assessment

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her own ability (minimization). Later in the week the same student must miss an

English class and is convinced that she will be unable to keep up the rest of the semester (magnification).

Finally, depressed people have automatic thoughts, a steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and their

situation is hopeless. Beck labels these thoughts “automatic” because they seem to just happen, as if by reflex. In the course of only a few hours, depressed people may be visited by hundreds of such thoughts: “I’m worthless…. I’ll never amount to anything…. I let everyone down…. Everyone hates me…. My responsibilities are overwhelming…. I’ve failed as a parent…. I’m stupid…. Everything is difficult for me…. Things will never change.”

Many studies have produced evidence in support of Beck’s explanation (Chahar Mahali et al., 2020; Brouwer et al., 2019; Krishnan, 2019). Several of them confirm that depressed people hold maladaptive attitudes and that the more of these maladaptive attitudes they hold, the more depressed they tend to be. A

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number of studies have found the cognitive triad at work in depressed people. And still others have supported Beck’s claims about errors of logic.

Finally, research has supported Beck’s notion that automatic thoughts are tied to depression (Chahar Mahali et al., 2020). In several classic studies, for example, nondepressed participants who were tricked into reading negative automatic- thought-like statements about themselves became increasingly depressed (Bates et al., 1999; Strickland et al., 1975). In a related line of research, it has been found that people who generally make ruminative responses during their depressed moods — that is, repeatedly dwell mentally on their mood without

acting to change it — feel dejection longer and are more likely to develop clinical depression later in life than people who avoid such ruminations (Watkins & Roberts, 2020).

LEARNED HELPLESSNESS: A COGNITIVE-BEHAVIORAL INTERPLAY

According to psychologist Martin Seligman (2018, 1975), feelings of helplessness are at the center of depression. Since the mid-1960s Seligman has been developing the learned helplessness theory of depression. It holds that people

become depressed when they think that (1) they no longer have control over the reinforcements (the rewards and punishments) in their lives, and (2) they themselves are responsible for this helpless state.

Seligman’s theory first began to take shape when he was working with

laboratory dogs. In one procedure, he strapped dogs into an apparatus called a hammock, in which they received shocks periodically no matter what they did. The next day each dog was placed in a shuttle box, a box divided in half by a barrier over which the animal could jump to reach the other side (see Figure 7- 4). Seligman applied shocks to the dogs in the box, expecting that they, like other dogs in this situation, would soon learn to escape by jumping over the barrier. However, most of these dogs failed to learn anything in the shuttle box. After a flurry of activity, they simply “lay down and quietly whined” and accepted

the shock.

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FIGURE 7-4

Jumping to Safety

Experimental animals learn to escape or avoid shocks

that are administered on one side of a shuttle box by jumping to the other (safe) side.

Seligman decided that while receiving inescapable shocks in the hammock the day before, the dogs had learned that they had no control over unpleasant

events (shocks) in their lives. That is, they had learned that they were helpless to do anything to change negative situations. Thus, when later they were placed in a new situation (the shuttle box) where they could in fact control their fate, they continued to believe that they were generally helpless. Seligman noted that the effects of learned helplessness greatly resemble the symptoms of human depression, and he proposed that people in fact become depressed after developing a general belief that they have no control over reinforcements in their lives.

In numerous human and animal studies, participants who undergo helplessness training have displayed reactions similar to depressive symptoms. When, for example, human participants are exposed to uncontrollable negative events, they later score higher than other individuals on a depressive mood scale. Similarly, helplessness-trained animal subjects lose interest in sexual and social

activities — a common symptom of human depression.

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of NOTE … Serious Oversight

Family physicians, internists, and pediatricians fail to detect depression in at least 50 percent of their depressed patients (Lyness, 2019).

The learned helplessness explanation of depression has been revised somewhat over the past several decades. According to one modified version of the theory, the attribution–helplessness theory, when people view events as beyond their control, they ask themselves why this is so (Cherry, 2020a; Abramson et al., 2002, 1989, 1978). If they attribute their present lack of control to some internal cause that is both global and stable (“I am inadequate at everything and I always will be”), they may well feel helpless to prevent future negative outcomes and they may experience depression. If they make other kinds of attributions, they are unlikely to have this reaction.

Consider a college student whose girlfriend breaks up with him. If he attributes this loss of control to an internal cause that is both global and stable — “It’s my fault [internal], I ruin everything I touch [global], and I always will [stable]” — he then has reason to expect similar losses of control in the future and may generally experience a sense of helplessness. According to the learned helplessness view, he is a prime candidate for depression. If the student had instead attributed the breakup to causes that were more specific (“The way I’ve behaved the past couple of weeks blew this relationship”), unstable (“I don’t

know what got into me — I don’t usually act like that”), or external (“She never did know what she wanted”), he might not expect to lose control again and would probably not experience helplessness and depression. Hundreds of studies have supported the relationship between styles of attribution, helplessness, and depression (Houston, 2019; O’Sullivan et al., 2018).

Although the learned helplessness theory of unipolar depression has been very influential, it too has imperfections. For example, much of the learned

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helplessness research relies on animal subjects. It is impossible to know whether the animals’ symptoms do in fact reflect the clinical depression found in humans. In addition, the attributional feature of the theory raises difficult questions. What about the dogs and rats who learn helplessness? Can animals

make attributions, even implicitly?

COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapists combine behavioral and cognitive techniques to help clients suffering from depression. On the behavioral side, they seek to get the clients moving again — to engage in and enjoy more activities. On the cognitive side, they guide the clients to think in more adaptive, less negative ways. A variety of approaches have been developed to help bring about these changes. Two of the leading ones are behavioral activation and Beck’s cognitive therapy.

