psychology case study
SchoolDaze
beginning_to_ch_2_pg_56.pdf
Ronald 1. Corner Princeton University
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Credits for miscellaneous text excerpts: p. 228, Dennis Yusko, "At Home, but Locked in War," Times Union (Albany) Online. Copyright 0 2008 by Times Union/Albany. Reproduced with permission via Copyright Clearance Center; pp. 396-397, case study excerpt from Bernstein et a1., Personality Disorders. Copyright 0 2007 by Sage Publications Inc. Books. Reproduced with permission via Copyright Clearance Center; p. 411, case study excerpts from Meyer and Osborne, Case Studies in Abnormal Behavior, 2"d edition. Copyright 2002. Reprinted with permission of Pearson Education, Inc.; pp. 418-419, case study excerpt reprinted with permission from the DSM-IV-TR Casebook. Copyright © 2002 American Psychiatric Association.
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To Marlene whose grace, generosity,
and love fill my life
ABOUT THE AUTHOR
Ronald J. Corner has been a professor in Princeton University's Department of Psychology for the past 35 years and has served as Director of Clinical Psychology Studies for most of that time. His courses—Abnormal Psychology, Theories of Psychotherapy, Childhood Psychopathology, Experimental Psychopathology, and Controversies in Clinical Psychology—have been among the university's most popular offerings.
Professor Corner has received the President's Award for Distinguished Teaching at the university. He is also a practicing clinical psychologist and serves as a consultant to the Eden Institute for Persons with Autism and to hospitals and family practice residency programs throughout New Jersey.
In addition to writing Fundamentals of Abnormal Psycnology, Professor Corner is the author of the textbook Abnormal Psychology, now in its seventh edition, co-author of the introductory psychology textbook Psychology Around Us, and co-author of Case Studies
in Abnormal Psychology, He is the producer of various educational videos, including The Higher Education Video Library Series, Video Segments in Abnormal Psychology, Video Segments in Neuroscience, Introduction to Psychology Video Clipboard, and Developmental Psychology Video Clipboard. He also has published numerous journal articles in clinical psychology, social psychology, and family medicine.
Professor Corner completed his undergraduate studies at the University of Pennsylvania and his graduate work at Clark University. He lives in Lawrenceville, New Jersey, with his wife, Marlene. From there he can keep an eye on the Philadelphia sports teams with which he grew up. After years of frustration, he was shaken to the core by the 2008 World Series success (and 2009 near-success) of the Philadelphia Phillies and currently is trying his best to adjust to the new world order.
viii :11
CONTENTS IN BRIEF
Abnormal Psychology in Science and Clinical Practice
1 Abnormal Psychology: Past and Present
2 Models of Abnormality 31
3 Clinical Assessment, Diagnosis, and Treatment 67
Problems of Anxiety and Mood
4 Anxiety Disorders 95
5 Stress Disorders 133
6 Somatoform and Dissociative Disorders 163
7 Mood Disorders 193
8 Suicide 229
Problems of the Mind and Body
9 Eating Disorders 257
10 Substance-Related Disorders 2C5
11 Sexual Disorders and Gender Identity Disorder 321
Problems of Psychosis and the Cognitive Function
12 Schizophrenia
357
Life-Span Problems
13 Personality Disorders 393
14 Disorders of Childhood and Adolescence 429
15 Disorders of Aging and Cognition 467
Conclusion
16 Law, Society, and the Mental Health Profession 491
CONTENTS
Preface
CHAPTER
Abnormal Psychology:
xvii
Past and Present 1
What Is Psychological Abnormality? 2
Deviance 2
Distress 3
Dysfunction 3
Danger 3
The Elusive Nature of Abnormality 3
What Is Treatment? 4
How Was Abnormality Viewed and Treated in the Past? 6
Ancient Views and Treatments 7
Greek and Roman Views and Treatments 7
Europe in the Middle Ages: Demonology Returns 7
The Renaissance and the Rise of Asylums 8
The Nineteenth Century: Reform and Moral
Treatment 9
The Early Twentieth Century: The Somatogenic
and Psychogenic Perspectives 10
Current Trends 13
How Are People with Severe Disturbances
Cared For? 13
How Are People with Less Severe Disturbances
Treated? 14 A Growing Emphasis on Preventing Disorders
and Promoting Mental Health 16
Mu lticultural Psychology 17
The Growing Influence of Insurance Coverage 17
What Are Today's Leading Theories and Professions? 18
What Do Clinical Researchers Do? 19 The Case Study 20
The Correlational Method 20
The Experimental Method 23
What Are the Limits of Clinical Investigations? 27
PUTTING IT TOGETHER A WORK IN PROGRESS 27
CRITICAL THOUGHTS
28
KEY TERMS
28
QUICK QUIZ
29
CYBERSTUDY
29
A CLOSER LOOK Marching to a Different Drummer: Eccentrics 5
PSYCH WATCH Verbal Debuts 12
PSYCH WATCH Modern Pressures: Modern Problems
15
PSYCH WATCH Positive Psychology: Happiness Is All Around Us 16
THE MEDIA SPEAKS On Facebook, Scholars Link Up with Data 23
CHAPTER
Models of Abnormality
The Biological Model How Do Biological Theorists Explain
31 33
Abnormal Behavior? 33
Biological Treatments 35
Assessing the Biological Model 36
The Psychodynamic Model 37 How Did Freud Explain Normal and
Abnormal Functioning? 37
How Do Other Psychodynamic Explanations
Differ from Freud's? 39 Psychodynamic Therapies 40
Assessing the Psychodynamic Model 43
The Behavioral Model 43 How Do Behaviorists Explain Abnormal
Functioning? 44
Behavioral Therapies 45
Assessing the Behavioral Model 46
The Cognitive Model 47 How Do Cognitive Theorists Explain
Abnormal Functioning? 47
Cognitive Therapies 47
Assessing the Cognitive Model 49
The Humanistic-Existential Model
50 Rogers's Humanistic Theory and Therapy
51
Gestalt Theory and Therapy
52
Spiritual Views and Interventions
53
Existential Theories and Therapy
53
Assessing the Humanistic-Existential Model
54
The Sociocultural Model: Family-Social and Multicultural Perspectives
How Do Family-Social Theorists Explain Abnormal
55
Functioning? 55
Family-Social Treatments 57
How Do Multicultural Theorists Explain Abnormal
Functioning? 60
Multicultural Treatments 61
Assessing the Sociocultural Model 62
PUTTING IT TOGETHER INTEGRATION OF THE MODELS 63
CRITICAL THOUGHTS 64 KEY TERMS 64
QUICK QUIZ 65
CYBERSTUDY 65
PSYCH WATCH Maternal Instincts 42
PSYCH WATCH Surfing for Help 48
PSYCH WATCH Self- Help Groups: Too Much of a Good Thing? 59
CHAPTER
Clinical Assessment, Diagnosis, and Treatment
Clinical Assessment: How and Why Does the
67
Client Behave Abnormally? 67 Characteristics of Assessment Tools 68
Clinical Interviews 69 Clinical Tests 71
Clinical Observations 80
Diagnosis: Does the Client's Syndrome Match a Known Disorder? 81
Classification Systems 82
DSM-IV-TR 83
Is DSM-IV-TR an Effective Classification System? 84
Can Diagnosis and Labeling Cause Harm? 86
Treatment: How Might the Client Be Helped? 87 Treatment Decisions 87
The Effectiveness of Treatment 89
Contents
PUTTING IT TOGETHER RENEWED RESPECT COLLIDES WITH ECONOMIC PRESSURE 91
CRITICAL THOUGHTS 92 KEY TERMS 92 QUICK QUIZ 93 CYBERSTUDY 93
A CLOSER LOOK The Truth, the Whole Truth, and Nothing but the Truth 77
THE MEOLA SPEI-Vel.S Tests, eBay, and the Public Good 79
PSYCH WATCH Dark Sites 85
E.7E ON MLR! E Culture-Bound Abnormality 88
CHAPTER
a Anxiety Disorders 95 Generalized Anxiety Disorder 96
The Sociocultural Perspective: Societal and
Multicultural Factors 97
The Psychodynamic Perspective 98
The Humanistic Perspective 99
The Cognitive Perspective 100
The Biological Perspective 104
Phobias 106 Specific Phobias 107
Social Phobias 107
What Causes Phobias? 108
How Are Phobias Treated? 112
Panic Disorder 116 The Biological Perspective 117
The Cognitive Perspective 118
Obsessive-Compulsive Disorder 121 What Are the Features of Obsessions and
Compulsions? 122
The Psychodynamic Perspective 124
The Behavioral Perspective 125
The Cognitive Perspective 127
The Biological Perspective 127
PUTTING IT TOGETHER DIATHESIS-STRESS IN ACTION 129 CRITICAL THOUGHTS 130 KEY TERMS 130 QUICK QUIZ 131 CYBERSTUDY 131
A CLOSER LOOK Fears, Shmears: The Odds Are Usually on Our Side 101
A CLOSER LOOK Phobias, Familiar and Not So Familiar 111
PSYCH WATCH Panic: Everyone Is Vulnerable
119
THE MEDIA SPEi-kKS Dining Out: The Obsessive-Compulsive Experience
124
CHAPTER
0 Stress Disorders
133
Stress and Arousal: The Fight-or-Flight Response 134
The Psychological Stress Disorders: Acute and Post-traurnatic Stress Disorders 136
What Triggers a Psychological Stress Disorder? 137
Why Do People Develop a Psychological
Stress Disorder? 142
How Do Clinicians Treat the Psychological
Stress Disorders? 144
The Physical Stress Disorders: Psychophysiological Disorders
148
Traditional Psychophysiological Disorders
148
New Psychophysiological Disorders
152
Psychological Treatments for Physical Disorders
156
PUTTING IT TOGETHER EXPANDING THE BOUNDARIES OF 159 ABNORMAL PSYCHOLOGY 160 CRITICAL THOUGHTS 160 KEY TERMS 161 QUICK QUIZ 161 CYBERSTUDY
PSYCH WATCH September 11, 2001: The Psychological Aftermath
141
THE MEDIA SPEAKS Combat Trauma Takes the Stand
145
THE MEDIA SPEAKS Empathy Goes a Long Way
159
CHAPTER
* Somatoform and Dissociative Disorders
163
Somatoform Disorders
164 What Are Hysterical Somatoform Disorders?
164
What Are Preoccupation Somatoform Disorders?
