dimension and then its cognitive dimension.

2504743 - Macmillan US ©

The ethics of conditioning animals Animals can be taught many tricks by using the principles of conditioning — but at what cost? Here an Asian elephant performs one

called “the living statue” as she acknowledges the crowd at a circus in Virginia. In recent years the public has become alarmed at the training procedures used on

circus animals, contributing to the closing of several circuses, including the famous Ringling Brothers and Barnum & Bailey Circus.

The Behavioral Dimension Many learned behaviors help people to cope with daily challenges and to lead happy, productive lives. However, abnormal behaviors also can be learned. Philip Berman, for example, might be viewed as a man who has received improper training: he has learned behaviors that offend others and get him into various kinds of trouble.

Theorists have identified several forms of conditioning, and each may produce abnormal behavior as well as normal behavior. In classical conditioning, for

2504743 - Macmillan US ©

example, people learn to respond to one stimulus the same way they respond to another as a result of the two stimuli repeatedly occurring together close in time. If, say, a physician wears a white lab coat whenever she gives painful allergy shots to a little boy, the child may learn to fear not only injection needles,

but also white lab coats. Many phobias are acquired by classical conditioning, as you will see in Chapter 5 (Fullana et al., 2020). In modeling, another form of conditioning, individuals learn responses simply by observing other individuals and then repeating their behaviors. Phobias can also be acquired by modeling. If a little girl observes her father becoming frightened whenever a dog crosses his path, she herself may develop a phobic fear of dogs.

In a third form of conditioning, operant conditioning, individuals learn to behave in certain ways as a result of experiencing consequences of one kind or another — reinforcements (for example, rewards) or punishments — whenever they perform the behavior (Eder, Krishna, & Van Dessel, 2019; Skinner, 1958, 1957). Research suggests that a number of abnormal behaviors may be acquired by operant conditioning (Fullana et al., 2020). Some children, for example, learn to display extremely aggressive behaviors when their parents or peers

consistently surrender to their threats or demands or shower them with extra attention when they act out. In addition, a number of people learn to abuse alcohol because initially such behaviors bring feelings of calm, comfort, or pleasure.

In treatment, behavior-focused therapists seek to replace a person’s problematic behaviors with more appropriate ones, applying the principles of operant conditioning, classical conditioning, or modeling (Antony, Roemer, & Lenton-Brym, 2020). When treating extremely aggressive children, for example, the therapists may guide parents to change the reinforcements they have been unintentionally providing for their children’s behaviors. The parents may be taught to systematically reinforce polite and appropriate behaviors by their children by providing the children with displays of extra attention or special

privileges. In addition, the parents may be taught to systematically punish highly

2504743 - Macmillan US ©

aggressive behaviors by withdrawing attention and withholding privileges in the aftermath of such behaviors (Joseph et al., 2019).

See and do Modeling may account for some forms of abnormal behavior. A well-known study by Albert Bandura and his colleagues (1963) demonstrated that children learned to abuse a doll by observing an adult hit it. Children

who had not been exposed to the adult model did not mistreat the doll.

The Cognitive Dimension Philip Berman, like the rest of us, has cognitive abilities — special intellectual capacities to think, remember, and anticipate. These abilities can help him

accomplish a great deal in life. Yet they can also work against him. As he thinks about his experiences, Philip may misinterpret them in ways that lead to poor decisions, maladaptive responses, and painful emotions.

In the 1960s two clinicians, Albert Ellis (1962) and Aaron Beck (1967), proposed

that we can best explain and treat abnormal functioning, not only by looking at behaviors, but also by focusing on cognitions. Ellis and Beck claimed that clinicians must ask questions about the assumptions and attitudes that color a client’s perceptions, the thoughts running through that person’s mind, and the conclusions to which the assumptions and thoughts are leading.

According to these and other cognition-focused theorists, abnormal functioning can result from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes that are disturbing and inaccurate (Beck & Weishaar, 2019; Ellis & Ellis, 2019). Philip Berman, for example, often seems to assume that his past history has locked him into his present situation. He

2504743 - Macmillan US ©

believes that he was victimized by his parents and that he is now forever doomed by his past. He approaches all new experiences and

relationships with expectations of failure and disaster.