In behavioral activation, therapists work systematically to increase the number of constructive and rewarding activities and events in a client’s life. The approach builds on the work of Peter Lewinsohn, the theorist who, as you’ll

recall, ties mood to the rewards one experiences in life. There are three key components to the approach. The therapists (1) reintroduce depressed clients to pleasurable events and activities, (2) consistently reward nondepressive behaviors and withhold rewards for depressive behaviors, and (3) help clients improve their social skills (Dimidjian, 2019; Martell, Dimidjian, & Herman-Dunn, 2013).

First, the therapist selects activities that the client considers pleasurable, such as going shopping or taking photos, and encourages the person to set up a weekly schedule for engaging in them. Studies have shown that adding positive activities to a person’s life can indeed lead to a better mood. Second, while reintroducing pleasurable events into a client’s life, the therapist makes sure that the person’s various behaviors are reinforced correctly. Behavioral

activation theorists argue that when people become depressed, their negative

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behaviors — crying, ruminating, complaining, or self-depreciation — keep others at a distance, reducing chances for rewarding experiences and interactions. To change this pattern, therapists guide clients to monitor their negative behaviors and to try new, more positive ones. Dozens of smartphone apps are now

available to help clients accurately record the negative and positive activities they perform in life and the mood changes that result, making behavioral activation a more precise approach than it once was (Kwasny et al., 2019; Huguet et al., 2016). Finally, behavior activation therapists train clients in effective social skills. In group therapy programs, for example, members may work together to improve eye contact, facial expression, posture, and other behaviors that send social messages.

Reintroducing pleasure Following the principles of behavioral activation, depressed

patients at the Zhongshan Mental Hospital in China are encouraged to weed a garden. Behavioral activation therapists guide clients to increase the number of

pleasurable activities in their lives, particularly activities that brought them joy (in this case, gardening) prior to their disorders.

Can you think of other uses, advantages, and disadvantages that might result from the growing use of mood-tracking apps?

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Behavioral activation techniques seem to be of only limited help when they are the sole feature of treatment, particularly if the severity of depression is more than modest (Dimidjian, 2019). But when they are combined with cognitive techniques, they are, as you’ll see next, often quite helpful (Stein et al., 2020;

Moshier & Otto, 2017).

To help depressed clients overcome their negative thinking, Aaron Beck has developed a treatment approach that he calls cognitive therapy. He uses this label because the approach focuses largely on guiding clients to recognize and change negative cognitive processes (Beck & Weishaar, 2019; Beck, 2016).

However, as you will note, the approach also includes several behavioral techniques such as those we have just examined. The approach follows four phases and usually requires fewer than 20 sessions.

PHASE 1: INCREASING ACTIVITIES AND ELEVATING MOOD

Using behavioral techniques to set the stage for the cognitive dimensions of treatment, therapists first encourage clients to become more active and confident. Clients spend time during each session preparing a detailed schedule of hourly activities for the coming week. As they become more active from week to week, their mood is expected to improve.

PHASE 2: CHALLENGING AUTOMATIC THOUGHTS

Once people are more active and feeling some emotional relief, therapists begin to educate them about their negative automatic thoughts. The individuals are instructed to recognize and record automatic thoughts and to bring their lists to each session. Here again, clients may use smartphone apps to accurately identify and document such thoughts as they arise in their daily lives (Lattie et al., 2019; Huguet et al., 2016). The therapist and client then test the reality behind the thoughts, often concluding that they are groundless.

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PHASE 3: IDENTIFYING NEGATIVE THINKING AND BIASES

As people begin to recognize the flaws in their automatic thoughts, the therapists show them how illogical thinking processes are contributing to these thoughts. The therapists also guide clients to recognize that almost all their interpretations of events have a negative bias and to change that style of interpretation, as in the following therapy discussion with a client who has

concluded, after a recent breakup, that she must be unattractive:

Therapist: You said your evidence of being unattractive is that you feel ugly and that Roger broke up

with you.

Client: I just don’t feel attractive….

Therapist: Are there some men who think you’re attractive?

Client: Well, there have been a number of men who find me attractive. But I’m not interested in

them.

Therapist: As evidence that you are not attractive, you cite the fact that Roger broke up with you.

What were the reasons for the breakup?

Client: We weren’t getting along. He just can’t commit to anyone. And he lies.

Therapist: So you personalized his shortcomings and concluded that you are not attractive?

Client: That’s true.

Therapist: I wonder if we could look at the evidence that you use to support your negative beliefs and

see if the evidence is relevant and convincing or if it is characterized by these kinds of distortions.

(Leahy, 2017, pp. 66–67)

of NOTE … Their Words

“No one can make you feel inferior without your consent.”

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Eleanor Roosevelt

PHASE 4: CHANGING PRIMARY ATTITUDES

Therapists help clients change the maladaptive attitudes that set the stage for their depression in the first place. As part of the process, therapists encourage

clients to test their attitudes in discussion after discussion.

Numerous studies have shown that cognitive-behavioral approaches help with unipolar depression. Depressed adults who receive these therapies improve much more than those who receive placebos or no treatment at all (Gautam et

al., 2020; Zakhour et al., 2020). Around 50 to 60 percent show significant improvement in or elimination of their symptoms. To help prevent relapses, a number of therapists follow up successful cognitive-behavioral therapy with preventive cognitive therapy — a short series of “booster” sessions conducted months later that focus on reducing negative automatic thoughts and developing a relapse prevention plan. Research finds that clients who receive this follow-up therapy experience significantly fewer recurrences of depression (de Jonge et al., 2019).