169
What Causes Somatoform Disorders?
170
How Are Somatoform Disorders Treated?
174
Dissociative Disorders
176
Dissociative Amnesia
177
Dissociative Fugue
180
Dissociative Identity Disorder
(Multiple Personality Disorder)
181
How Do Theorists Explain Dissociative
Disorders?
184
How Are Dissociative Disorders Treated?
187
PUTTING IT TOGETHER DISORDERS REDISCOVERED
189 CRITICAL THOUGHTS
190
KEY TERMS
190
QUICK QUIZ
191
CYBERSTUDY
191
A CLOSER LOOK Munchausen Syndrome by Proxy 168
EYE OrcuLTLI PE. Beauty Is in the Eye of the Beholder 171
A CLOSER LOOK Repressed Childhood Memories or False Memory Syndrome? 178
THE MEDIA SPEAKS Homeward Hound: A Case of Dog Fugue?
181
A CLOSER LOOK Peculiarities of Memory
185
CHAPTER
0 Mood Disorders
193
Unipolar Depression
194 How Common Is Unipolar Depression?
194
What Are the Symptoms of Depression?
194
Diagnosing Unipolar Depression
197
Stress and Unipolar Depression
197
The Biological Model of Unipolar Depression
198
Psychological Models of Unipolar Depression
205
The Sociocultural Model of Unipolar Depression
213
Bipolar Disorders
218
What Are the Symptoms of Mania?
219
Diagnosing Bipolar Disorders
219
What Causes Bipolar Disorders?
220
What Are the Treatments for Bipolar Disorders?
222
PUTTING IT TOGETHER MAKING SENSE OF
ALL THAT IS KNOWN
225 CRITICAL THOUGHTS
226 KEY TERMS
226 QUICK QUIZ
227 CYBERSTUDY
227
PSYCH WATCH Sadness at the Happiest of Times 196
EYE ON CLJLTLIF-- - First Dibs on Antidepressant Drugs? 202
THE MEDIA SPEAKS How Well Do Colleges Treat Depression? 207
PSYCH WATCH ABNORMALITY AND THE ARTS Abnormality and Creativity: A Delicate Balance 223
Contents :// xiii
CHAPTER
Suicide
What Is Suicide?
How Is Suicide Studied?
Patterns and Statistics
229
231 233
234
What Triggers a Suicide?
Stressful Events and Situations
Mood and Thought Changes
Alcohol and Other Drug Use
Mental Disorders
Modeling: The Contagion of Suicide
What Are the Underlying Causes of Suicide?
The Psychodynamic View
Durkheim's Sociocultural View
The Biological View
Is Suicide Linked to Age?
Children
Adolescents
The Elderly
Treatment and Suicide
What Treatments Are Used after Suicide
Attempts?
What Is Suicide Prevention?
Do Suicide Prevention Programs Work?
PUTTING IT TOGETHER PSYCHOLOGICAL AND BIOLOGICAL INSIGHTS LAG BEHIND
CRITICAL THOUGHTS
KEY TERMS QUICK QUIZ CYBERSTUDY
Bulimia Nervosa
Binges
Compensatory Behaviors
Bulimia Nervosa versus Anorexia Nervosa
260 262
263
264
What Causes Eating Disorders? 265 Psychodynamic Factors: Ego Deficiencies 265
Cognitive Factors 267
Mood Disorders 267
Biological Factors 267
Societal Pressures 270
Family Environment 271
Multicultural Factors: Racial and Ethnic
Differences 272
Multicultural Factors: Gender Differences 274
236 236
237
237
237
238
241 241
242
243
244 244
245
248
250
250
251
253
254 254
255 255 255
How Are Eating Disorders Treated? 275 Treatments for Anorexia Nervosa 275
Treatments for Bulimia Nervosa 279
PUTTING IT TOGETHER A STANDARD FOR INTEGRATING PERSPECTIVES 282
CRITICAL THOUGHTS 282 KEY TERMS 282 QUICK QUIZ 283
CYBERSTUDY 283
PSYCH WATCH ABNORMALITY AND THE ARTS We've Only Just Begun 259
A CLOSER LOOK Obesity: To Lose or Not to Lose 268
CLILTOME: Eating Disorders across the World 273
PSYCH WATCH And She Lived Happily Ever After? 279
PSYCH WATCH ABNORMALITY AND THE ARTS Suicide in the Family
PSYCH WATCH ABNORMALITY AND THE ARTS Can Music Inspire Suicide?
A CLOSER LOOK The Black Box Controversy: Do Antidepressants Cause Suicide?
PSYCH WATCH The Right to Commit Suicide
233
239
246
249
CHAPTER
0 Eating Disorders
Anorexia Nervosa
The Clinical Picture
Medical Problems
CHAPTER
0 Substance-Related Disorders 285
Depressants 287
Alcohol 287
Sedative-Hypnotic Drugs 292
Opioids 293
Stimulants 295 Cocaine 295
Amphetamines 298
Hallucinogens, Cannabis, and Combinations of Substances 299
Hallucinogens 299
Cannabis 301
Combinations of Substances 304
257
258 258
260
xiv :1/Contents
What Causes Substance-Related Disorders? 305 Sociocultural Views 305
Psychodynamic Views 306
Cognitive-Behavioral Views 306
Biological Views 307
How Are Substance -Related Disorders Treated? 310 Psychodynamic Therapies 310
Behavioral Therapies 310
Cognitive-Behavioral Therapies 312
Biological Treatments 312
Sociocultural Therapies 314
PUTTING IT TOGETHER NEW WRINKLES TO A FAMILIAR STORY 317
CRITICAL THOUGHTS 318 KEY TERMS 318
QUICK QUIZ 318
CYBERSTUDY 319
PSYCH WATCH College Binge Drinking: An Extracurricular Crisis 290
A CLOSER LOOK Tobacco, Nicotine, and Addiction 297
PSYCH WATCH Club Drugs: X Marks the {Wrong) Spot 300
THE MEDIA SPEAKS In Real Time, Amy Winehouse's Deeper Descent 313
CHAPTER
Sexual Disorders and Gender Identity Disorder 321
Sexual Dysfunctions 322 Disorders of Desire 322
Disorders of Excitement 325
Disorders of Orgasm 328
Disorders of Sexual Pain 332
Treatments for Sexual Dysfunctions 333 What Are the General Features of Sex Therapy? 334
What Techniques Are Applied to Particular
Dysfunctions? 336
What Are the Current Trends in Sex Therapy? 338
Paraphilias 339 Fetishism 340
Transvestic Fetishism 341
Exhibitionism 342
Voyeurism 342
Frotteurism 343
Pedophilia 343
Sexual Masochism 345
Sexual Sadism 346
A Word of Caution 347
Gender Identity Disorder 348 Explanations of Gender Identity Disorder 349
Treatments for Gender Identity Disorder 349
PUTTING IT TOGETHER A PRIVATE TOPIC DRAWS PUBLIC ATTENTION 353
CRITICAL THOUGHTS 354 KEY TERMS 354 QUICK QUIZ 354 CYBERSTUDY 355
PSYCH WATCH Lifetime Patterns of Sexual Behavior 324
PSYCH WATCH Serving the Public Good 344
`Y`? ON CLILTJJE .
Homosexuality and Society 347
THE MEDIA SPEAKS Battling a Culture of Shame 351
CHAPTER
* Schizophrenia 357
The Clinical Picture of Schizophrenia 358 What Are the Symptoms of Schizophrenia? 360
What Is the Course of Schizophrenia? 363
Diagnosing Schizophrenia 363
How Do Theorists Explain Schizophrenia? 364 Biological Views 364
Psychological Views 370
Sociocultural Views 371
How Are Schizophrenia and Other Severe Mental Disorders Treated? 373
Institutional Care in the Past 375 Institutional Care Takes a Turn for the Better 375
Antipsychotic Drugs 377
Psychotherapy 380
The Community Approach 383
PUTTING IT TOGETHER AN IMPORTANT LESSON 389
CRITICAL THOUGHTS 390 KEY TERMS 390 QUICK QUIZ 391 CYBERSTUDY 391
A CLOSER LOOK Postpartum Psychosis: The Case of Andrea Yates 367
PSYCH WATCH Howling for Attention 368
A CLOSER LOOK Lobotomy: How Could It Happen? 374
ON First Dibs on Atypical Antipsychotic Drugs?
378
THE MEDIA SPEAK'S Can You Live with the Voices in Your Head?