Illogical thinking processes are another source of abnormal functioning, according to cognition-

focused theorists. Beck has found that depressed people consistently think in illogical ways and keep arriving at self-defeating conclusions (Beck & Weishaar, 2019). They may,

for example, overgeneralize — draw broad negative conclusions on the basis of single insignificant events. One depressed student couldn’t remember the date of Columbus’ third voyage to America while she was in history class.

Overgeneralizing, she spent the rest of the day in despair over her wide-ranging ignorance.

In treatment, cognition-focused therapists use several strategies to help people with psychological disorders adopt new, more functional ways of thinking. In an

influential approach developed by Beck, the therapists guide depressed clients to identify and challenge any negative thoughts, biased interpretations, and errors in logic that dominate their thinking and contribute to their disorder. The therapists also guide the clients to try out new ways of thinking in their daily lives. As you will see in Chapter 7, depressed people treated with Beck’s approach improve much more than those who receive no treatment (Beck & Weishaar, 2019).

In the case excerpt that follows, a Beck-like therapist works with a depressed woman who feels she is a general failure — a belief that emerged in full force

2504743 - Macmillan US ©

after a recent breakup:

Therapist: You said you feel like a failure since Bill le� you. How would you define failure?

Client: Well, the marriage didn’t work out.

Therapist: So you believe the marriage didn’t work out because you, as a person, are a failure?

Client: If I had been successful, then he would still be with me.

Therapist: So could we conclude that people whose marriages don’t work out are all failures?

Client: No, I guess I wouldn’t go that far….

Therapist: You can see that your definition of failure is quite different from the way other people might

see it. Few people would say a person who is divorced is a failure…. How would most people define

success in relation to a person?

Client: Well, they might say people are successful when they accomplish some of their goals….

Therapist: So, if we applied these ideas to you, could we say you have accomplished some of your goals

in life?

Client: Yes, I did graduate from college, and I have been working for the past 6 years. I’ve been busy

raising Ted, and he had some medical problems a couple of years ago, but I got the right doctors for

him….

Therapist: Is there a contradiction, then, in your thinking — calling yourself a failure but saying that you

have had several successes?

Client: Yes, that doesn’t make sense, does it? …

(Leahy, 2017, pp. 52–53)

The Cognitive-Behavioral Interplay As you read earlier, most of today’s cognitive-behavioral theorists and therapists interweave both behavioral and cognitive elements in their explanations and

2504743 - Macmillan US ©

treatments for psychological disorders. Let’s look, for example, at the cognitive- behavioral approach to social anxiety disorder, a problem that you will be reading more about in Chapter 5.

of NOTE … Wandering Thoughts

Your mind wanders between one-third and one-half of the time on average (Shepherd, 2019; Killingsworth & Gilbert, 2010).

People with social anxiety disorder have severe anxiety about social situations in which they may face scrutiny by other people. They worry that they will function poorly in front of others and will wind up feeling humiliated. Thus they may avoid speaking in public, reject social opportunities, and limit their lives in numerous ways.

Cognitive-behavioral theorists contend that people with this disorder hold a group of social beliefs and expectations that consistently work against them (Romano et al., 2020; Dixon et al., 2019). These include:

Holding unrealistically high social standards and so believing that they must perform perfectly in social situations. Viewing themselves as unattractive social beings. Viewing themselves as socially unskilled and inadequate. Believing they are always in danger of behaving incompetently in social situations. Believing that inept behaviors in social situations will inevitably lead to terrible consequences.

Overrun by such beliefs and expectations, people with social anxiety disorder find that their anxiety levels increase as soon as they enter into a social situation. In turn, say cognitive-behavioral theorists, the individuals learn to

regularly perform “avoidance” and “safety” behaviors (Carnahan, Carter, & Herr,

2504743 - Macmillan US ©

Meeting at your place … and mine. An elderly woman (back to camera) sits in her living room and works with

her therapist in an online therapy session. Telemental health treatment of this kind has become increasingly

common, particularly since the COVID-19 outbreak first raised widespread concerns about the health risks

accompanying many kinds of in-person contact.