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It is worth noting that many of today’s cognitive-behavioral therapists do not agree with the proposition that individuals must fully discard their negative cognitions in order to overcome depression. These therapists, the new-wave cognitive-behavioral therapists about whom you read in Chapters 3 and 5,

including those who practice acceptance and commitment therapy (ACT), use mindfulness training and other cognitive-behavioral techniques to help depressed clients recognize and accept their negative cognitions simply as unimportant streams of thinking that flow through their minds. As the clients increasingly accept their negative thoughts for what they are, rather than use them as guides for behaviors and decisions, the individuals learn to work around them in life. Research suggests that thought acceptance of this kind helps prevent recurrences of depression after individuals have recovered (Ruiz

et al., 2020; Segal, 2020).

The Sociocultural Model of Unipolar Depression Sociocultural theorists propose that unipolar depression is strongly influenced by the social context that surrounds people. Their belief is supported by the finding, discussed earlier, that depression is often triggered by outside stressors (Wang et al., 2020). Once again, there are two kinds of sociocultural views — the

family-social perspective and the multicultural perspective.

The Family-Social Perspective

Earlier you read that some cognitive-behavioral theorists believe that a decline in social rewards is particularly important in the development of depression. This view is also consistent with the family-social perspective.

The connection between declining social rewards and depression is a two-way street (Hammen, 2018, 2016). On the one hand, researchers have found that depressed people often display weak social skills and communicate poorly. They seek repeated reassurances from others, and they typically speak more slowly

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and quietly than nondepressed people, pause longer between words, and take longer to respond to others. Such social deficits make other people uncomfortable and may cause them to avoid the depressed individuals. As a result, the social contacts and rewards of depressed people decrease, and, as

they participate in fewer and fewer social interactions, their social skills deteriorate still further.

Why might problems in the social arena — for example, social loss, social ties, and social rewards — be particularly tied to depression?

Consistent with these findings, depression has been tied repeatedly to the unavailability of social support such as that found in a happy marriage (MHF, 2020; Pastor, 2020). Research indicates that people in troubled marriages are 25

times more likely to have a depressive disorder than people in untroubled marriages (Keitner, 2017). In some cases, the spouse’s depression may contribute to marital discord or divorce, but often the interpersonal conflicts and low social support found in troubled relationships seem to lead to depression (Williams & Nieuwsma, 2018).

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Is texting a relationship buster? Studies suggest that communicating excessively by text may affect intimate relationships negatively — producing needless

misunderstandings and fewer face-to-face encounters.

Researchers have also found that people whose lives are characterized by weak social supports, isolation, and lack of intimacy are particularly likely to become depressed and to remain depressed longer than other people (Pastor, 2020; Liang et al., 2019). For example, some highly publicized studies conducted in England several decades ago showed that women who had three or more young children, lacked a close confidante, and had no outside employment were more likely than other women to become depressed after going through stressful

events (Brown, 2002; Brown & Harris, 1978).

Everyone has social needs Researchers have found that macaque monkeys — like many other animals — are greatly affected by friends and relatives. Moreover, the

facial expressions of macaques show emotions ranging from anger to fear to sadness — expressions that influence each other’s social judgments, behaviors, and moods.

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Research has likewise revealed that one of the most problematic features of disease epidemics is the social isolation and distancing imposed on people to help contain the spread of infection. Studies conducted across various epidemics, including the COVID-19 pandemic, find that the rate of clinical

depression in stricken communities rises to as much as 37 percent among adults and 23 percent among children (Brooks et al., 2020; NORC, 2020; Xie et al., 2020). Although economic, family, and health concerns certainly contribute to these increases, one of the most closely linked factors is the sense of loneliness that emerges during extended periods of isolation and distancing (NORC, 2020; Ornell et al., 2020). Indeed, as many as 60 percent of people confined to their homes during epidemics report substantial feelings of loneliness — and the longer the social isolation, the greater the likelihood of

developing both loneliness and depression (Brooks et al., 2020; NORC, 2020; Ornell et al., 2020). The link between isolation, loneliness, and depression seems to be implicitly recognized by people in these situations, as they often try to improve such matters on their own. Throughout the COVID-19 pandemic, for example, 87 percent of adults said they were communicating with friends and family by phone, text, social media, or Zoom every day, a significant increase over their rate of communication prior to the outbreak (NORC, 2020).

Family-Social Treatments

Therapists who use family and social approaches to treat depression help clients change how they deal with the close relationships in their lives. The most effective family-social approaches are interpersonal psychotherapy and couple therapy.

INTERPERSONAL PSYCHOTHERAPY

Developed by clinical researchers Myrna Weissman and Gerald Klerman, interpersonal psychotherapy (IPT) holds that any of four interpersonal

problem areas may lead to depression and must be addressed: interpersonal loss, interpersonal role dispute, interpersonal role transition, and interpersonal

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deficits (Lemmens et al., 2020; Swartz, 2019). Over the course of around 20 sessions, IPT therapists address these areas.

First, depressed people may, as psychodynamic theorists suggest, be having a grief reaction over an important interpersonal loss, the loss of a loved one. In such cases, IPT therapists encourage clients to explore their relationship with the lost person and express any feelings of anger they may discover. Eventually clients develop new ways of remembering the lost person and also look for new relationships.

of NOTE … Fathers Too

Between 3 and 13 percent of new fathers may also experience some degree of postpartum depression (Viguera, 2019c). Research indicates that, as in cases of a mother’s postpartum

depression, this syndrome can affect a child’s psychological development.

Second, depressed people may find themselves in the midst of an interpersonal role dispute. Role disputes occur when two people have different expectations of their relationship and of the role each should play. IPT therapists help clients examine whatever role disputes they may be involved in and then develop ways of resolving them.

Depressed people may also be going through an interpersonal role transition, brought about by major life changes such as divorce or the birth of a child. They may feel overwhelmed by the role changes that accompany the life change. In such cases, IPT therapists help them develop the social supports and skills the new roles require.

of NOTE …

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Waning Confidants

When research participants were asked in 1985 how many confidants they turned to for discussion of

important matters, most answered 3. Today, the most common response to the same question is 2 or

less (GSS, 2020, 2016).