380
CHAPTER
Personality Disorders
393 "Odd" Personality Disorders
396
Paranoid Personality Disorder 396
Schizoid Personality Disorder
398 Schizotypal Personality Disorder
399
"Dramatic" Personality Disorders
402 Antisocial Personality Disorder
402
Borderline Personality Disorder
406 Histrionic Personality Disorder
411
Narcissistic Personality Disorder
413
"Anxious" Personality Disorders
416 Avoidant Personality Disorder
416
Dependent Personality Disorder 418 Obsessive-Compulsive Personality Disorder
420
Multicultural Factors: Research Neglect
422
Are There Better Ways to Classify Personality Disorders?
423 The "Big Five" Theory of Personality and
Personality Disorders
424
Alternative Dimensional Approaches
425
PUTTING IT TOGETHER DISORDERS OF PERSONALITY ARE REDISCOVERED
425
CRITICAL THOUGHTS 426 KEY TERMS 426 QUICK QUIZ 427 CYBERSTUDY 427
A CLOSER LOOK Gambling and Other Impulse Problems 405
THE MEDIA:1, SPEAKS Self-Cutting: The Wound That Will Not Heal 409
PSYCH WATCH Lying: "Oh What a Tangled Web . . . " 415
CHAPTER
Disorders of Childhood and Adolescence
429 Childhood and Adolescence
430
Childhood Anxiety Disorders
431
Contents
Separation Anxiety Disorder 431 Treatments for Childhood Anxiety Disorders 432
Childhood Mood Disorders 434 Major Depressive Disorder 434 Bipolar Disorder 435
Oppositional Defiant Disorder and Conduct Disorder 436
What Are the Causes of Conduct Disorder? 437 How Do Clinicians Treat Conduct Disorder? 437
Attention-Deficit/Hyperactivity Disorder 440 What Are the Causes of ADHD? 441 How Is ADHD Treated? 442 Multicultural Factors and ADHD 442
Elimination Disorders 444 Enuresis 444
Encopresis 446
Long-Term Disorders That Begin in Childhood 447
Pervasive Developmental Disorders 447 Mental Retardation 454
PUTTING IT TOGETHER CLINICIANS DISCOVER CHILDHOOD AND ADOLESCENCE 463
CRITICAL THOUGHTS 464 KEY TERMS 464 QUICK QUIZ 465 CYBERSTUDY 465
THE MEDIA SPEAK S Alone in a Parallel Life 433
PSYCH WATCH Bullying: A Growing Crisis? 438
A CLOSER LOOK Child Abuse 444
PSYCH WATCH A Special Kind of Talent 451
A CLOSER LOOK Reading and 'Riting and 'Rithmetic 456
* Disorders of Aging and
CHAPTER
Cognition 467
Old Age and Stress 468
Depression in Later Life 469
Anxiety Disorders in Later Life 470
Substance Abuse in Later Life 471
Psychotic Disorders in Later Life 473
xv
xvi :// Contents
Disorders of Cognition
Delirium
Dementia
Issues Affecting the Mental Health of the Elderly
PUTTING IT TOGETHER CLINICIANS DISCOVER THE ELDERLY
CRITICAL THOUGHTS KEY TERMS QUICK QUIZ CYBERSTU DY
A CLOSER LOOK Sleep and Sleep Disorders among the Old and Not So Old
A CLOSER LOOK Amnestic Disorders: Forgetting to Remember
PSYCH WATCH ABNORMALITY AND THE ARTS "You Are the Music, while the Music Lasts"
THE MEDIA SPEAKS Doctor, Do No Harm
CHAPTER
Law, Society, and the Mental Health Profession
Psychology in Law: How Do Clinicians Influence the Criminal Justice System?
Criminal Commitment and Insanity during
Commission of a Crime
Criminal Commitment and Incompetence
to Stand Trial
Law in Psychology: How Does the Legal System Influence Mental Health Care?
Civil Commitment
Protecting Patients' Rights
In What Other Ways Do the Clinical and Legal Fields Interact? 507
Malpractice Suits 507
Professional Boundaries 507
Jury Selection 507
Psychological Research of Legal Topics 507
Ethics and Mental Health Professionals? 510
Mental Health, Business, and Economics 512
Bringing Mental Health Services to the
Workplace 512
The Economics of Mental Health 513
The Person within the Profession 514
PUTTING IT TOGETHER OPERATING WITHIN A LARGER SYSTEM 516
CRITICAL THOUGHTS 518 KEY TERMS 518 QUICK QUIZ 519 CYBERSTUDY 519
A CLOSER LOOK Famous Insanity Defense Cases 495
PSYCH WATCH Violence against Therapists 502
PSYCH WATCH Serial Murderers: Madness or Badness? 509
PSYCH WATCH "Ask Your Doctor If This Medication Is Right for You" 514
THE MEDIA 'PEAICS "Mad Pride" Fights a Stigma 517
Glossary G-1
References R-1
Name Index NI-1
Subject Index SI-1
491
492
493
498
500
500
504
486
474
474
475
487 488 488 488 489
478
481
484
472
Chanpes and Features New trit ditibn
PREFACE
TI have been writing my textbooks Fundamentals of Abnormal Psychology and Abnormal Psychology for close to three decades—almost half of my life. The current version, Fundamentals of Abnormal Psychology, Sixth Edition, is the thirteenth edition of one or the other of the textbooks. I am deeply gratified that so many students and profes-
sors have embraced these books, and I feel privileged to have had the opportunity to help educate more than a half-million readers over the past years.
My goal for each edition of the books has been that it be a fresh, comprehensive, and exciting presentation of the current state of this ever-changing field and that it include state-of-the-art pedagogical techniques and insights.This "new book" approach to each edition is, I believe, the key reason for the continuing success of the textbooks, and the current edition has been written in this same tradition.
In fact, this edition of Fundamentals of Abnormal Psychology includes even more changes than those in previous editions for several reasons: (1) the field of abnormal psychology has had a dramatic growth spurt over the past several years; (2) the field of education has produced many new pedagogical tools; (3) the world of publishing has developed new, striking ways of presenting material; (4) the world at large has changed dramatically, featuring a monumental rise in the Internet's impact on our lives, grow- ing influence by the media, near-unthinkable economic and political events, and a changing world order. Changes of this kind should find their way into a book about the current state of human functioning, and I have worked hard to include them in a stimulating way.
That said, I believe I have produced a new edition of Fundamentals of Abnormal Psychology that will once again excite readers, open the field of abnormal psychology to them, and speak to them and their times. Throughout the book I have again sought to convey my passion for the field, and I have built on the generous feedback of my colleagues in this enterprise—the students and professors who have used this textbook over the years. Let me describe what I believe to be special about this edition, apologiz- ing at the top if these descriptions at times seem grandiose or self-serving. I'm usually better at hiding such traits.
In line with the enormous changes that have occurred over the past several years in the fields of abnormal psychology, education, and publishing and in the world, I have brought the following changes and new features to the current edition.
EXPANDED MULTICULTURAL COVERAGE In the twenty-first century, the study of ethnic, racial, gender, and other cultural factors has, appropriately, been elevated to a broad perspective—the multicultural perspective—a theoretical and treatment approach to abnormal behavior that is now applied across all forms of psycho- pathology and treatment. Consistent with this clinical movement, the current edition includes the following:
1. Broad Multicultural Perspective sections in each chapter of the textbook, each examining the impact of cultural issues on the diagnosis, development, and treat- ment of the abnormal pattern in question. Chapter 2, Models of Abnormality, for example, includes sections on culture-sensitive therapies and gender-sensitive therapies (pages 61-62); Chapter 5, Stress Disorders, examines the ties between race, culture, and posttraumatic stress disorder (pages 143-144); and
xvii
xviii :11 Preface
multicultural perspective sections in Chapter 7, Mood Disorders, consider the links between gender, culture, and depression (pages 215-217).
2. Numerous Eye on Culture boxes appear throughout the text, further empha- sizing multicultural issues. These boxes address topics such as Culture-Bound Abnormality (Chapter 3), First Dibs on Antidepressant Drugs? (Chapter 7), Eating Disorders across the World (Chapter 9), and First Dibs on Atypical Antipsychotic Drugs? (Chapter 12).
3. Multicultural photography, figures, and cases. Even a quick look through the pages of the textbook will reveal that it truly reflects the cultural diversity of our society and of the field of abnormal psychology.
"NEW-WAVE" COGNITIVE AND COGNITIVE-BEHAVIORAL THEORIES AND TREATMENTS Beginning in the 1960s, cognitive and cognitive-behavioral thera- pists sought to help clients undo the maladaptive attitudes and thought processes that contribute to their psychological dysfunctioning. This approach has been joined in recent years by another focus, "new-wave" cognitive and cognitive-behavioral theories and therapies that help clients "accept" and objectify maladaptive thoughts that are resistant to change. The current edition of Fundamentals of Abnormal Psychology fully covers these "new-wave" theories and therapies, including mind- fulness-based cognitive therapy and Acceptance and Commitment Therapy (ACT), presenting their propositions, techniques, and research in chapters throughout the text (for example, pages 50, 103, 213, and 382).
EXPANDED NEUROSCIENCE COVERAGE The twenty-first century has witnessed the continued growth and impact of remarkable brain-imaging techniques, genetic mapping strategies, and other neuroscience approaches. Correspondingly, biologi- cal theories and treatments for abnormal behavior have taken unprecedented leaps forward during the past several years. The current edition brings these leaps to life. In addition to the biochemical view of abnormal behavior on display in previous editions, the current edition includes detailed coverage of the following:
1 Broader discussions of the genetic underpinnings of abnormal behavior (for example, pages 34-35, 142-143, 198-199, and 365-366).