2019; Gray, Beierl, & Clark, 2019). Avoidance behaviors include, for example, talking only to people they already know well at gatherings or

parties, or avoiding social gatherings altogether. Safety behaviors include wearing makeup to cover up blushing. Such behaviors are reinforced by eliminating or reducing the individuals’ feelings of anxiety and the number of unpleasant events they encounter.

To undo this cycle of problematic beliefs and behaviors, cognitive- behavioral therapists combine several techniques, including exposure therapy, a behavior-

focused intervention in which fearful people are repeatedly exposed to the objects or situations they dread (Pelissolo, Abou Kassm, & Delhay, 2019). In cases of social anxiety

disorder, the therapists encourage clients to immerse themselves in various dreaded social situations and to remain there until their fears subside. Usually the exposure is gradual. Then, using a cognitive-focused intervention, the

clinicians and clients reexamine and challenge the individuals’ maladaptive beliefs and expectations in light of the recent social encounters.

In cognitive-behavioral approaches of this kind, clients come to adopt more accurate social beliefs, engage in more social situations, and experience less fear

during, and in anticipation of, social encounters. Avoidance and safety behaviors drop away, while social approach behaviors are reinforced by opening the door

2504743 - Macmillan US ©

to the joy and enrichment of social encounters. Studies show that such approaches do indeed help many individuals to overcome social anxiety disorder (Pelissolo et al., 2019; Yang et al., 2019).

New Wave Cognitive-Behavioral Therapies As it turns out, clients are not always able to rid themselves fully of their negative thoughts and biased interpretations (Rupp et al., 2019). In light of this, a

new group of therapies, sometimes called the new wave cognitive-behavioral therapies, has emerged in recent years. These new approaches, including the increasingly used acceptance and commitment therapy (ACT), help clients to accept many of their problematic thoughts rather than judge them, act on them, or try fruitlessly to change them (Hayes, 2019). The hope is that by recognizing such thoughts for what they are — just thoughts — clients will eventually be able to let them pass through their awareness without being particularly troubled by them.

As you will see in Chapter 5, ACT and similar therapies often employ mindfulness- based techniques to help clients achieve such acceptance. These techniques borrow heavily from a form of meditation called mindfulness meditation, which teaches individuals to pay attention to the thoughts and feelings that are flowing

through their minds during meditation and to accept such thoughts in a nonjudgmental way (see InfoCentral).

 

INFOCENTRAL MINDFULNESS

Over the past decade, mindfulness has become one of the most common terms in psychology.

Mindfulness involves being in the present moment, intentionally and nonjudgmentally. Mindfulness

training programs use mindfulness meditation techniques to help treat people suffering from pain,

anxiety disorders, and depres-sive disorders, as well as a variety of other psychological disorders.

2504743 - Macmillan US ©

Assessing the Cognitive-Behavioral Model The cognitive-behavioral model has become a powerful force in the clinical field. Various cognitive and behavioral theories have been proposed over the years, and many treatment techniques have been developed. As you can see in Figure

2504743 - Macmillan US ©

3-4, nearly half of today’s clinical psychologists report that their approach is cognitive and/or behavioral (Prochaska & Norcross, 2018).

FIGURE 3-4

Theoretical Orientations of Today’s Clinical Psychologists

In surveys, 22 percent of clinical psychologists labeled their approach as “eclectic,”

46 percent considered their model “cognitive” and/or “behavioral,” and 18 percent called their orientation “psychodynamic.” (Information from: Prochaska & Norcross,

2018.)

One reason for the appeal of the cognitive-behavioral model is that it can be tested in the laboratory, whereas psychodynamic theories generally cannot. Many of the model’s basic concepts — stimulus, response, reward, attitude, and interpretation — can be observed or at least measured. Moreover, investigators have found that people with psychological disorders often display the kinds of reactions, assumptions, and errors in thinking that cognitive-behavioral theorists would predict (Kube et al., 2018).

Yet another reason for the popularity of this model is the impressive research performance of cognitive-behavioral therapies. Both in the laboratory and real life, cognitive-behavioral therapies have proved very helpful to many people with anxiety disorders, depression, sexual dysfunction, intellectual disability, and yet

other problems (Cattie et al., 2020; Masuda & Rizvi, 2020; Hayes, 2019; Lebow, 2019).