Finally, some depressed people display interpersonal deficits, such as extreme shyness or social awkwardness, that prevent them from having intimate relationships. IPT therapists may help such clients recognize their deficits and

teach them social skills and assertiveness in order to improve their social effectiveness. In the following discussion, the therapist encourages a depressed man to recognize the effect his behavior has on others:

Client: (A�er a long pause with eyes downcast, a sad facial expression, and slumped posture)

People always make fun of me. I guess I’m just the type of guy who really was meant to be a loner,

damn it. (Deep sigh)

Therapist: Could you do that again for me?

Client: What?

Therapist: The sigh, only a bit deeper.

Client: Why? (Pause) Okay, but I don’t see what … okay. (Client sighs again and smiles)

Therapist: Well, that time you smiled, but mostly when you sigh and look so sad I get the feeling that I

better leave you alone in your misery, that I should walk on eggshells and not get too chummy or I

might hurt you even more.

Client: (A bit of anger in his voice) Well, excuse me! I was only trying to tell you how I felt.

Therapist: I know you felt miserable, but I also got the message that you wanted to keep me at a

distance, that I had no way to reach you.

Client: (Slowly) I feel like a loner, I feel that even you don’t care about me — making fun of me.

Therapist: I wonder if other folks need to pass this test, too?

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(Beier & Young, 1984, p. 270)

Studies suggest that IPT and related interpersonal treatments for depression

have a success rate similar to that of cognitive-behavioral therapy (Lemmens et al., 2020; Swartz, 2019). That is, symptoms almost totally disappear in 50 to 60 percent of clients who receive treatment. Not surprisingly, IPT is considered especially useful for depressed people who are struggling with social conflicts or undergoing changes in their careers or social roles.

COUPLE THERAPY

As you have read, depression can result from marital discord, and recovery from

depression is often slower for people who do not receive support from their spouse (MHF, 2020). In fact, as many as half of all depressed clients may be in a dysfunctional relationship. Thus it is not surprising that many cases of depression have been treated by couple therapy, the approach in which a therapist works with two people who share a long-term relationship.

Therapists who offer integrative behavioral couples therapy combine cognitive- behavioral and sociocultural techniques to teach couples specific communication and problem-solving skills, guide them to recognize that their problematic interactions often reflect basic differences between them, and steer them to become more accepting and supportive of each other (see Chapter 3). When the depressed person’s spousal relationship is filled with conflict, this approach and similar ones may be as effective as — or even more effective than — individual cognitive-behavioral therapy, interpersonal psychotherapy, or drug

therapy in helping to reduce depression (Christensen, Doss, & Jacobson, 2020).

The Multicultural Perspective

Two kinds of relationships have captured the interest of multicultural theorists: (1) links between gender and depression, and (2) ties between cultural and ethnic

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background and depression. In the case of gender, a strong relationship has been found, but a clear explanation for that relationship has yet to emerge. The clinical field is still sorting out whether and what ties exist between cultural factors and depression.

Victimization and learned helplessness At a 2019 demonstration in Paris, participants lie on the floor

and hold placards with the names of French women who had been killed by their current or former partners

that year. Research suggests that some women who are abused by their spouses develop feelings of

helplessness, thus helping to explain why they stay in such dangerous relationships.

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GENDER AND DEPRESSION

As you have read, there is a strong link between gender and depression. Women in places as far apart as France, Sweden, Lebanon, New Zealand, and the United States are at least twice as likely as men to receive a diagnosis of unipolar depression. Why the huge difference between the sexes? A variety of theories have been offered and studied (Hyde & Mezulis, 2020; Nolen-Hoeksema, 2012,

2002, 1990).

The artifact theory holds that women and men are equally prone to depression but that clinicians often fail to detect depression in men. Perhaps depressed women display more emotional symptoms, such as sadness and crying, which

are easily diagnosed, while depressed men mask their depression behind traditionally “masculine” symptoms such as anger. Although this is a popular explanation, research indicates that women are actually no more willing or able than men to identify their depressive symptoms and to seek treatment.

The hormone explanation holds that hormone changes trigger depression in many women, particularly during puberty, pregnancy, and menopause. Research suggests, however, that the social and life events that accompany these developmental milestones are also profound and may account for experiences of depression as well as, or better than, hormone shifts. Hormone explanations have also been criticized as sexist, since they imply that a woman’s normal biology is flawed.

The life stress theory suggests that women in our society are subject to more stress than men. On average they face more poverty, more menial jobs, less adequate housing, more discrimination, and more victimization than men — all factors that have been linked to depression. And in many families, women bear a disproportionate share of responsibility for child care and housework.

The body dissatisfaction explanation states that females in Western society are taught, almost from birth, but particularly during adolescence, to seek a low

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body weight and slender body shape — goals that are unreasonable, unhealthy, and often unattainable. As you’ll read in Chapter 10, research finds that, as adolescence unfolds, girls do become more and more dissatisfied with their weight and body and, on average, display an increased rate of depression.

However, it is not clear that eating and weight concerns actually cause depression; they may instead be the result of depression.

The lack-of-control theory, which draws on the learned helplessness research, proposes that women may be more prone to depression because they feel less control than men over their lives. It has been found that victimization of any

kind, from discrimination to burglary to rape, often produces a sense of helplessness and increases the symptoms of depression — and women in our society are, on average, more likely than men to be victimized across various domains (BJS, 2019).

A final explanation for the gender differences found in depression is the rumination theory. As you read earlier, rumination is related to depression. Research reveals that women are more likely than men to ruminate when their mood darkens, perhaps making them more vulnerable to the onset of clinical depression.