2. Detailed explanations of both the brain structures and brain functions at the root of abnormal behavior, including, for example, presentations of how vari- ous neural networks contribute to panic disorder (pages 117-118), obsessive- compulsive disorder (page 128), depression (pages 199-200), and other forms of psychopathology.
3. Neuroscience photography and art. This edition is filled with photos of exciting brain scans that reveal the brain structures and activities at work in abnormality (for example, pages 78, 221, 308, and 370). Similarly, numerous pieces of new, current, and enlightening brain art fill each chapter of the book to help readers better appreciate the locations and interactions of various brain struc- tures (for example, pages 117, 118, 128, 200, and 369).
4. Analyses of how genetic factors, brain chemicals, and brain structures interact with psychosocial factors to produce abnormal behavior (for example, pages 63-64, 129-130, and 282).
•NEW, THE MEDIA SPEAKS The media is an extraordinary force in our society. And its role has become even more powerful in the twenty-first century as use of the Internet has exploded and ordinary people are now able to communicate with masses of unknown others through blogging, social networking, and the like. Given the media's profound impact on our behaviors, thoughts, and knowledge, I have added an important recurring feature throughout the text—boxes called The Media Speaks in which news and magazine writers offer pieces on subjects in abnormal
Preface xix
psychology (How Well Do Colleges Treat Depression? on page 207), individuals write firsthand about their experiences with psychological disorders (Self-Cutting: The Wound That Will Not Heal on page 409), and editorial writers consider the clinical implications of pop culture (in Real Time, Amy Winehouse's Deeper Descent on page 313).
EXPANDED COVERAGE OF KEY DISORDERS AND TOPICS In line with the field's (and society's) increased interest in certain psychological problems and treatments, I have added or greatly expanded the coverage of topics such as torture, terrorism, and psychopathology (pages 140-142), methamphetamine use (pages 298-299}, transgender issues (pages 348-353), childhood bipolar disorders (pages 435- 436), self-cutting (pages 407-409), dialectical behavior therapy (page 410), anti- depressant drugs and suicide risk (page 246), music and suicide attempts (page 239), brain interventions such as vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation (pages 204-205), and metaworry explana- tions of generalized anxiety disorder (pages 100-103), among other topics.
EXPANDED COVERAGE OF PREVENTION AND OF THE PROMOTION OF MENTAL HEALTH In accord with the clinical field's growing emphasis on prevention, positive psychology, and psychological wellness, I have increased significantly the text- book's attention to these important approaches (for example, pages 16-17, 60, and 487).
RESTRUCTURED CHAPTER ON CHILDHOOD AND ADOLESCENT DISORDERS To reflect current directions in the clinical field, I have made key changes to Chapter 14, Disorders of Childhood and Adolescence. Childhood disorders that parallel adult disorders—particularly anxiety and mood disorders—are now covered in depth in this chapter (rather than spread throughout the book), along with the dis- orders that are more narrowly tied to young age, such as conduct disorder, ADHD, and enuresis.
SPECIAL FOCUS ON TODAY'S WORLD An element that is often neglected in textbooks—psychology and otherwise—is, oddly, the modern world! We live in an ever-changing world that has in fact undergone a major face-lift over the past decade. If a textbook is to speak to today's readers, especially college-age readers, the book's elements—its topics, examples, cases, and photos—must represent the world in which they live. With this in mind, I have included throughout the book relevant discussions about "now" factors such as Facebook, MySpace, YouTube, ecoanxiety, cell phone use, transgender issues, pop culture, emo music, Internet addiction, and club drugs. The finished product is, in turn, a more complete book about abnormal psychology—past and present—relevant to all.
NEW BOXES In this edition, I have grouped the boxes into four categories to bet- ter orient the reader. In addition to The Media Speaks boxes and Eye on Culture boxes mentioned earlier, the sixth edition contains A Closer Look boxes (boxes that examine text topics in more depth) and Psych Watch boxes (boxes that look at examples of abnormal psychology in movies, the news, and the world around us). I have, of course, updated all the boxes retained from the last edition, and I have also added 21 completely new boxes, including the following:
O The Media Speaks: Can You Live with the Voices in Your Head? (Chapter 12)
• Psych Watch: Dark Sites on the Internet (Chapter 3)
* Eye on Culture: Eating Disorders across the World (Chapter 9)
® The Media Speaks: Mad Pride Fights a Stigma (Chapter 16)
* Psych Watch: Surfing for Help (Chapter 2)
xx :/Preface
NEW, CURRENT, AND INNOVATIVE DESIGN The sixth edition of Fundamentals of Abnormal Psychology has been strikingly redesigned to give it an eye-catching and modern look—a look that builds on new trends in publishing and pedagogy, speaks to the reader, and leads the way for new textbook designs. At the same time, the design retains a popular feature from past editions—reader-friendly elements called "Between the Lines" that appear in the book's margins and include text-relevant tidbits, surprising facts, current events, historical notes, interesting trends, fun lists, and provocative quotes.
THOROUGH UPDATE In this edition I present recent theories, research, and events, including more than 2,000 new references from the years 2007-2010, as well as hundreds of new photos, tables, and figures.
In this edition, I have retained the themes, material, and techniques that have worked successfully and been embraced enthusiastically by past readers.
MODERATE IN LENGTH, SOLID IN CONTENT Even though Fundamentals of Abnormal Psychology is of moderate length, it offers probing coverage of its broad subject. It expands and challenges students' thinking rather than short-changing or underestimating their intellectual capacity.
BREADTH AND BALANCE The field's many theories, studies, disorders, and treat- ments are presented completely and accurately. All major models—psychological, biological, and sociocultural—receive objective, balanced, up-to-date coverage without bias toward any single approach.
INTEGRATION OF MODELS Discussions throughout the text, particularly those headed Putting It Together, help students better understand where and how the vari- ous models work together and how they differ.
EMPATHY The subject of abnormal psychology is people—very often people in great pain. I have therefore tried to write always with empathy and to impart this awareness to students.
INTEGRATED COVERAGE OF TREATMENT Discussions of treatment are presented throughout the book. In addition to a complete overview of treatment in the open- ing chapters, each of the pathology chapters includes a full discussion of relevant treatment approaches.
RICH CASE MATERIAL I integrate numerous and culturally diverse clinical examples to bring theoretical and clinical issues to life. More than 25 percent of the clinical material in this edition is new or revised significantly.
TOPICS OF SPECIAL INTEREST I devote considerable attention to important subjects that are of special interest to college-age readers, such as eating disorders, the impact of managed care, direct-to-consumer advertising, the rise in use of Ritalin, virtual reality treatments, and the right to commit suicide.
DSM CHECKLISTS The discussion of each disorder is accompanied by a detailed checklist of the DSM-IV-TR criteria used to diagnose the disorder.
MARGIN GLOSSARY Hundreds of key words are defined in the margins of pages on which the words appear. In addition, a traditional glossary is available at the back of the book.
Preface :11 xxi
PUTTING IT TOGETHER This section toward the end of each chapter asks whether competing models can work together in a more integrated approach and also sum- marizes where the field now stands and where it may be going.
FOCUS ON CRITICAL THINKING The textbook provides tools for thinking critically about abnormal psychology. In particular, toward the end of each chapter a section called Critical Thoughts poses questions that help students to analyze and apply the material they have just read. Twenty-five percent of these questions are new to the sixth edition.
CHAPTER-ENDING KEY TERMS AND QUICK QUIZ SECTIONS These sections, keyed to appropriate pages in the chapter for easy reference, allow students to review and test their knowledge of chapter materials.
CYBERSTUDY Each chapter ends with a CyberStudy guide that integrates the chap- ter material with videos and other features found in the Fundamentals of Abnormal Psychology Video Tool Kit.
STIMULATING ILLUSTRATIONS Concepts, disorders, treatments, and applications are illustrated with stunning photographs, diagrams, graphs, and anatomical fig- ures. All the figures, graphs, and tables, many new to this edition, reflect the most up-to-date data available.
ADAPTABILITY Chapters are self-contained, so they can be assigned in any order that makes sense to the professor.
I have been delighted by the enthusiastic responses of both professors and students to the supplements that accompany my textbooks. This edition offers those supple- ments once again, revised and enhanced, and adds a number of exciting new ones.
FOR PROFESSORS
•NEW. VIDEO SEGMENTS FOR ABNORMAL PSYCHOLOGY, THIRD EDITION, pro- duced and edited by Ronald Comer, Princeton University, and Gregory Corner, Princeton Academic Resources. Faculty Guide included. This incomparable video series offers 125 clips—half of them new to this edition—that depict disorders, show historical footage, and illustrate clinical topics, pathologies, treatments, experi- ments, and dilemmas. Videos are available on DVD or CD-ROM. I have also written an accompanying guide that fully describes and discusses each video clip so that professors can make informed decisions about the use of the segments in lectures.
In addition, Nicholas Greco, College of Lake County, has written a completely new set of questions to accompany each video segment in the series. The questions have been added to the Faculty Guide (now available in the Instructor's Resource Manual) and are also available in PowerPoinP on the companion Web site or the Instructor's Resource CD-ROM (for use with Worth Publishers' iClicker Classroom Response System).