2504743 - Macmillan US ©

At the same time, the cognitive-behavioral model has drawbacks. First, although maladaptive behaviors and disturbed cognitive processes are found in many forms of abnormality, their precise role has yet to be determined. The problematic behaviors and cognitions seen in psychologically troubled people

could well be a result rather than a cause of their difficulties. Second, although cognitive-behavioral therapies are clearly of help to many people, they do not help everyone. Third, by focusing primarily on clients’ current experiences and functioning, cognitive-behavioral therapists may be paying too little attention to the influence of early life experiences and relationships on a client’s current difficulties.

A final drawback of the cognitive-behavioral model is that it is narrow in certain ways. Although behavior and cognition obviously are key dimensions in life, they are still only two aspects of human functioning. Shouldn’t explanations of human functioning also consider broader issues, such as how people approach life, what value they extract from it, and how they deal with the question of life’s meaning? This is the position of the humanistic-existential model.

2504743 - Macmillan US ©

The Humanistic-Existential Model

PHILIP BERMAN IS MORE than the sum of his psychological conflicts, learned behaviors, or cognitions. Being human, he also has the ability to pursue philosophical goals such as self-awareness, strong values, a sense of meaning in life, and freedom of choice. According to humanistic and existential theorists, Philip’s problems can be understood only in the light of such complex goals. Humanistic and existential theorists are often grouped together — in an approach known as the humanistic-existential model — because of their common focus on these broader dimensions of human existence. At the same time, there

are important differences between them.

Humanists, the more optimistic of the two groups, believe that human beings are born with a natural tendency to be friendly, cooperative, and constructive. People, these theorists propose, are driven to self-actualize — that is, to fulfill

their potential for goodness and growth. They can do so, however, only if they honestly recognize and accept their weaknesses as well as their strengths and establish satisfying personal values to live by. Humanists further suggest that self-actualization leads naturally to a concern for the welfare of others and to behavior that is loving, courageous, spontaneous, and independent (Selva, 2019; Maslow, 1970).

Existentialists agree that human beings must have an accurate awareness of themselves and live meaningful — they say “authentic” — lives in order to be psychologically well-adjusted. These theorists do not believe, however, that people are naturally inclined to live positively. They believe that from birth we have total freedom, either to face up to our existence and give meaning to our lives or to shrink from that responsibility. Those who choose to “hide” from

2504743 - Macmillan US ©

responsibility and choice will view themselves as helpless and may live empty, inauthentic, and dysfunctional lives as a result.

The humanistic and existential views of abnormality both date back to the 1940s. At that time Carl Rogers (1902–1987), often considered the pioneer of the humanistic perspective, developed client-centered therapy, a warm and supportive approach that contrasted sharply with the psychodynamic techniques of the day. He also proposed a theory of personality that paid little attention to irrational instincts and conflicts.

The existential view of personality and abnormality appeared during this same period. Many of its principles came from the ideas of nineteenth-century European existential philosophers who held that human beings are constantly defining and so giving meaning to their existence through their actions (Schneider & Krug, 2020).

The humanistic and existential theories, and their uplifting implications, were extremely popular during the 1960s and 1970s, years of considerable soul- searching and social upheaval in Western society. They have since lost some of their popularity, but they continue to influence the ideas and work of many

clinicians. In particular, humanistic principles are apparent throughout positive psychology (the study and enhancement of positive feelings, traits, abilities, and selfless virtues), an area of psychology that, as you read in Chapter 1, has gained much momentum in recent years (see page 16).

Rogers’ Humanistic Theory and Therapy

According to Carl Rogers, the road to dysfunction begins in infancy (Raskin, Rogers, & Witty, 2019; Rogers, 1987, 1951). We all have a basic need to receive positive regard from the important people in our lives (primarily our parents). Those who receive unconditional (nonjudgmental) positive regard early in life are likely to develop unconditional self-regard. That is, they come to recognize their

2504743 - Macmillan US ©

Unconditional positive regard Carl Rogers argued that clients must receive unconditional positive regard in

order to overcome their problems. In this spirit, a number of organizations now arrange for individuals to

have close relationships with gentle and nonjudgmental dogs, o�en called emotional support

dogs. Here a child’s therapy is greatly facilitated by the physical closeness and reassuring presence of her dog.

worth as persons, even while recognizing that they are not perfect. Such people are in a good position to actualize their positive

potential.