Each of these explanations for the gender difference in unipolar depression offers food for thought. Each has gathered just enough supporting evidence to make it interesting and just enough evidence to the contrary to raise questions about its usefulness. Thus, at present, the gender difference in depression remains one of the most talked-about but least understood phenomena in the clinical field.

CULTURAL BACKGROUND AND DEPRESSION

Depression is a worldwide phenomenon, and certain symptoms of this disorder seem to be constant across all countries. The majority of depressed people across very different countries report symptoms of sadness, joylessness,

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tension, lack of energy, loss of interest, loss of ability to concentrate, ideas of insufficiency, and thoughts of suicide (WHO, 2020c). Beyond such core symptoms, however, research suggests that the precise picture of depression varies from country to country (Nemade, 2020; Kok et al., 2012). Depressed

people in non-Western countries — China and Nigeria, for example — are more likely to be troubled by physical symptoms such as fatigue, weakness, sleep disturbances, and weight loss. Depression in those countries is less often marked by cognitive symptoms such as self-blame, low self-esteem, and guilt.

Non-Western depression Depressed people in non-

Western countries tend to have fewer cognitive symptoms, such as self-blame, and more physical

symptoms, such as fatigue, weakness, and sleep disturbances.

Within the United States, researchers have found few differences in the symptoms of depression among members of different ethnic or racial groups.

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Nor have they found significant differences in the overall rates of depression between such minority groups. On the other hand, research reveals that there are often striking differences between ethnic/racial groups in the recurrence of depression. Hispanic Americans and African Americans are 50 percent more

likely than non-Hispanic white Americans to have recurrent episodes of depression (Krishnan, 2019). Why this difference? Around 60 percent of depressed non-Hispanic white Americans receive treatment for their disorders (medication and/or psychotherapy), compared with 36 percent of depressed Hispanic Americans and 41 percent of depressed African Americans (Alegria et al., 2015). It may be that minority groups in the United States are more vulnerable to repeated experiences of depression partly because many of their members have more limited treatment opportunities when they are depressed.

Research has also revealed that depression is distributed unevenly within some minority groups. This is not totally surprising, given that each minority group itself consists of people of varied backgrounds and cultural values. For example, depression is more common among Hispanic and African Americans born in the United States than among Hispanic and African American immigrants (MHA,

2020a; Salas-Wright et al., 2018). Moreover, within the Hispanic American population, Mexican Americans and Puerto Ricans have a higher rate of depression than do Cuban Americans and other Hispanic groups (MHA, 2020a).

Multicultural Treatments

In Chapter 3, you read that culture-sensitive therapies are designed to address the unique issues faced by members of cultural minority groups (Comas-Díaz, 2019). For such approaches, therapists typically have cultural training and a heightened

awareness of their clients’ cultural values and the culture-related stressors, prejudices, and stereotypes that their clients face. They make an effort to help clients develop a comfortable (for them) bicultural balance and to recognize the impact of their own culture and the dominant culture on their views of themselves and on their behaviors.

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Do you think culture-sensitive therapies might be more useful for some kinds of disorders than for others? Why or why not?

In the treatment of unipolar depression, culture-sensitive approaches increasingly are being combined with traditional forms of psychotherapy to help minority clients overcome their disorders (Sue et al., 2019; Chang et al., 2018). A number of today’s therapists, for example, offer cognitive-behavioral therapy for depressed minority clients while also focusing on the clients’ economic

pressures, minority identity, and related cultural issues (Salamanca-Sanabria et al., 2020; Rathod, Phiri, & Naeem, 2019). A range of studies indicate that Hispanic American, African American, American Indian, and Asian American clients are more likely to overcome their depressive disorders when a culture- sensitive focus is added to the form of psychotherapy that they are otherwise receiving (Sue et al., 2019).

Integrating the Models: The Developmental Psychopathology Perspective As with their explanations of other psychological disorders, proponents of the developmental psychopathology perspective contend that unipolar depression is caused by a combination of the factors we have been examining throughout

this chapter. Moreover, they believe that the factors unfold and intersect in a developmental sequence, with early negative factors generally setting the stage for later negative factors and ultimately for depression, but with later positive factors, called protective factors, sometimes able to offset the lingering impact of early negative factors. Such explanations of unipolar depression have received considerable research support (Lippard & Nemeroff, 2020; Meng et al., 2018).

Consistent with biological findings, developmental psychopathologists believe that the road to unipolar depression often begins with a genetically inherited

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predisposition — a predisposition that is characterized by low activity of key neurotransmitters (serotonin, norepinephrine, or glutamate) in key brain structures, an overly reactive brain–body stress route (the HPA axis), and a dysfunctional depression-related brain circuit (see pages 192–194) (Lippard &

Nemeroff, 2020; Bagot et al., 2016). Researchers from this perspective have found that such biological predispositions will most likely result in later depression if the individual is also subjected to significant losses or other traumas early in life and/or inadequate parenting, such as parenting that is disrupted, depressive in style, inconsistent, or rejecting (Dittrich et al., 2018; Wang et al., 2018). Still other studies indicate that this combination of biological and childhood factors often leads to a low self-concept, a temperament marked by guilt, a negative style of thinking, general feelings of helplessness, and

interpersonal dependence — variables that are themselves each linked to depression (Kalin, 2020; Lippard & Nemeroff, 2020; Reinfjell et al., 2016). According to developmental psychopathologists, individuals who travel through this unfavorable developmental sequence are particularly likely to become depressed when they experience stress in adult life, especially interpersonal stress (Hammen, 2018, 2016).

