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Abnormal Psychology: Past and Present

chapter one

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Abnormal Psychology: Past and Present

What is ABNORMAL PSYCHOLOGY?

Scientific study of abnormal behavior in an effort to describe, predict, explain, and change abnormal patterns of functioning

Workers in the field may be:

Clinical scientists

Clinical practitioners

When did these and similar words (including slang terms) make their debut in print as expressions of psychological dysfunction?

The Oxford English Dictionary offers the above terms and dates.

VERBAL DEBUTS

There was a time not that long ago when terms used today did not exist.

PSYCH WATCH

What Is Psychological Abnormality?

Many definitions have been proposed, yet none has won total acceptance

Most definitions, however, have four features in common: “The Four Ds”

DEVIANCE

DISTRESS

DYSFUNCTION

DANGER

While this definition is a useful starting point, it has key limitations

DEVIANCE – Different, extreme, unusual, perhaps even bizarre

DISTRESS – Unpleasant and upsetting to the person

DYSFUNCTION – Interfering with the person’s ability to conduct daily activities in a constructive way

DANGER – Posing risk of harm

Common Features of Psychological Abnormality

From what?

From behaviors, thoughts, and emotions that differ markedly from a society’s ideas about proper functioning

From SOCIAL NORMS

Stated and unstated rules for proper conduct

Abnormal behavior tends to be dysfunctional – it interferes with daily functioning

Here again culture plays a role in the definition of abnormality

Abnormal behavior may become dangerous to oneself or others

Behavior may be consistently careless, hostile, or confused

Although often cited as a feature of psychological abnormality, research suggests that dangerousness is the exception rather than the rule

Examples?

Judgments of abnormality vary from society to society as norms grow from a particular culture

They also depend on specific circumstances

Examples?

According to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they can be labeled abnormal

Not always the case

Examples?

Deviance

From what?

Distress

Behavior, ideas, or emotions

Dysfunction

Abnormal behavior tends to interfere with daily functioning

SOCIAL NORMS and societal values

Specific circumstances or context

Usually have to cause distress before being labeled abnormal

Culture plays a role

Danger

Dangerous to oneself or others

May be exception rather than the rule

MARCHING TO A DIFFERENT DRUMMER: ECCENTRICS

Eccentrics

Deviate from common behavior patterns or display odd or whimsical behavior (Dictionary)

Possess many common characteristics: Nonconformity, creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being different, high intelligence, outspokenness, disinterests in others, noncompetitiveness, unusual eating and living habits, eldest or only child, poor spelling skills (Weeks and others)

Do not typically suffer from mental disorders or severely disrupted thought processes (Weeks)

Lady Gaga

Musical Eccentric?

PSYCH WATCH

The Elusive Nature of Abnormality

A society selects general criteria for defining abnormality and then uses those criteria to judge particular cases

Szasz finds the concept of mental illness to be invalid, a myth of sorts

Do you know why?

Szasz finds the concept of mental illness to be invalid, a myth of sorts.

Deviations called “abnormal” are only “problems of living.”

Societies invent the concept of mental illness to better control or change people who threaten social order.

The Elusive Nature of Abnormality

Even if we assume that psychological abnormality is a valid concept

Our definition may not be applied consistently

Criteria often are vague and subjective

Few categories of abnormality are clear-cut; most continue to be debated by clinicians

Although abnormality generally is defined as behavior that is deviant, distressful, dysfunctional, and sometimes dangerous, these criteria often are vague and subjective.

Examples:

Diagnosis of alcohol problems in colleges

Issue of abnormality versus eccentricity

What Is Treatment?

TREATMENT, OR THERAPY

Procedure designed to change abnormal behavior into more normal behavior

Clinical treatment requires a careful definition

Carl Rogers

Jerome Frank

Others

Once clinicians decide that a person is suffering from abnormality, they seek to treat it.

Treatment requires careful definition.

Carl Rogers

“Therapists are not in agreement as to their goals or aims. . . . They are not in agreement as to what constitutes a successful outcome of their work. They cannot agree as to what constitutes a failure. It seems as though the field is completely chaotic and divided.”