Unfortunately, some children repeatedly are made to feel that they are not worthy of positive regard. As a result, they acquire

conditions of worth, standards that tell them they are lovable and acceptable only when they conform to certain guidelines. To maintain positive self-regard, these people have to look at themselves very selectively, denying or distorting thoughts and actions that do not

measure up to their conditions of worth. They thus acquire an inauthentic view of themselves and their experiences. They do not know what they are truly feeling, what they genuinely need, or what values and goals would be meaningful for them. Problems in functioning are

then inevitable.

Rogers might view Philip Berman as a man who has gone astray. Rather than striving to fulfill his positive human potential, he drifts from job to job and relationship to relationship. In every interaction he is defending himself, trying

to interpret events in ways he can live with, usually blaming his problems on other people. Nevertheless, his basic negative self-image continually reveals

2504743 - Macmillan US ©

itself. Rogers would probably link this problem to the critical ways Philip was treated by his mother throughout his childhood.

Clinicians who practice Rogers’ client-centered therapy try to create a supportive climate in which clients feel able to look at themselves honestly and acceptingly (Raskin et al., 2019). The therapist must display three important qualities throughout the therapy — unconditional positive regard (full and warm acceptance for the client), accurate empathy (skillful listening and restating), and genuineness (sincere communication). In the following case, the client-centered therapist uses these qualities to move the client toward greater self-awareness:

Client: No one else would be as cruel to me as I am.

Therapist: And make such harsh judgments, you’re pretty tough on yourself.

Client: Yes, I wouldn’t judge my friends the way I judge myself….

Therapist: Maybe because you can see what is lovable in them, but not in yourself. To you, you’re

unlovable.

Client: Maybe there are small pieces of me that are lovable.

Therapist: (Pause) So there are parts of you that you see as OK, as worthy of being loved.

Client: Yes, I guess. The child in me…. She, I, can still be playful and fun and warm.

Therapist: Those are very wonderful qualities…. She’s a part of you that you can hold on to.

Client: Yes.

Therapist: Do you think she’d judge you so harshly?

Client: No, she loves me.

Therapist: To this special child part of you, none of you is unforgivable.

Client: No, she loves all of me.

(Farber, Suzuki, & Lynch, 2019)

2504743 - Macmillan US ©

of NOTE … Their Words

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Maya Angelou

In such an atmosphere, clients are expected to feel accepted and understood by their therapists. They then may be able to look at themselves with honesty and acceptance. They begin to value their own emotions, thoughts, and behaviors, and so they are freed from the insecurities and doubts that prevent self- actualization.

Client-centered therapy has not fared very well in research. Although some studies show that participants who receive this therapy improve more than control participants, many other studies have failed to find any such advantage (Prochaska & Norcross, 2018). All the same, Rogers’ therapy has had a positive influence on clinical practice (Bohart & Watson, 2020). It was one of the first major alternatives to psychodynamic therapy, and it helped open up the clinical field to new approaches. Rogers also helped pave the way for psychologists to

practice psychotherapy, which had previously been considered the exclusive territory of psychiatrists. And his commitment to clinical research helped promote the systematic study of treatment. Approximately 2 percent of today’s clinical psychologists, 1 percent of social workers, and 3 percent of counseling psychologists report that they employ the client-centered approach (Prochaska & Norcross, 2018).

2504743 - Macmillan US ©

Gestalt Theory and Therapy Gestalt therapy, another humanistic approach, was developed in the 1950s by

a charismatic clinician named Frederick (Fritz) Perls (1893–1970). Gestalt therapists, like client-centered therapists, guide their clients toward self- recognition and self-acceptance (Yontef & Jacobs, 2019). But unlike client- centered therapists, they try to achieve this goal by challenging and even frustrating the clients, demanding that they stay in the here and now during therapy discussions, and pushing them to embrace their real emotions.

For example, gestalt therapists often use the technique of role playing, instructing clients to act out various roles. A person may be told to be another person, an object, an alternative self, or even a part of the body. The gestalt version of role playing can become intense, as individuals are encouraged to express emotions fully. Many cry out, scream, kick, or pound. Through this experience they may come to “own” (accept) feelings that previously made them

uncomfortable.