However, this precise sequence of intersecting factors is not the only avenue to later depression. Developmental psychopathology studies indicate, for example, that individuals who experience severe childhood traumas or inadequate parenting often develop depression when they later encounter life stress, even if they have no genetic predisposition for the disorder (Nishikawa et al., 2018). Such findings are apparently related to the two-way relationship that exists between many of these factors. Research has found, for example, that exposure

to severe traumas at key points early in life may negatively alter a child’s HPA axis and depression-related brain circuit, even if that HPA axis and brain circuit had previously been functioning properly (Lippard & Nemeroff, 2020; Palagini et al., 2019; Hammen, 2016).

At the same time, the developmental psychopathology perspective is not all gloom and doom. The presence of negative developmental factors does not

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inevitably produce a march toward depression. Studies have found, for example, that individuals who experience moderate and manageable adversities throughout their childhood often develop resilience — an important protective factor — and become better able to withstand the depressive effects of life

stress in adulthood (Easterlin et al., 2019; Oldehinkel et al., 2014). One study even found that participants who had repeatedly experienced moderate adversities throughout their lives were less likely to become depressed in the face of significant life stress than were participants who had faced little or no adversity in their lives (Seery, Holman, & Silver, 2010).

Born to run “The Boss,” Bruce Springsteen, performs

at a sold-out concert while his image is projected on a mega-screen behind him. In his 2016 memoir Born to

Run, Springsteen detailed his long history of depression, describing one episode as “a freight train

bearing down … running quickly out of track.”

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Bipolar Disorders

PEOPLE WITH A BIPOLAR disorder experience both the lows of depression and the highs of mania. Many describe their lives as an emotional roller coaster, as they shift back and forth between extreme moods. A number of sufferers become suicidal. Approximately 10 to 15 percent of them eventually end their own lives, usually out of a sense of hopelessness (Suppes, 2020). Their roller- coaster ride also has a dramatic impact on relatives and friends.

What Are the Symptoms of Mania? Unlike people sunk in the gloom of depression, those in a state of mania typically experience dramatic and inappropriate rises in mood. The symptoms of mania span the same areas of functioning — emotional, motivational, behavioral, cognitive, and physical — as those of depression, but mania affects those areas in an opposite way.

A person in the throes of mania has active, powerful emotions in search of an outlet. The mood of euphoric joy and well-being is out of all proportion to the

actual happenings in the person’s life. Not every person with mania is a picture of happiness, however. Some instead become very irritable and angry, especially when others get in the way of their exaggerated ambitions.

In the motivational realm, people with mania seem to want constant excitement,

involvement, and companionship. They enthusiastically seek out new friends and old, new interests and old, and have little awareness that their social style is overwhelming, domineering, and excessive.

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The behavior of people with mania is usually very active. They move quickly, as though there were not enough time to do everything they want to do. They may talk rapidly and loudly, their conversations filled with jokes and efforts to be clever or, conversely, with complaints and verbal outbursts. Flamboyance is not

uncommon: dressing in flashy clothes, giving large sums of money to strangers, or even getting involved in dangerous activities.

In the cognitive realm, people with mania usually show poor judgment and planning, as if they feel too good or move too fast to consider possible pitfalls. Filled with optimism, they rarely listen when others try to slow them down,

interrupt their buying sprees, or prevent them from investing money unwisely. They may also hold an inflated opinion of themselves, and sometimes their self- esteem approaches grandiosity. During severe episodes of mania, some have trouble remaining coherent or in touch with reality.

Finally, in the physical realm, people with mania feel remarkably energetic. They typically get little sleep, yet feel and act wide awake (Suppes, 2020). Even if they miss a night or two of sleep, their energy level may remain high.

Diagnosing Bipolar Disorders People are considered to be in a full manic episode when for at least one week they display an abnormally high or irritable mood, increased activity or energy, and at least three other symptoms of mania (see Table 7-4). The episode may even include psychotic features such as delusions or hallucinations. When the symptoms of mania are less severe (causing little impairment), the person is said

to be having a hypomanic episode.

TABLE: 7-4

Checklist

Manic Episode

1. For 1 week or more, person displays a continually abnormal, inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day.

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2. Person also experiences at least three of the following symptoms: Grandiosity or overblown self-esteem Reduced sleep need Increased talkativeness, or drive to continue talking Rapidly shi�ing ideas or the sense that one’s thoughts are moving very fast Attention pulled in many directions Heightened activity or agitated movements Excessive pursuit of risky and potentially problematic activities.

3. Significant distress or impairment.

Bipolar I Disorder

1. Occurrence of a manic episode.

2. Hypomanic or major depressive episodes may precede or follow the manic episode.

Bipolar II Disorder

1. Presence or history of major depressive episode(s).

2. Presence or history of hypomanic episode(s).

3. No history of a manic episode.

Information from: APA, 2022.

“Sometimes Mommy cries” Lawyer and social worker Loran Kundra reads and laughs with her daughters at their home in Pennsylvania. Kundra, who has a bipolar

disorder, is co-founder of a program called Child and Family Connections, which helps parents with psychological disorders effectively discuss their disorders with

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their children. During one depressive episode, Kundra explained to her daughter, “Sometimes Mommy cries and gets upset just the way that you cry and get upset.”

DSM-5-TR distinguishes two kinds of bipolar disorders — bipolar I and bipolar II.

People with bipolar I disorder have full manic and major depressive episodes. Most of them experience an alternation of the episodes; for example, weeks of mania followed by a period of wellness, followed in turn by an episode of depression. Some, however, have mixed features, in which they display both manic and depressive symptoms within the same episode — for example, having racing thoughts amidst feelings of extreme sadness. In bipolar II disorder, hypomanic — that is, mildly manic — episodes alternate with major depressive episodes over the course of time. Some people with this pattern

accomplish huge amounts of work during their mild manic periods (see PsychWatch). In both bipolar I and bipolar II disorders, the individual’s depressive episodes usually are more frequent and last longer than the manic episodes (Baldessarini, Vázquez, & Tondo, 2020).