According to Jerome Frank, all forms of therapy have three essential features:

A sufferer who seeks relief from the healer

A trained, socially accepted healer, whose expertise is accepted by the sufferer and his or her social group

A series of contacts between the healer and the sufferer, through which the healer tries to produce certain changes in the sufferer’s emotional state, attitudes, and behavior

Others

Abnormality as illness: therapy cures

Abnormality as problem in living: therapy teaches

Clinical treatment is surrounded by conflict and confusion:

Lack of agreement about goals or aims

Lack of agreement about successful outcome

Lack of agreement about failure

Are clinicians seeking to cure? To teach?

Are sufferers patients (ill) or clients (having difficulty)?

What Is Treatment?

But…despite their differences, most clinicians agree that large numbers of people need therapy of one kind or another

Evidence also indicates that therapy is indeed often helpful

How Was Abnormality Viewed and Treated in the Past?

In any given year as many as 30 percent of adults and 19 percent of children and adolescents in the United States display serious psychological disturbances and are in need of clinical treatment

In addition, most people have difficulty coping at various times

Is this the fault of modern society?

Although modern pressures may contribute, they are hardly the primary cause; every society, past and present, has witnessed psychological abnormality.

How Was Abnormality Viewed and Treated in the Past?

Many present-day ideas and treatments have roots in the past

Let’s take a look on the next slides

Ancient Views and Treatments

Ancient societies probably regarded abnormal behavior as the work of evil spirits

Treatment for severe abnormality was to force the demons from the body through trephination and exorcism

The two holes in this skull recovered from ancient times indicate that the person underwent trephination

Ancient societies probably regarded abnormal behavior as the work of evil spirits.

This view may have begun as far back as the Stone Age.

Greek and Roman Views and Treatments

500 B.C. to 500 A.D.

Philosophers and physicians offered different explanations and treatments for abnormal behaviors

Hippocrates believed and taught that illnesses had natural causes

Looked to an imbalance of the four fluids, or humors

Sought to correct the underlying physical pathology

To treat psychological dysfunction, Hippocrates sought to correct the underlying physical pathology.

Four fluids, or humors, that flowed through the body: yellow bile, black bile, blood, and phlegm

Europe in the Middle Ages: Demonology Returns

500 – 1350 A.D.

The church rejected scientific forms of investigation and religious beliefs dominated all aspects of life

Abnormality greatly increased, was seen as a conflict between good and evil, and often subject to demonological treatment

At the end of the Middle Ages

Demonology and its methods began to lose favor again

500 – 1350 A.D.

The church rejected scientific forms of investigation and controlled all education.

Religious beliefs dominated all aspects of life.

Once again, abnormality was seen as a conflict between good and evil.

Abnormal behavior apparently increased greatly during this period.

Some of the earlier demonological treatments reemerged.

The Renaissance and the Rise of Asylums

1400 – 1700 A.D.

Demonological views of abnormality continued to decline

German physician Johann Weyer believed that the mind was as susceptible to sickness as the body

The care of people with mental disorders continued to improve in this atmosphere

The Renaissance and the Rise of Asylums

Shrines

Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders

Asylums

There was a rise of asylums where the mentally ill became virtual prisoners due to overcrowding

The “crib”

Outrageous devices and techniques, such as the “crib,” were used in asylums, and some continued to be used even during the reforms of the nineteenth

century.

Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders.

One, at Gheel, became a community mental health program of sorts.

Unfortunately, this time also saw a rise of asylums – institutions whose primary purpose was care of the mentally ill.

The intention was good care, but because of overcrowding they became virtual prisons.

The Nineteenth Century: Reform and Moral Treatment

As 1800 approached

Treatment of people with mental disorders began to improve once again

Advocacy for more moral treatment emerged

Pinel (France) and Tuke (England)

Benjamin Rush and Dorothea Dix (U.S.)

By the end of the nineteenth century, reversal of the moral treatment movement began

Pinel (France) and Tuke (England) advocated moral treatment – care that emphasized moral guidance and humane and respectful techniques.

In the United States, Benjamin Rush (father of American psychiatry) and Dorothea Dix (Boston schoolteacher) were the primary proponents of moral treatment.

Dix’s work led to the creation of state hospitals.