Approximately 1 percent of clinical psychologists and other kinds of clinicians describe themselves as gestalt therapists (Prochaska & Norcross, 2018). Because they believe that subjective experiences and self-awareness cannot be

measured objectively, proponents of gestalt therapy have not often performed controlled research on this approach (Yontef & Jacobs, 2019).

2504743 - Macmillan US ©

Beating the blues Gestalt therapists o�en guide clients to express their needs and feelings in their full intensity

by banging on pillows, crying out, kicking, or pounding things. Building on these techniques, a new approach,

drum therapy, teaches clients, such as this woman, how to beat drums in order to help release traumatic

memories, change beliefs, and feel more liberated.

Spiritual Views and Interventions For most of the nineteenth and twentieth centuries, clinicians viewed religion as a negative — or at best neutral — factor in mental health. Indeed, “religious insanity” was a common diagnosis assigned to patients admitted to mental hospitals in the 1800s, reflecting the clinical notion that religious beliefs and

practices often caused mental disorders (Geppert, 2019). And in the early 1900s, Freud argued that religious beliefs were defense mechanisms “born from man’s need to make his helplessness tolerable” (1961, p. 23). This negative view of

2504743 - Macmillan US ©

religion now seems to be ending, however. During the past decade, many articles and books linking spiritual issues to clinical treatment have been published, and the ethical codes of psychologists, psychiatrists, and counselors have each concluded that religion is a type of diversity that mental health

professionals must respect (Barnett, 2019).

Researchers have learned that spirituality does, in fact, often correlate with psychological health. In particular, studies have examined the mental health of people who are devout and who view God as warm, caring, helpful, and dependable. Repeatedly, these individuals are found to be less lonely,

pessimistic, depressed, or anxious than people without any religious beliefs or those who view God as cold and unresponsive (Hardy et al., 2019; Scott, 2019). Such people also seem to cope better with major life stressors — from illness to war — and to attempt suicide less often. In addition, they are less likely to abuse drugs.

Spirituality and science A few years ago, Tibetan spiritual leader the Dalai Lama (right) met with professor of psychiatry Zindel Segal (le�) and other mental health

2504743 - Macmillan US ©

researchers at a conference examining possible ties between science, mental health, and spirituality.

What various explanations might account for the correlation between spirituality and mental health?

Do such correlations indicate that spirituality helps produce greater mental health? Not necessarily. As you’ll recall from Chapter 2, correlations do not indicate causation. It may be, for example, that a sense of optimism leads to more spirituality, and that, independently, optimism contributes to greater mental health. Whatever the proper interpretation, many therapists now make a point of including spiritual issues when they treat religious clients, and some further encourage clients to use their spiritual resources to help them cope with

current stressors (Hai et al., 2019; LeDoux et al., 2019). Similarly, a number of religious institutions offer counseling services to their members.

Existential Theories and Therapy Like humanists, existentialists believe that psychological dysfunction is caused by self-deception; existentialists, however, are talking about a kind of self- deception in which people hide from life’s responsibilities and fail to recognize that it is up to them to give meaning to their lives. According to existentialists, many people become overwhelmed by the pressures of present-day society and so look to others for explanations, guidance, and authority. They overlook their

personal freedom of choice and avoid responsibility for their lives and decisions (Schneider & Krug, 2020; Yalom & Josselson, 2019). Such people are left with empty, inauthentic lives. Their dominant emotions are anxiety, frustration, boredom, alienation, and depression.

of NOTE …

2504743 - Macmillan US ©

Their Words

“The greatest discovery of my generation is that human beings can alter their lives by altering their

attitudes of mind.”

William James (1842–1910).

Existentialists might view Philip Berman as a man who feels overwhelmed by the forces of society. He sees his parents as “rich, powerful, and selfish,” and he perceives teachers, acquaintances, and employers as being oppressive. He fails

to appreciate his choices in life and his own capacity for finding meaning and direction. Quitting becomes a habit with him — he leaves job after job, ends every romantic relationship, and flees difficult situations.