CLINICAL VIDEO CASE FILE FOR ABNORMAL PSYCHOLOGY, produced and edited by Ronald Cotner and Gregory Corner. Faculty Guide included. I have produced a set of 10 longer authentic video case studies that bring to life particularly interest- ing cases of psychopathology and treatment. The videos are available on DVD or CD-ROM.
xxii : Preface
POWERPOINT® SLIDES, available at www.worthpublishers.com/comer or on the Instructor's Resource CD-ROM. These PowerPoint® slides can be used directly or customized to fit a professor's needs. There are two customizable slide sets for each chapter of the book—one featuring chapter text, the other featuring all chapter photos and illustrations.
POWERPOINT® PRESENTATION SLIDES, by Karen Clay Rhines, Northampton Community College, available at www.worthpublishers.com/comer or on the Instructor's Resource CD-ROM. These customized slides focus on key text terms and themes, reflect the main points in significant detail, and feature tables, graphs, and figures from the book. Each set of chapter slides is accompanied by a set of hand- outs, which can be distributed to students for use during lectures. The handouts are based on the instructor slides, with key points replaced by "fill-in" items. Answer keys and suggestions for use are also provided.
STEP UP TO ABNORMAL PSYCHOLOGY: A PowerPoint® Review Game, by John Schulte, Cape Fear Community College and University of North Carolina, available at www.worthpublishers.com/comer or on the Instructor's Resource CD-ROM. This PowerPoinP-based review adopts a game-show approach: students divide into teams to compete to climb the pyramid by answering questions related to chapter material.
DIGITAL PHOTO LIBRARY, available at www.worthpublishers.com/comer or on the Instructor's Resource CD-ROM. This collection provides access to all the photo- graphs used in Fundamentals of Abnormal Psychology, Sixth Edition.
INSTRUCTOR'S RESOURCE MANUAL by Karen Clay Rhines, Northampton Community College. This comprehensive guide ties together the ancillary package for professors and teaching assistants. The manual includes detailed chapter out- lines, lists of principal learning objectives, ideas for lectures, discussion launchers, classroom activities, extra credit projects, word search and crossword puzzles, and precise DSM-IV-TR criteria for each of the disorders discussed in the text. It also offers strategies for using the accompanying media, including the video segments series, the CD-ROM, the companion Web site, and the transparencies. Finally, it includes a comprehensive list of valuable materials that can be obtained from out- side sources—items such as relevant feature films, documentaries, and Internet sites related to abnormal psychology.
ASSESSMENT TOOLS
PRINTED TEST BANK, by John H. Hull, Bethany College, and Debra B. Hull, Wheeling Jesuit University. The comprehensive test bank offers more than 2,200 multiple-choice, fill-in-the-blank, and essay questions. Each question is graded according to difficulty, identified as factual or applied, and keyed to the topic and page in the text where the source information appears.
DIPLOMA COMPUTERIZED TEST BANK, available as a Windows and Macintosh dual-platform CD-ROM, guides professors step by step through the process of creating a test and allows them to add an unlimited number of questions, edit or scramble questions, format a test, and include pictures, equations, and multimedia links. The accompanying grade book enables them, among other things, to record students' grades throughout the course and includes the capacity to sort student records and view detailed analyses of test items, curve tests, generate reports, and add weights to grades. The CD-ROM also provides the access point for Diploma Online Testing, as well as Blackboard- and WebCT -formatted versions of the Test Bank for Fundamentals of Abnormal Psychology, Sixth Edition.
ONLINE TESTING, POWERED BY DIPLOMA, available at www.wimba.com/ products/diploma. With Diploma, professors can create and administer secure
Preface :1/ xxiii
exams over a network and over the Internet, with questions that incorporate multimedia and interactive exercises. The program also allows them to restrict tests to specific computers or time blocks and includes a suite of grade-book and result- analysis features.
ONLINE QUIZZING, POWERED BY QUESTIONMARK, accessed via the companion Web site at www.worthpublishers.com/comer . Professors can easily and securely quiz students online using provided multiple-choice questions for each chapter (note that questions are not from the Test Bank). Students receive instant feedback and can take the quizzes multiple times. Professors can view results by quiz, student, or question, or can get weekly results via e-mail.
FOR STUDENTS
NEW• PSYCHPORTAL, integrating the best online material Worth offers. PsychPortal is an innovative course space that combines a powerful quizzing engine with unpar- alleled media resources. PsychPortal conveniently offers all the functionality you need to support your online or hybrid course, yet it is flexible, customizable, and simple enough to enhance your traditional course. The following interactive learning materials contained in PsychPortal make it truly unique.
• Interactive eBook allows students to highlight, bookmark, and make their own notes just as they would with a printed textbook.
• Online Study Center combines PsychPortal's powerful assessment engine with Worth's unparalleled collection of interactive study resources. Based on their quiz results, students receive Personalized Study Plans that direct them to sections in the book and other activities that will help them succeed in mastering the concepts. Instructors can access reports indicating students' strengths and weaknesses (based on class quiz results) and browse suggestions for helpful presentation materials (from Worth's renowned videos and demonstrations) to focus their teaching efforts accordingly.
• Abnormal Psychology Video Tool Kit for Introductory Psychology is available in PsychPortal or on its own.
.NEW. ABNORMAL PSYCHOLOGY VIDEO TOOL KIT, produced and edited by Ronald Cotner, Princeton University, and Gregory Comer, Princeton Academic Resources. Tied directly to the CyberStudy sections in the text, the Student Tool Kit offers 57 intriguing video cases running 3 to 7 minutes each. The video cases focus on per- sons affected by disorders discussed in the text. Students first view a video case and then answer a series of thought-provoking questions about it. Additionally, the Student Tool Kit contains multiple-choice practice test questions with built-in instruc- tional feedback for every option.
STUDENT WORKBOOK by Ronald Corner, Princeton University, and Gregory Corner, Princeton Academic Resources. The engaging exercises in this student guide actively involve students in the text material. Each chapter includes a selection of practice tests and exercises, as well as key concepts, guided study questions, and section reviews.
FUNDAMENTALS OF ABNORMAL PSYCHOLOGY COMPANION WEB SITE by Nicholas Greco, College of Lake County, and Jason Spiegelman, Community College of Baltimore County, accessible at www.worthpublishers.com/comer . This Web site provides students with a virtual study guide, 24 hours a day, 7 days a week. These resources are free and do not require any special access codes or passwords. The tools on the site include chapter outlines, quizzes, interactive flash cards, research exercises, and frequently asked questions about clinical psychology. In addition, the site includes nine case studies by Elaine Cassel,
Marymount University and Lord Fairfax Community College, Danae L. Hudson, Missouri State University, and Brooke L. Whisenhunt, Missouri State University. Each case describes an individual's history and symptoms and is accompanied by a set of guided questions that point to the precise DSM-IV-TR criteria for the disorder and suggest a course of treatment.
CASE STUDIES IN ABNORMAL PSYCHOLOGY by Ethan E. Gorenstein, Behavioral Medicine Program, New York—Presbyterian Hospital, and Ronald Corner, Princeton University. This casebook provides 20 case histories, each going beyond DSM-IV-TR diagnoses to describe the individual's history and symptoms, a theoretical discus- sion of treatment, a specific treatment plan, and the actual treatment conducted. The casebook also provides three cases without diagnoses or treatment so that students can identify disorders and suggest appropriate therapies. In addition, case study evaluations by Ann Brandt-Williams, Glendale Community College, are avail- able at www.worthpublishers.com/comer . Each evaluation accompanies a specific case and can be assigned to students to assess their understanding as they work through the text.
THE SCIENTIFIC AMERICAN READER TO ACCOMPANY FUNDAMENTALS OF ABNORMAL PSYCHOLOGY, SIXTH EDITION, edited by Ronald Corner, Princeton University. On request, this reader is free when packaged with the text. Drawn from Scientific American, the articles in this full-color collection enhance coverage of important topics covered by the course. Keyed to specific chapters, the selections provide a preview of and discussion questions for each article.
SCIENTIFIC AMERICAN EXPLORES THE HIDDEN MIND: A COLLECTOR'S EDITION. On request, this reader is free when packaged with the text. In this special edition, Scientific American provides a compilation of updated articles that explore and reveal the mysterious inner workings of our wondrous minds and brains.
iCLICKER RADIO FREQUENCY CLASSROOM RESPONSE SYSTEM, offered by Worth Publishers in partnership with ;Clicker. ;Clicker is Worth's new polling system, created by educators for educators. This radio frequency system is the hassle-free way to make your class time more interactive. Among other functions, the system allows you to pause to ask questions and instantly record responses, as well as take attendance, direct students through lectures, and gauge students' understanding of the material.
COURSE MANAGEMENT
•ENHANCED. COURSE MANAGEMENT SOLUTIONS: SUPERIOR CONTENT, ALL IN ONE PLACE, available for WebCT, Blackboard, Desire2Learn, and Angel at www. bfwpub.com/cms . As a service for adopters, Worth Publishers is offering an enhanced turnkey course for Fundamentals of Abnormal Psychology, Sixth Edition. The enhanced course includes a suite of robust teaching and learning materials in one location, organized so that you can quickly customize the content for your needs, eliminating hours of work. For instructors, our enhanced course cartridge includes the complete Test Bank and all PowerPoint© slides. For students, we offer interactive flash cards, quizzes, crossword puzzles, chapter outlines, annotated Web links, research exercises, and case studies.