By the end of the nineteenth century, several factors led to a reversal of the moral treatment movement:

Money and staff shortages

Declining recovery rates

Overcrowding

Emergence of prejudice

The Early Twentieth Century: Dual Perspectives

As the moral movement was declining in the late 1800s, two opposing perspectives emerged

By the early years of the twentieth century

The moral treatment movement had ground to a halt; long-term hospitalization became the rule once again

As the moral movement was declining in the late 1800s, two opposing perspectives emerged

The Somatogenic Perspective

Abnormal functioning has physical causes

The Psychogenic Perspective

Abnormal functioning has psychological causes

The Early Twentieth Century: The Somatogenic Perspective

Two factors were responsible for the rebirth of this perspective

Argument that physical factors (such as fatigue) are responsible for mental dysfunction

New biological discoveries

Biological approaches yielded mostly disappointing and sometimes immoral solutions

Eugenics

A number of effective medications were finally discovered

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

Two factors were responsible for the rebirth of this perspective:

Emil Kraepelin’s textbook argued that physical factors (such as fatigue) are responsible for mental dysfunction

New biological discoveries were made, such as the link between untreated syphilis and general paresis

Biological approaches yielded mostly disappointing results throughout the first half of the twentieth century.

A number of effective medications were finally discovered.

See Table 1.1 for additional information about eugenics and mental disorders.

The Early Twentieth Century: The Psychogenic Perspective

Perspective was based on work of

Friedrich Mesmer and hysterical disorders

Recent research has clarified, however, that hypnotic procedures are as capable of creating false memories as they are of uncovering real memories.

Hypnotism

Perspective based on work of

Breuer

Psychoanalysis

Perspective holds that many forms of abnormal and normal psychological function are psychogenic

Mesmer and hysterical disorders

Recent research

Hypnotic procedures are as capable of creating false memories as they are of uncovering real memories

Freud

Unconscious psychological processes

Techniques of psychoanalysis developed

Current Trends

This not yet a period of great enlightenment about or dependable treatment of mental disorders

43 percent of people surveyed believe that people bring mental health disorders upon themselves

35 percent consider mental health disorders to be caused by sinful behavior

Past half century has brought major changes in the ways clinicians understand and treat abnormal functioning—and more disagreements

How Are People with Severe Disturbances Cared For?

In the 1950s, researchers discovered a number of new psychotropic medications

Antipsychotic drugs

Antidepressant drugs

Antianxiety drugs

These discoveries led to deinstitutionalization and a rise in outpatient care

This change in care was not without problems

Can you identify any of these problems?

The impact of deinstitutionalization in the United States

As a result, hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets.

At least 100,000 people with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons. Their abandonment is truly a national disgrace.

The approach has been helpful for many patients, but too few community programs are available in the United States; only 40 to 60% of those with severe disturbances receive treatment of any kind

Figure 1-1

The impact of deinstitutionalization

The number of patients (fewer than 40,000) now hospitalized in public mental hospitals in the United States is a small fraction of the number hospitalized in 1955. (Information from: Althouse, 2010; Torrey, 2001; Lang, 1999.)

How Are People with Less Severe Disturbances Treated?

Since the 1950s

Outpatient care has continued to be the preferred mode of treatment for those with moderate disturbances

Once exclusive to private psychotherapy

Now covered by most health insurance plans

Includes various settings and specialty care

How Are People with Less Severe Disturbances Treated?

Surveys suggest

Nearly 1 in 6 adults in the United States receives treatment for psychological disorders in the course of a year

Majority receive fewer than 5 sessions

Outpatient treatments are becoming available for more kinds of problems

Some outpatient care is devoted exclusively to one kind of psychological problem

A Growing Emphasis on Preventing Disorders and Promoting Mental Health

The community mental health approach has given rise to the prevention movement

Correct the social conditions that underlie psychological problems

Help individuals at risk for developing disorders

Prevention programs have been further energized by the growing interest in POSITIVE PSYCHOLOGY

A Growing Emphasis on Preventing Disorders and Promoting Mental Health

POSITIVE PSYCHOLOGY

Clinical practitioners teach people coping skills that may

Help protect them from stress

Encourage them to pursue psychological wellness, meaningful activities, and enriching relationships

Prevent mental disorders

Positive psychology in action

POSITIVE PSYCHOLOGY is the study and promotion of positive feelings such as optimism and happiness, positive traits like hard work and wisdom, positive abilities, and group-directed virtues, including altruism and tolerance.