PSYCHWATCH Abnormality and Creativity: A Delicate Balance

The ancient Greeks believed that various forms of “divine madness” inspired creative acts,

from poetry to performance. Even today many people expect “creative geniuses” to be

psychologically disturbed. A popular image of the artist includes a glass of liquor, a cigarette, and a

tormented expression. Classic examples include writer William Faulkner, who suffered from

alcoholism and received electroconvulsive therapy for depression; poet Sylvia Plath, who was

depressed for most of her life and eventually died by suicide at age 31; and ballet dancer Vaslav

Nijinsky, who suffered from schizophrenia and spent many years in institutions. In fact, a number of

studies indicate that artists and writers are somewhat more likely than others to suffer from certain

mental disorders, particularly bipolar disorders (Greenwood, 2020).

Why might creative people be prone to such psychological disorders? Some may be genetically

predisposed to such disorders long before they begin their artistic careers (Greenwood, 2020).

Indeed, creative people o�en have a family history of psychological problems (Ehrenfeld, 2019;

Parnas et al., 2019). A number also have experienced intense psychological trauma during childhood

(Zsedel, 2019). English writer Virginia Woolf, for example, endured sexual abuse as a child.

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A second explanation for the link between creativity and psychological disorders is that the creative

professions offer a welcome climate for those with psychological disturbances. In the worlds of

poetry, painting, and acting, for example, emotional expression, unusual thinking, and/or personal

turmoil are valued as sources of inspiration and success (Collingwood, 2016).

Much remains to be learned about the relationship between emotional turmoil and creativity, but

work in this area has already clarified two important points. First, psychological disturbance is

hardly a requirement for creativity. Most “creative geniuses” are, in fact, psychologically stable and

happy throughout their entire lives (Rothenberg, 2015). Second, mild psychological disturbances

relate to creative achievement much more strongly than severe disturbances do (Ehrenfeld, 2019).

For example, nineteenth-century composer Robert Schumann produced 27 works during one

hypomanic year but next to nothing during years when he was severely depressed and suicidal

(Jamison, 1995a).

Some artists worry that their creativity would disappear if their psychological suffering were to stop.

In fact, however, research suggests that successful treatment for severe psychological disorders

more o�en than not improves the creative process (Rothenberg, 2015). Romantic notions aside,

severe mental dysfunction has little redeeming value, in the arts or anywhere else.

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Kanye’s “superpower” Fans and the media have long speculated about the

mental state of the enigmatic musical artist Kanye West, speaking here at the 2015 MTV Video Music Awards. In his Ye album and related interviews, West

himself hinted at a diagnosis of bipolar disorder and suggested that his bipolar functioning enhances his creativity and serves as a kind of “superpower.”

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Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder. If a person has four or more episodes within a one-year period, their disorder is considered to be rapid cycling. A woman describes her rapid cycling in the following excerpt, taken from a journal article she wrote

anonymously several years ago.

My mood may swing from one part of the day to another. I may wake up low at 10 am, but be high and

excitable by 3 pm. I may not sleep for more than 2 hours one night, being full of creative energy, but by

midday be so fatigued it is an effort to breathe.

If my elevated states last more than a few days, my spending can become uncontrollable…. I will

sometimes drive faster than usual, need less sleep and can concentrate well, making quick and

accurate decisions. At these times I can also be sociable, talkative and fun, focused at times, distracted

at others. If this state of elevation continues I o�en find that feelings of violence and irritability towards

those I love will start to creep in….

My thoughts speed up…. I frequently want to be able to achieve several tasks at the same moment….

Physically my energy levels can seem limitless. The body moves smoothly, there is little or no fatigue. I

can go mountain biking all day when I feel like this and if my mood stays elevated not a muscle is sore

or stiff the next day. But it doesn’t last, my elevated phases are short…. [T]he shi� into severe

depression or a mixed mood state occurs sometimes within minutes or hours, o�en within days and will

last weeks o�en without a period of normality….

Initially my thoughts become disjointed and start slithering all over the place…. I start to believe that

others are commenting adversely on my appearance or behaviour…. My sleep will be poor and

interrupted by bad dreams…. The world appears bleak…. I become repelled by the proximity of people

… I will be overwhelmed by the slightest tasks, even imagined tasks…. Physically there is immense

fatigue: my muscles scream with pain…. Food becomes totally uninteresting….

I start to feel trapped, that the only escape is death…. I become passionate about one subject only at

these times of deep and intense fear, despair and rage: suicide…. I have made close attempts on my life

… over the last few years….

Then inexplicably, my mood will shi� again. The fatigue drops from my limbs like shedding a dead

weight, my thinking returns to normal, the light takes on an intense clarity, flowers smell sweet and my

mouth curves to smile at my children, my husband and I are laughing again. Sometimes it’s for only a

day but I am myself again, the person that I was a frightening memory. I have survived another bout of

this dreaded disorder….

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(Anonymous, 2006)

of NOTE … Frenzied Masterpiece

George Frideric Handel wrote his Messiah in less than a month during a manic episode (Roesch,

1991).

Surveys indicate that between 1 and 2.8 percent of all adults suffer from a

bipolar disorder at any given time (NIMH, 2020i, 2017g; Stovall, 2020). As many as 4.4 percent experience one of the bipolar disorders at some point in their life. Bipolar disorders are equally common in women and men, but they are more common among people with low incomes than those with higher incomes (Bressert, 2018; Sareen et al., 2011). Onset usually occurs between the ages of 15 and 44 years (Stovall, 2020). In most untreated cases, the manic and depressive episodes eventually subside, only to recur at a later time.