In existential therapy, people are encouraged to accept responsibility for their

lives and for their problems. Therapists try to help clients recognize their freedom so that they may choose a different course and live with greater meaning (Krug, 2019; Yalom & Josselson, 2019). The precise techniques used in existential therapy vary from clinician to clinician. At the same time, most existential therapists place great emphasis on the relationship between therapist and client and try to create an atmosphere of honesty, hard work, and shared learning and growth.

Client: I turn[ed] to a person I thought was a close friend, and even she, apparently, can’t stand the

sight of me, and I just don’t get it — don’t know where to turn….

Therapist: Boy, you have a lot of energy all of a sudden, James.

Client: Yeah, I do — but what the hell good is it? I can get mad from now until doomsday, and it won’t

change the fact that women think I’m a pervert, men think I’m a weakling, and my boss thinks I’m

incompetent!

Therapist: And what do you think of you? What do you feel towards yourself?

Client: I feel like a jerk — what do you think!?

2504743 - Macmillan US ©

Therapist: I don’t know, James, I can’t speak for you, but I hear you….

Client: (Eyes moistening) I’m stuck, I’m screwed … Yeah, sometimes I feel like my life is a big wall —

and I’m the bug that constantly gets squashed.

Therapist: Is that where you are now?

Client: Not exactly.

Therapist: Take a moment and be with where you are, James.

Client: I’m hurting…. How could I have done that? How could I have taken a perfectly decent

relationship … and push it off the cliff? There’s just no way around it, I’m doomed to be a shit.

Therapist: Is that all you are, James? Is that what your whole life and all you’ve been through comes

down to?

Client: Seems so.

Therapist: …. Is that acceptable to you?

Client: No, but there’s nothing I can do about it.

Therapist: What are you willing to do about it? …

Client: Well, I am sick and tired of it.

Therapist: I hear you. What else is here, James?

Client: That maybe I wasn’t as much the shit as I made myself out to be — that I always make myself

out to be. That I slipped up — I made a stupid comment, am I gonna condemn myself for life?

Therapist: Stay with it, James, what else is present for you?

Client: A hint of pride, fight …

(Schneider, 2007)

Existential therapists do not believe that experimental methods can adequately test the effectiveness of their treatments. To them, research dehumanizes individuals by reducing them to test measures. Not surprisingly, then, little controlled research has been devoted to the effectiveness of this approach (Vos,

2504743 - Macmillan US ©

2019). Nevertheless, around 1 percent of today’s clinical psychologists use an approach that is primarily existential (Prochaska & Norcross, 2018).

Assessing the Humanistic-Existential Model The humanistic-existential model appeals to many people in and out of the clinical field. In recognizing the special challenges of human existence, humanistic and existential theorists tap into an aspect of psychological life that typically is missing from the other models (Bohart & Watson, 2020; Schneider & Krug, 2020). Moreover, the factors that they say are essential to effective functioning — self-acceptance, personal values, personal meaning, and personal choice — are certainly lacking in many people with psychological disturbances.

The optimistic tone of the humanistic-existential model is also an attraction. Such optimism meshes quite well with the goals and principles of positive psychology (see page 16) (Rashid & Seligman, 2019). Theorists who follow the principles of the humanistic-existential model offer great hope when they assert

that, despite past and present events, we can make our own choices, determine our own destiny, and accomplish much. Still another attractive feature of the model is its emphasis on health. Unlike clinicians from some of the other models who see individuals as patients with psychological illnesses, humanists and existentialists view them simply as people who have yet to fulfill their potential.

At the same time, the humanistic-existential focus on abstract issues of human fulfillment gives rise to a major problem from a scientific point of view: these issues are difficult to research. In fact, with the notable exception of Rogers, who tried to investigate his clinical methods carefully, humanists and existentialists have traditionally rejected the use of empirical research. This anti-research position is now beginning to change among some humanistic and existential researchers — a change that may lead to important insights about the merits of

this model in the coming years (Schneider & Krug, 2020; Vos, 2019).

2504743 - Macmillan US ©

of NOTE … Self-Actualization Through Giving

70% Percentage of adult Americans who make charitable contributions each year

38% Percentage of charitable donations contributed to religious organizations

62% Percentage of donations directed to education, human services, health, and the arts

35% Percentage of adult Americans who do volunteer work each year

(Information from: Charities Aid Foundation, 2019)