Multicultural Psychology

In response to growing diversity in the United States, MULTICULTURAL PSYCHOLOGY has emerged

MULTICULTURAL PSYCHOLOGISTS seek to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders may differ psychologically

The Increasing Influence of Insurance Coverage

Today the dominant form of insurance coverage is the MANAGED CARE PROGRAM

At least 75 percent of all privately insured persons in the United States are enrolled in managed care programs

Reimbursements for mental disorders tend to be lower than those for medical disorders

Legislation

U.S. Congress federal parity law (2008)

Affordable Care Act (ACA/2014)

MANAGED CARE PROGRAM – A program in which the insurance company determines key care issues

Reimbursements for mental disorders tend to be lower than those for medical disorders; this places persons with psychological difficulties at a distinct disadvantage.

It is not yet clear whether such provisions in the legislation mentioned above will in fact result in better treatment for people with psychological problems.

What Are Today’s Leading Theories

One of the most important developments in the field of abnormal psychology is growth of numerous THEORETICAL PERSPECTIVES

Psychoanalytic

Biological

Behavioral

Cognitive

Humanistic-existential

Sociocultural

At present, no single perspective dominates the clinical field

What Are Today’s Leading Professions?

In addition to multiple perspectives, a variety of professionals now offer help to people with psychological problems

How many can you identify?

Psychiatrists

Clinical psychologists

Counseling psychologists

Educational and school psychological psychologists

Psychiatric nurses

Marriage therapists

Family therapists

Psychiatric social workers

Profiles of Mental Health Professionals in the United States

	Degree	Began to Practice	Current Number	Average Annual Salary	Percent Female
Psychiatrists	MD, DO	1840s	50,000	$144,020	25
Psychologists	PhD, PsyD, EdD	Late 1940s	174,000	$63,000	52
Social workers	MSW, DSW	Early 1950s	607,000	$43,040	77
Counselors	Various	Early 1950s	475,000	$47,530	90

Table 1-2

Technology and Mental Health

Effects of technological change on mental health and psychological dysfunction

Provision of new triggers and tools for abnormal behaviors

Negative consequences of violent media

Contributions to cognitive difficulties

Development and growth of CYBERTHERAPY (offered by professionals and non-professionals)

MIND TECH

How can consumers optimize the chance of good outcomes when using a mental health app today?

New tools for stalking or bullying others, sexual exhibitionism, and pedophilic desires

CYBERTHERAPY The use of computer technology, such as Skype or avatars, to provide therapy. In the absence of regulation and proper research, consumers and therapists alike would be wise to investigate the reputation, manufacturer, content, and therapeutic principles of apps that they are considering.

What Do Clinical Researchers Do?

Clinical researchers face certain challenges that make their work very difficult

They work to discover universal laws, or principles, of abnormal psychological functioning

Search for NOMOTHETIC UNDERSTANDING

Typically do not assess, diagnose, or treat individual clients

Rely on the scientific method to pinpoint relationships between variables

Search for NOMOTHETIC UNDERSTANDING

General or universal laws or truths

Clinical researchers face certain challenges that make their work very difficult:

Measuring unconscious motives

Assessing private thoughts

Monitoring mood changes

Calculating human potential

Clinical researchers must consider different cultural backgrounds, races, and genders of the people they study.

They must always ensure that the rights of their research participants, both human and animal, are not violated.

What Do Clinical Researchers Do?

Three methods of investigation are used to form and test hypotheses and to draw broad conclusions

Case study

Correlational method

Experimental method

The Case Study

Freud’s theories based mainly on case studies

Limitations addressed by the two other methods of investigation

Definition: Case study

Provides a detailed, interpretative description of a person’s life and psychological problems

Advantages

Can be a source of new ideas about behavior

May offer tentative support for a theory

May challenge a theory’s assumptions

May inspire new therapeutic techniques

May offer opportunities to study unusual problems

Limitations

May include reports by biased observers

Relies on subjective evidence

Provides little basis for generalization

The Correlational Method

Freud’s theories are based mainly on case studies.

Limitations are addressed by the two other methods of investigation.

Preferred method of clinical investigation

Typically involve observing many individuals

Researchers apply procedures uniformly

Studies can be replicated

Researchers use statistical tests to analyze results.