I am very grateful to the many people who have contributed to writing and pro- ducing this book. I particularly thank Marlene Comer for her outstanding work on the manuscript and her constant good cheer. In addition, I sincerely appreciate
Preface :At xxv
the superb work of the book's research assistants, including Dina Altshuler, Linda Chamberlin, Jon Comer, Greg Corner, Lindsay Downs, Jomi Furr, and Jamie Hambrick.
I am greatly indebted to the outstanding academicians and clinicians who have reviewed the manuscript of this new edition of Fundamentals of Abnormal Psychology, along with that of its partner, Abnormal Psychology, Seventh Edition, and have commented with great insight and wisdom on its clarity, accuracy, and completeness. Their collective knowledge has in large part shaped the sixth edi- tion of Fundamentals: Dave W. Alfano, Community College of Rhode Island; Jillian Bennett, University of Massachusetts Boston; Jeffrey A. Buchanan, Minnesota State University; Miriam Ehrenberg, John Jay College of Criminal Justice; Carlos A. Escoto, Eastern Connecticut State University; David M. Fresco, Kent State University; Alan J. Fridlund, University of California, Santa Barbara; Jinni A. Harrigan, California State University, Fullerton; Lynn M. Kemen, Hunter College; Audrey Kim, University of California, Santa Cruz; Barbara Lewis, University of West Florida; Regina Miranda, Hunter College; Linda M. Montgomery, University of Texas, Permian Basin; Crystal Park, University of Connecticut; Julie C. Piercy, Central Virginia Community College; Lloyd R. Pilkington, Midlands Technical College; Laura A. Rabin, Brooklyn College; Susan J. Simonian, College of Charleston; Joanne H. Stohs, California State University, Fullerton; Mitchell Sudolsky, University of Texas at Austin.
also thank the professors and clinicians around the country who offered spe- cial counsel during the writing of the text: Jeffrey Cohn, University of Pittsburgh; Marie Dacey, Massachusetts College of Pharmacy and Health Sciences; Elizabeth Lindner, Madison Area Technical College; Professor Joni Mihura, University of Toledo, Professor David Mrad, Missouri State University; Salma Osmani, University of Leicester, UK; Deborah Podwika, Kankakee Community College; Irving Weiner, President, Society of Personality Assessment.
Earlier I also received valuable feedback from academicians and clinicians who reviewed portions of the first five editions of Fundamentals of Abnormal Psychology. Certainly their collective knowledge has also helped shape the sixth edition, and I gratefully acknowledge their important contributions: Kent G. Bailey, Virginia Commonwealth University; Sonja Barcus, Rochester College; Mama S. Barnett, Indiana University of Pennsylvania; Otto A. Berliner, Alfred State College; Allan Berman, University of Rhode Island; Douglas Bernstein, University of Toronto, Mississauga; Greg Bolich, Cleveland Community College; Barbara Brown, Georgia Perimeter College; Jeffrey A. Buchanan, Minnesota State University, Mankato; Gregory M. Buchanan, Beloit College; Laura Burlingame-Lee, Colorado State University; Loretta Butehorn, Boston College; Glenn M. Callaghan, San Jose State University; E. Allen Campbell, University of St. Francis; Julie Carboni, San Jose College and National University; David N. Carpenter, Southwest Texas University; Sarah Cirese, College of Marin; June Madsen Clausen, University of San Francisco; Victor B. Cline, University of Utah; E. M. Coles, Simon Fraser University; Michael Connor, California State University, Long Beach; Frederick L. Coolidge, University of Colorado, Colorado Springs; Timothy K. Daugherty, Winthrop University; Mary Dozier, University of Delaware; S. Wayne Duncan, University of Washington, Seattle; Morris N. Eagle, York University; Anne Fisher, University of Southern Florida; William F. Flack Jr., Bucknell University; John Forsyth, State University of New York, Albany; Alan Fridlund, University of California, Santa Barbara; Stan Friedman, Southwest Texas State University; Dale Fryxell, Chaminade University; Lawrence L. Galant, Gaston College; Karla Gingerich, Colorado State University; Nicholas Greco, College of Lake County; Jane Halonen, James Madison University; James Hansel], University of Michigan; Neth Hansjoerg, Rensselaer Polytechnic Institute;
ABNORvAL PSYCHOLOGY: PAST AND PRESENT
lisha cries herself to sleep every night. She is certain that the future holds nothing but misery. Indeed, this is the only thing she does feel certain about. "I'm going to suffer and suffer and suffer, and my daughters will suffer as well. We're doomed. The world
1...1 is ugly. I hate every moment of my life." She has great trouble sleeping. She is afraid to close her eyes. When she does, the hopelessness of her life—and the ugly future that awaits her daughters—becomes all the clearer to her. When she drifts off to sleep, her dreams are nightmares filled with terrible images—bodies, flooding, decay, death, destruction.
Some mornings Alisha even has trouble getting out of bed. The thought of facing another day overwhelms her. She wishes that she and her daughters were dead. "Get it over with. We'd all be better off." She feels paralyzed by her depression and anxiety, overwhelmed by her sense of hopelessness, too tired to move, too negative to try anymore. On such mornings, she huddles her daughters close to her, makes sure that the shades of her trailer home are drawn and the door locked, and sits away the day in the darkened room. She feels she has been assaulted by society and then deserted by the world and left to rot. She is both furious at life and afraid of it at the same time.
During the past year Brad has been hearing mysterious voices that tell him to quit his job, leave his family, and prepare far the coming invasion. These voices have brought tremendous confu- sion and emotional turmoil to Brad's life. He believes that they come from beings in distant parts of the universe who are somehow wired to him. Although it gives him a sense of purpose and specialness to be the chosen target of their communications, they also make him tense and anxious. He dreads the coming invasion, When he refuses an order, the voices insult and threaten him and turn his days into a waking nightmare.
Brad has put himself on a sparse diet against the possibility that his enemies may be contami- nating his food. He has found a quiet apartment far from his old haunts where he has laid in a good stock of arms and ammunition. His family and friends have tried to reach out to Brad, to understand his problems, and to dissuade him from the disturbing course he is taking. Every day, however, he retreats further into his world of mysterious voices and imagined dangers.
Most of us would probably consider Alisha's and Brad's emotions, thoughts, and behavior psychologically abnormal, the result of a state sometimes called psychopa- thology, maladjustment, emotional disturbance, or mental illness.These terms have been applied to the many problems that seem closely tied to the human brain or mind. Psychological abnormality affects the famous and the unknown, the rich and the poor. Actors, writers, politicians, and other public figures of the present and the past have struggled with it. Psychological problems can bring great suffering, but they can also be the source of inspiration and energy.
Because they are so common and so personal, these problems capture the interest of us all. Hundreds of novels, plays, films, and television programs have explored what many people see as the dark side of human nature, and self-help books flood the market. Mental health experts are popular guests on both televi- sion and radio, and some even have their own shows.
TOPIC OVERVIEW What Is Psychological Abnormality? Deviance Distress
Dysfunction Danger The Elusive Nature of Abnormality
What Is Treatment?
How Was Abnormality Viewed and Treated in the Past? Ancient Views and Treatments Greek and Roman Views and Treatments
Europe in the Middle Ages: Demonology Returns
The Renaissance and the Rise of Asylums
The Nineteenth Century: Reform and Moral Treatment The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives
Current Trends How Are People with Severe Disturbances Cared For?
How Are People with Less Severe Disturbances Treated? A Growing Emphasis on Preventing Disorders and Promoting Mental Health
Multicultural Psychology The Growing Influence of Insurance Coverage What Are Today's Leading Theories and Professions?
What Do Clinical Researchers Do? The Case Study
The Correlational Method The Experimental Method
What Are the Limits of Clinical Investigations?
Putting It Together: A Work in Progress
•abnormal psychology•The scien- tific study of abnormal behavior in an effort to describe, predict, explain, and change abnormal patterns of functioning.
•norms•A society's stated and unstated rules for proper conduct.
pculture•A people's common history, values, institutions, habits, skills, technol- ogy, and arts.
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The field devoted to the scientific study of the problems we find so fascinating is usually called abnormal psychology. As in any science, workers in this field, called clinical scientists, gather information systematically so that they may describe, predict, and explain the phenomena they study. The knowledge that they acquire is then used by clinical practitioners to detect, assess, and treat abnormal patterns of functioning.
,,,:What Is Psychological Abnormality? Although their general goals are similar to those of other scientific professionals, clinical scientists and practitioners face problems that make their work especially difficult. One of the most troubling is that psychological abnormality is very hard to define. Consider once again Alisha and Brad. Why are we so ready to call their responses abnormal?
While many definitions of abnormality have been proposed over the years, none has won total acceptance (Regier et al., 2009; Boysen, 2007). Still, most of the definitions have some common features, often called "the four Ds": deviance, distress, dysfunction, and danger. That is, patterns of psychological abnormality are typically deviant (differ- ent, extreme, unusual, perhaps even bizarre), distressing (unpleasant and upsetting to the person), dysfunctional (interfering with the person's ability to conduct daily activities in a constructive way), and possibly dangerous. This definition offers a useful starting point from which to explore the phenomena of psychological abnormality. As you will see, however, it has key limitations.
Deviance Abnormal psychological functioning is deviant, but deviant from what? Alisha's and Brad's behaviors, thoughts, and emotions are different from those that are considered normal in our place and time.We do not expect people to cry themselves to sleep each night, hate the world, wish themselves dead, or obey voices that no one else hears.