Some people have numerous periods of hypomanic symptoms and mild depressive symptoms, a pattern that is called cyclothymic disorder in DSM-5- TR. The symptoms of this milder form of bipolar disorder continue for 2 or more years, interrupted occasionally by normal moods that may last for only days or weeks. This disorder, like bipolar I and bipolar II disorders, usually begins in

adolescence or early adulthood and is equally common among women and men. At least 0.4 percent of the population develops cyclothymic disorder. In some cases, the milder symptoms eventually blossom into a bipolar I or bipolar II disorder.

What Causes Bipolar Disorders? Biological research has produced some promising — though limited thus far — clues about the causes of bipolar disorders. The biological insights have come

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from studies into neurotransmitter activity, ion activity, brain structure and circuitry, and genetic factors.

Neurotransmitters

Could abnormal activity of neurotransmitters be related to bipolar disorders? This was the expectation of clinicians back in the 1960s after investigators first found a relationship between low norepinephrine activity and unipolar depression (Schildkraut, 1965). And indeed, over the years, a number of studies have found abnormal activity of neurotransmitters — norepinephrine, serotonin, glutamate, and dopamine — in the brains of people with bipolar disorders (Kato, 2019; Purse, 2019). But the kind of abnormal neurotransmitter activity has varied from study to study (sometimes high and sometimes low,

sometimes one neurotransmitter and sometimes another), leaving most of today’s theorists unconvinced that neurotransmitters directly cause bipolar disorders.

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Marvel heroes trying to cope In Issue No. 5 of the Unstoppable Wasp, a Marvel Comics series, the title

hero comes to the realization “I think I’m bipolar … and I don’t think I can handle this alone.” According to the storyline, her father, Ant-Man, also displayed a

bipolar disorder.

Ion Activity

While neurotransmitters play a significant role in the communication between neurons, ions seem to play a critical role in relaying messages within a neuron. That is, ions help transmit messages down the neuron’s axon to the nerve endings. Positively charged sodium ions (Na ) sit on both sides of a neuron’s cell membrane. When the neuron is at rest, more sodium ions sit outside the membrane. When the neuron receives an incoming message at its receptor sites, pores in the cell membrane open, allowing the sodium ions to flow to the

+

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inside of the membrane, thus increasing the positive charge inside the neuron. This starts a wave of electrical activity that travels down the length of the neuron and results in its “firing.”

If messages are to be relayed effectively down the axon, the sodium ions and nearby ions must be able to travel easily between the outside and the inside of the neural membrane. Some studies suggest that, among bipolar individuals, irregularities in the transport of these ions may cause neurons to fire too easily (resulting in mania) or to stubbornly resist firing (resulting in depression) (Mack et al., 2019).

Brain Structure and Circuitry

Brain-imaging studies have identified a number of abnormal brain structures in people with bipolar disorders (Stovall, 2020; Dusi et al., 2019; Kato, 2019). For example, the hippocampus, basal ganglia, and cerebellum of these individuals tend to be smaller than those of other people; they have lower amounts of gray matter in the brain; and their raphe nuclei, striatum, amygdala, and prefrontal cortex have some structural abnormalities. It is not clear what role such

abnormalities play in bipolar disorders. Some researchers believe that they collectively reflect dysfunction throughout a bipolar-related brain circuit (Gong et al., 2019). It may also be that they are related to the brain’s depression-related circuit that you read about earlier (see pages 193–194).

of NOTE … Higher Risk

The risk of developing bipolar disorder is six times higher for children of older men (over 45 years

when their children were born) than children of young men (20−24 years). Why? One theory is that, as

men age, they produce increased genetic mutations during the manufacture of sperm cells (Stovall, 2020; Chudal et al., 2014).

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Genetic Factors

Many theorists believe that people inherit a biological predisposition to develop bipolar disorders (Stovall, 2020). Family pedigree studies support this idea. Identical twins of those with a bipolar disorder have a 40 to 70 percent likelihood of developing the same disorder, and fraternal twins, siblings, and other close relatives of such persons have a 5 to 10 percent likelihood, compared with the 1 to 2.8 percent prevalence rate in the general population.

Researchers have also used techniques from molecular biology to more directly examine possible genetic factors in large families. Their work has linked bipolar disorders to a variety of genes located on at least 13 different chromosomes (Stovall, 2020; Kato, 2019). Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders.

What Are the Treatments for Bipolar Disorders? Until the latter part of the twentieth century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster. Psychotherapists reported almost no success, and early antidepressant drugs were of limited help. In fact, those drugs sometimes triggered a manic episode (Baldessarini et

al., 2020).

Mood-Stabilizing Drugs and Strategies

This gloomy picture changed dramatically in 1970 when the FDA approved the use of lithium, a silvery-white element found in various simple mineral salts throughout the natural world, as a treatment for bipolar disorder. It was lithium that first brought hope to those suffering from bipolar disorder. In her widely read memoir, An Unquiet Mind, psychiatric researcher Kay Redfield Jamison

describes how lithium, combined with psychotherapy, enabled her to overcome bipolar disorder:

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I took [lithium] faithfully and found that life was a much stabler and more predictable place than I

had ever reckoned. My moods were still intense and my temperament rather quick to the boil, but I

could make plans with far more certainty and the periods of absolute blackness were fewer and less

extreme….

At this point in my existence, I cannot imagine leading a normal life without both taking lithium and

having had the benefits of psychotherapy. Lithium prevents my seductive but disastrous highs,

diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me

down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital,

alive, and makes psychotherapy possible. [At the same time], ineffably, psychotherapy heals. It makes

some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and

hope and possibility of learning from it all…. No pill can help me deal with the problem of not wanting

to take pills; likewise, no amount of psychotherapy alone can prevent my manias and depressions. I

need both….

(Jamison, 1995b)

of NOTE … Misdiagnosed

More than one-third of people with a bipolar disorder do not receive the correct diagnosis until 10 or

more years a�er first seeking treatment (Suppes, 2020).