Correlations can be trusted based on a STATISTICAL ANALYSIS OF PROBABILITY.

They ask how likely it is that the study's particular findings have occurred by chance.

Definitions

CORRELATION is the degree to which events or characteristics vary with each other

Advantages

Can be trusted based on STATISTICAL ANALYSIS OF PROBABILITY

Measures variables, observes participants, and applies statistical analyses

Limitations

Does not explain the relationship

CORRELATIONAL METHOD is a research procedure used to determine the “co-relationship” between variables

Can repeat studies with new samples to check earlier study results and generalize findings

Does not explain causation

Can determine co-relationships between variables

Correlations

Relationships

When variables change the same way, their correlation is said to have a POSITIVE direction.

In a NEGATIVE correlation, the value of one variable increases as the value of the other variable decreases.

Variables also may be UNRELATED, meaning there is no consistent relationship between them.

The magnitude (strength) of a correlation is also important.

HIGH MAGNITUDE = variables that vary closely together

LOW MAGNITUDE = variables that do not vary as closely together

Direction and magnitude of a correlation are often calculated numerically.

This statistic is the “CORRELATION COEFFICIENT.”

The correlation coefficient can vary from +1.00 (perfect positive correlation) to -1.00 (perfect negative correlation).

SIGN (+ or -) indicates direction.

NUMBER indicates magnitude.

0.00 = no consistent relationship

Most correlations found in psychological research fall far short of “perfect.”

Correlational relationships

POSITIVE correlation

NEGATIVE correlation

UNRELATED correlation

Correlational strength or magnitude

HIGH MAGNITUDE

LOW MAGNITUDE

Correlational numerical calculation

CORRELATION COEFFICIENT

Perfect positive correlation to perfect negative correlation

SIGN

NUMBER

Special Forms of Correlational Research

EPIDEMIOLOGICAL STUDIES

Reveal the incidence and prevalence of a disorder in a particular population

INCIDENCE

PREVALENCE

Epidemiologic Catchment Area Study

LONGITUDINAL STUDIES

Involve observation of same individuals on many occasions over a long period

Incidence = Number of new cases that emerge in a given period

Prevalence = Total number of cases in a given period

Over the past 40 years, clinical researchers throughout the United States have worked on one of the largest epidemiological studies of mental disorders ever conducted, called the Epidemiologic Catchment Area Study.

Most Investigated Correlational Questions in Clinical Research

Most Common Correlational Questions

Are stress and onset of mental disorders related?

Is culture (or gender or race) generally linked to mental disorders?

Are income and mental disorders related?

Are social skills tied to mental disorders?

Is social support tied to mental disorders?

Are family conflict and mental disorders related?

Is treatment responsiveness tied to culture?

Which symptoms of a disorder appear together?

How common is a disorder in a particular population?

Twins, Correlation, and Inheritance

Correlational studies of many pairs of twins have suggested a link between genetic factors and certain psychological disorders. Identical twins (who have identical genes) display a higher correlation for some disorders than do fraternal twins (whose genetic makeup is not identical).

These healthy twin sisters are participating in a twin cultural festival at Honglingjin Park in Beijing, China.

The Experimental Method

EXPERIMENT is a research procedure in which a variable is manipulated and the manipulation’s effect on another variable is observed

INDEPENDENT variable

DEPENDENT variable

Questions about causal relationships can only be answered by an experiment

Manipulated variable = INDEPENDENT variable

Variable being observed = DEPENDENT variable

Experimental method allows researchers to ask questions such as: Does a particular therapy relieve the symptoms of a particular disorder?”

The Experimental Method

Statistics and research design are very important

Researchers must try to eliminate all CONFOUNDS

Three features are included in experiments to guard against confounds:

Control group

Random assignment

Bias, blind, and double-blind design

Researchers must try to eliminate all CONFOUNDS – variables other than the independent variable that may also be affecting the dependent variable.

A CONTROL GROUP is a group of research participants who are not exposed to the independent variable, but whose experience is similar to that of the experimental group.

By comparing the two groups, researchers can better determine the effect of the independent variable.

Researchers must also watch out for differences in the makeup of the experimental and control groups.

To do so, researchers use RANDOM ASSIGNMENT – any selection procedure that ensures that every participant in the experiment is as likely to be placed in one group as in another.