In short, abnormal behavior, thoughts, and emotions are those that differ markedly from a society's ideas about proper functioning. Each society establishes norms—stated and unstated rules for proper conduct. Behavior that breaks legal norms is considered to be criminal. Behavior, thoughts, and emotions that break norms of psychological functioning are called abnormal.
Judgments of abnormality vary from society to society.A society's norms grow from its particular culture—its history, values, institutions, habits, skills, technol- ogy, and arts. A society that values competition and assertiveness may accept ag- gressive behavior, whereas one that emphasizes cooperation and gentleness may consider aggressive behavior unacceptable and even abnormal. A society's values may also change over time, causing its views of what is psychologically abnormal to change as well. In Western society, for example, a woman's participation in the business world was widely considered inappropriate and strange a hundred years ago. Today the same behavior is valued.
Judgments of abnormality depend on specific circumstances as well as on cultural norms. What if, for example, we were to learn that the desperate unhappiness of Alisha was in fact occurring in the days, weeks, and months following Hurricane Katrina, the deadly storm that struck New Orleans in the summer of 2005—a storm whose aftermath destroyed her home and deprived her of all of her earthly possessions, shattering the modest but happy life she and her family had once known? In the weeks and months that followed the storm, Alisha came to ap- preciate that help was not coming and that she would probably not be reunited with the friends and neighbors who had once given her life so much meaning. As she and her daughters moved from one temporary run-down location to another throughout Louisiana and Mississippi,Alisha gradually gave up all hope that her life would ever return to normal. In this light, Alisha's reactions do not seem quite so inappropriate. If anything is abnormal here, it is her situation. Many human experiences produce intense reactions—large-scale catastrophes and di-
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Abnormal Psychology: Past and Present :1/ 3
sasters, rape, child abuse, war, terminal illness, chronic pain (Miller, 2007). Is there an "appropriate" way to react to such things? Should we ever call reactions to them abnormal?
Distress Even functioning that is considered unusual does not necessarily qualify as abnormal.According to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they can be labeled abnormal. Consider the Ice Breakers, a group of people in Michigan who go swimming in lakes throughout the state every weekend from November through February. The colder the weather, the better they like it. One man, a member of the group for 17 years, says he loves the challenge of man against nature. A 37-year-old lawyer believes that the weekly shock is good for her health. "It cleanses me," she says. "It perks me up and gives me strength."
Certainly these people are different from most of us, but is their be- havior abnormal? Far from experiencing distress, they feel energized and challenged. Their positive feelings must cause us to hesitate before we decide that they are functioning abnormally.
Should we conclude, then, that feelings of distress must always be present before a person's functioning can be considered abnormal? Not necessarily. Some people who function abnormally maintain a positive frame of mind. Consider once again Brad, the young man who hears mysterious voices. Brad does ex- perience distress over the coming invasion and the life changes he feels forced to make. But what if he enjoyed listening to the voices, felt honored to be chosen, and looked forward to saving the world? Shouldn't we still regard his functioning as abnormal?
Dysfunction Abnormal behavior tends to be dysfunctional; that is, it interferes with daily functioning. It so upsets, distracts, or confuses people that they cannot care for themselves properly, participate in ordinary social interactions, or work productively. Brad, for example, has quit his job, left his family, and prepared to withdraw from the productive life he once led.
Here again one's culture plays a role in the definition of abnormality. Our society holds that it is important to carry out daily activities in an effective manner.Thus Brad's behavior is likely to be regarded as abnormal and undesirable, whereas that of the Ice Breakers, who continue to perform well in their jobs and enjoy fulfilling relationships, would probably be considered simply unusual.
Danger Perhaps the ultimate in psychological dysfunctioning is behavior that becomes danger- ous to oneself or others. Individuals whose behavior is consistently careless, hostile, or confused may be placing themselves or those around them at risk. Brad, for example, seems to be endangering both himself, with his diet, and others, with his buildup of arms and ammunition.
Although danger is often cited as a feature of abnormal psychological functioning, research suggests that it is actually the exception rather than the rule (Freedman et al., 2007). Most people struggling with anxiety, depression, and even bizarre thinking pose no immediate danger to themselves or to anyone else.
The Eiusive Nature of Abnormality Efforts to define psychological abnormality typically raise as many questions as they answer. Ultimately, a society selects general criteria for defining abnormality and then uses those criteria to judge particular cases.
What Is Psychological Abnormality'?
The field devoted to the scientific study of abnormal behavior is called abnormal psychology. Abnormal functioning is generally considered to be deviant, distressful, dysfunctional, and dangerous. Behavior must also be considered in the context in which it occurs, however, and the concept of abnormality depends on the norms and values of the society in question.
4 ://CHAPTER 1
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One clinical theorist, Thomas Szasz (2006, 1997, 1960), places such emphasis on society's role that he finds the whole concept of mental illness to be invalid, a myth of sorts. According to Szasz, the deviations that society calls abnormal are simply "problems in living," not signs of something wrong within the person. Societies, he is convinced, invent the concept of mental illness so that they can better control or change people whose unusual pat- terns of functioning upset or threaten the social order.
Even if we assume that psychological abnormality is a valid concept and that it can indeed be defined, we may be unable to apply our definition consistently. If a behavior—excessive use of alcohol among college students, say—is familiar enough, the society may fail to recognize that it is devi- ant, distressful, dysfunctional, and dangerous. Thousands of college students throughout the United States are so dependent on alcohol that it interferes with their personal and academic lives, causes them great discomfort, jeop- ardizes their health, and often endangers them and the people around them. Yet their problem often goes unnoticed and undiagnosed.Alcohol is so much a part of the college subculture that it is easy to overlook drinking behavior that has become abnormal.
Conversely, a society may have trouble separating an abnormality that needs interven- tion from an eccentricity, an unusual pattern with which others have no right to interfere. From time to time we see or hear about people who behave in ways we consider strange, such as a man who lives alone with two dozen cats and rarely talks to other people. The behavior of such people is deviant, and it may well be distressful and dysfunctional, yet many professionals think of it as eccentric rather than abnormal.
In short, while we may agree to define psychological abnormalities as patterns of functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that these criteria are often vague. In turn, few of the current categories of abnormality that you will read about in this book are as clear-cut as they may seem, and most continue to be debated by clinicians.
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*What Is Treatment? Once clinicians decide that a person is indeed suffering from some form of psychologi- cal abnormality, they seek to treat it. Treatment, or therapy, is a procedure to help change abnormal behavior into more normal behavior; it, too, requires careful definition. For clinical scientists, the problem is closely related to defining abnormality. Consider the case of Bill:
February: He cannot leave the house; Bill knows that for a fact. Home is the only place where he feels safe—safe from humiliation, danger, even ruin. If he were to go to work, his co-workers would somehow reveal their contempt for him. A pointed remark, a quizzi- cal look—that's all it would take for him to get the message. If he were to go shopping, before long everyone in the store would be staring at him. Surely others would see his dark
Marching to a Different Drummer: Eccentrics Writer James Joyce always carried a tiny pair of lady's bloomers, which he waved in the air to show approval.
z= Benjamin Franklin took "air baths" for his health, sitting naked in front of an open window.
Alexander Graham Bell covered the windows of his house to keep out the rays of the full moon. He also tried to teach his dog how to talk.
ti Writer D. H. Lawrence enjoyed removing his clothes and climbing mulberry trees.
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Abnormal Psydralagy: Past and Present :11 5
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!hese famous persons have been called eccentrics. The dictionary defines an
eccentric as a person who deviates from common behavior patterns or displays odd or whimsical behavior. But how can we separate a psychologically healthy person who has unusual habits from a person whose oddness is a symptom of psycho- pathology? Little research has been done on eccentrics, but a few studies seem to offer some insights (Pickover, 1999; Weeks & James, 1995).
Researcher David Weeks studied 1,000 eccentrics and estimated that as many as
1 in 5,000 persons may be "classic, full- time eccentrics." Weeks pinpointed 15 characteristics common to the eccentrics in his study: nonconformity, creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being dif- ferent, high intelligence, outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others' opinions or company, mischievous sense of humor, nonmarriage, eldest or only child, and poor spelling skills.
Weeks suggests that eccentrics do not typically suffer from mental disorders.
Whereas the unusual behavior of persons with mental disorders is thrust upon them and usually causes them suffering, ec- centricity is chosen freely and provides pleasure. In short, "Eccentrics know they're different and glory in it" (Weeks & James, 1995, p. 14). Similarly, the thought processes of eccentrics are not severely disrupted and do not leave these persons dysfunctional. In fact, Weeks found that eccentrics in his study actually had fewer emotional problems than individuals in the general population. Perhaps being an "original" is good for mental health.
mood and thoughts; he wouldn't be able to hide them. He dare not even go for a walk alone in the woods—his heart would probably start racing again, bringing him to his knees and leaving him breathless, incoherent, and unable to get home. No, he's much better off staying in his room, trying to get through another evening of this curse coiled life.
July: Bill's life revolves around his circle of friends: Bob and Jack, whom he knows from the office, where he was recently promoted to director of customer relations, and Frank and Tim, his weekend tennis partners. The gong meets for dinner every week at some- one's house, and they chat about life, politics, and their jobs. Particularly special in Bill's life is Lisa. They go to movies, restaurants, and shows together. She thinks Bill's just terrific, and Bill finds himself beaming whenever she's around. Bill looks forward to work each day and to his one-on-one dealings with customers. He is enjoying life and basking in the glow of his many activities and relationships.