A final confound problem is bias.

To avoid bias by the participant, experimenters employ a “BLIND DESIGN,” in which participants are kept from knowing which assigned group (experimental or control) they are in.

One strategy for this is providing a PLACEBO – something that simulates real therapy but has none of its key ingredients.

To avoid bias by the experimenter, experimenters employ a “DOUBLE-BLIND DESIGN,” in which the experimenters and the participants are kept from knowing which condition of the study participants are in.

Often used in medication trials

Alternative Experimental Designs

It is not easy to devise an experiment that is both well controlled and enlightening

Clinical researchers often must settle for designs that are less than ideal

QUASI-EXPERIMENTAL, or MIXED, DESIGNS

NATURAL EXPERIMENTS

ANALOGUE EXPERIMENTS

SINGLE-SUBJECT EXPERIMENTS

REVERSAL DESIGN

Can you give an example for each of these?

In QUASI-EXPERIMENTAL, or MIXED, DESIGNS, investigators do not randomly assign participants to groups, but make use of groups that already exist.

Example: Children with a history of child abuse

To address the problem of confounds, researchers use MATCHED CONTROL GROUPS.

These groups are “matched” to the experimental group based on demographic and other variables.

In NATURAL EXPERIMENTS, nature manipulates the independent variable and the experimenter observes the effects.

Example: Psychological impact of flooding

ANALOGUE EXPERIMENTS allow investigators to freely manipulate independent variables while avoiding ethical and practical limitations.

They induce laboratory subjects to behave in ways that seem to resemble real life.

Example: Animal subjects

In a SINGLE-SUBJECT EXPERIMENT, a single participant is observed both before and after manipulation of an independent variable.

An example is the ABAB, or reversal, design.

In an ABAB (REVERSAL) DESIGN

Participant’s reactions are measured during a baseline period (A), after the introduction of the independent variable (B), after the removal of the independent variable (A), and after reintroduction of the independent variable (B).

Most Investigated Causal Questions in Clinical Research

Most Common Causal Questions

Does factor X cause a disorder?

Is cause A more influential than cause B?

How does family communication and structure affect family members?

How does a disorder affect the quality of a person’s life?

Does treatment X alleviate a disorder?

Is treatment X more helpful than no treatment at all?

Is treatment A more helpful than treatment B?

Why does treatment X work?

Can an intervention prevent abnormal functioning?

Table 1-4

The study: Spitzer’s (2001) research on “reparative” therapy

The findings: By undergoing reparative therapy, the paper claimed, gay men and women could change their sexual orientation

The recantation: Spitzer (2012) revealed two serious flaws in his study: Unreliable self-reports and lack of control group

The consequences: Then… and now?

Flawed Study, Gigantic Impact

Protesting reparative therapy

MEDIA SPEAK

Protesting reparative therapy Protestors from a gay rights group in Hong Kong hold up a banner outside a social welfare department in 2011 to protest the department’s endorsement of reparative therapy.

What Are the Limits of Clinical Investigations?

The field has yet to agree on one definition of abnormality

Currently made up of conflicting schools of thought and treatment

Members are often unimpressed by the claims and accomplishments of the others

Clinical practice is carried out by a variety of professionals trained in different ways

Current research methods each have flaws that limit our knowledge and use of clinical information

Protecting Human Participants

Human research participants have needs and rights that must be respected

Researchers’ primary obligation is to avoid physically or psychologically harming the human participants in their studies

INSTITUTIONAL REVIEW BOARD (IRB)

An ethics committee in a research facility that is empowered to protect the rights and safety of human research participants

Institutional Review Board

Government doctors and researchers conducted the Tuskegee Syphilis Study, a research undertaking conducted from 1932 to 1972, prior to the emergence of Institutional Review Boards. In this infamous study, 399 participants were not informed that they had the disease, and they continued to go untreated even after it was discovered that penicillin is an effective intervention for syphilis.

IRB Participant Rights

IRB Limitations

Unclear informed consent forms

Voluntary participation

Informed consent

Right to end participation at any time

Study benefits outweigh costs/risks

Protection from physical and psychological harm

Access to study information

Protection of privacy (confidentiality or anonymity)

Subtle and elusive notions not easily translated into regulations

Ethical decisions influenced by differences in perspective, interpretation, and decision-making style