Bill's thoughts, feelings, and behavior interfered with all parts of his life in Febru- ary. Yet most of his symptoms had disappeared by July. All sorts of factors may have contributed to Bill's improvement—advice from friends and family members, a new
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job or vacation, or perhaps a big change in his diet or exercise regimen. Any or all of these things may have been useful to Bill, but they could not be considered treatment, or therapy. Those terms are usually reserved for special, systematic procedures for help- ing people overcome their psychological difficulties. According to the clinical theorist Jerome Frank, all forms of therapy have three key features:
1. A sufferer who seeks relief from the healer.
2. A trained, socially accepted healer; whose expertise is accepted by the sufferer and his or her social group.
3. A series of contacts between the healer and the sufferer, through which the healer . . . often tries to produce certain changes in the sufferer's emotional state, attitudes, and behavior.
(Frank, 1973, pp. 2-3)
Despite this straightforward definition, clinical treatment is surrounded by conflict and confusion. Carl Rogers, a pioneer in the modern clinical field (you will meet him in Chapter 2), noted that "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."
Some clinicians view abnormality as an illness and so consider therapy a procedure that helps cure the illness. Others see abnormality as a problem in living and therapists as teachers of more functional behavior and thought. Clinicians even differ on what to call the person who receives therapy: those who see abnormality as an illness speak of the "patient," while those who view it as a problem. in living refer to the "client." Because both terms are so common, this book will use them interchangeably.
Despite their differences, most clinicians do agree that large numbers of people need therapy of one kind or another. Later we shall encounter evidence that therapy is indeed often helpful (Hofinann & Weinberger, 2007).
What Is Trec ,:ment?
Therapy is a systematic process for helping people overcome their psychological difficulties. It may differ from problem to problem and from therapist to therapist, but it typically includes a patient, a therapist, and a series of therapeutic contacts.
*Flow Was Abnormality Viewed and Treated in the Past? In any given year as many as 30 percent of the adults and 19 percent of the children and adolescents in the United States display serious psychological disturbances and are in need of clinical treatment (Kessler et al., 2009,2007,2005; Kazdin, 2003,2000; Narrow et al., 2002). The rates in other countries are similarly high. Furthermore, most people have difficulty coping at various times and go through periods of extreme tension, de- jection, or other forms of psychological discomfort.
It is tempting to conclude that something about the modern world is responsible for these many emotional problems—perhaps rapid technological change, the growing threat of terrorism, or a decline in religious, family, or other support systems (Corner & Kendall, 2007). Although the pressures of modern life probably do contribute to psychological dysfunctioning, they are hardly its primary cause. Every society, past and present, has witnessed psychological abnormality. Perhaps, then, the proper place to begin our examination of abnormal behavior and treatment is in the past.
6 . //CHAPTER 1
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Abnormal Psychology: Past and Present :fi 7
Ancient Views and Treatments Historians who have examined the unearthed bones, artwork, and other remnants of ancient societies have concluded that these societies probably regarded abnormal behavior as the work of evil spirits. People in prehistoric societies apparently believed that all events around and within them resulted from the actions of magical beings who controlled the world. In particular, they viewed the human body and mind as a battleground between external forces of good and evil.Abnormal behavior was typically interpreted as a victory by evil spirits, and the cure for such behavior was to force the demons from a victim's body.
This supernatural view of abnormality may have begun as far back as the Stone Age, a half-million years ago. Some skulls from that period recovered in Europe and South America show evidence of an operation called trephination, in which a stone instru- ment, or trephine, was used to cut away a circular section of the skull. Some historians have concluded that this early operation was performed as a treatment for severe abnor- mal behavior—either hallucinations, in which people saw or heard things not actually present, or melancholia, which was characterized by extreme sad- ness and immobility. The purpose of opening the skull was to release the j evil spirits that were supposedly causing the problem (Selling, 1940).
Later societies also explained abnormal behavior by pointing to possession by demons. Egyptian, Chinese, and Hebrew writings all accounted for psychological deviance this way, and the Bible describes how an evil spirit from the Lord affected King Saul and how David pretended to be mad to convince his enemies that he was visited by divine forces.
The treatment for abnormality in these early societies was often exorcism. The idea was to coax the evil spirits to leave or to make the person's body an uncomfortable place in which to live.A shaman, or priest, might recite prayers, plead with the evil spirits, insult them, perform magic, make loud noises, or have the person ingest bitter drinks. If these techniques failed, the shaman performed a more extreme form of exorcism, such as whipping or starving the person.
Greek and Roman Views and Treatments In the years from roughly 500 B.C. to 500 AM. , when the Greek and Roman civilizations thrived, philosophers and physicians often offered different explanations for abnormal behaviors. Hippocrates (460-377 B.c.), often called the father of modern medicine, taught that illnesses had natural causes. He saw abnormal behavior as a disease caused by internal physical problems. Specifically, he believed that some form of brain disease was to blame and that it resulted—like all other forms of disease, in his view—front an imbalance of four fluids, or humors, that flowed through the body: yellow bile, black bile, blood, and phlegm (Arikha, 2007). An excess of yellow bile, for example, caused frenzied activity; an excess of black bile was the source of unshakable sadness.
To treat psychological dysfunctioning, Hippocrates sought to correct the underlying physical pathology. He believed, for instance, that the excess of black bile underlying sadness could be reduced by a quiet life, a diet of vegetables, exercise, celibacy, and even bleeding. Hippocrates' focus on internal causes for abnormal behavior was shared by the great Greek philosophers Plato (427-347 B.c.) and Aristotle (384-322 B.c.) and by influential Greek and Roman physicians.
Europe in the Middle Ages: Demonology Returns The enlightened views of Greek and Roman physicians and scholars were not enough to shake ordinary people's belief in demons. And with the decline of Rome, demono- logical views and practices became popular once again. A growing distrust of science spread throughout Europe.
•trephination•An ancient operation in which a stone instrument was used to cut away a circular section of the skull, per- haps to treat abnormal behavior.
•humors•According to the Greeks and Romans, bodily chemicals that influence mental and physical functioning.
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'moral treatmentDA nineteenth-century approach to treating people with men- tal dysfunction that emphasized moral guidance and humane and respectful treatment.
From 500 to 1350 A.D., the period known as the Middle Ages, the power of the clergy increased greatly throughout Europe. In those days the church rejected scientific Corms of investigation, and it controlled all education. Religious beliefs, which were highly superstitious and demonological, came to dominate all aspects of life. Once again behavior was usually interpreted as a conflict between good and evil, God and the devil. Deviant behavior, particularly psychological dysfunctioning, was seen as evidence of Satan's influence. Although some scientists and physicians still insisted on medical explanations and treatments, their views carried little weight in this atmosphere.
The Middle Ages were a time of great stress and anxiety—a time of war, urban uprisings, and plagues. People blamed the devil for these troubles and feared being possessed by him. Abnormal behavior apparently increased greatly during this period (Henley & Thorne, 2005). In addition, there were outbreaks of mass madness, in which large numbers of people apparently shared absurd false beliefs and imagined sights or sounds. In one such disorder, tarantism (also known as Saint Vitus' dance), groups of people would suddenly start to jump, dance, and go into convulsions (Sigerist, 1943).All were convinced that they had been bitten and possessed by a wolf spider, now called a taran- tula, and they sought to cure their disorder by performing a dance called a tarantella. In another form of mass madness, lycanthron people thought they were possessed by wolves or other animals. They acted wolflike and imagined that fur was growing all over their bodies.
Not surprisingly, some of the earlier demonological treatments for psychological ab- normality reemerged during the Middle Ages. Once again the key to the cure was to rid the person's body of the devil that possessed it. Exorcisms were revived, and clergymen, who generally were in charge of treatment during this period, would plead, chant, or pray to the devil or evil spirit (Sluhovsky, 2007). If these techniques did not work, they had others to try, such as starving, whipping, scalding, or stretching the individual.
It was not until the Middle Ages drew to a close that demonology and its meth- ods began to lose favor. Towns throughout Europe grew into cities, and government officials gained more power and took over nonreligious activities. Among their other responsibilities, they began to run hospitals and direct the care of people suffering from mental disorders. Medical views of abnormality gained favor, and many people with psychological disturbances received treatment in medical hospitals, such as the Trinity Hospital in England (Allderidge, 1979, p. 322).
The Renaissance and the Rise of Asylums During the early part of the Renaissance, a period of flourishing cultural and scientific activity from about 1400 to 1700, demonological views of abnormality continued to decline. German doctor Johann Weyer (1515-1588), the first physician to specialize in mental illness, believed that the mind was as susceptible to sickness as the body was. He is now considered the founder of the modern study of psychopathology.
The care of people with mental disorders continued to improve in this atmosphere. In England such individuals might be kept at home while their families were aided financially by the local parish. Across Europe religious shrines were devoted to the humane and loving treatment of people with mental disorders. Perhaps the best known of these shrines was at Gheel in Belgium. Beginning in the fifteenth century, people came to it from all over the world for psychic healing. Local residents welcomed these pilgrims into their homes, and many stayed on to form the world's first "colony" of mental patients. Gheel was the forerunner of today's community mental health programs, and it continues to demonstrate that people with psychological disorders can respond to loving care and respectful treatment (van Walsum, 2004; Aring, 1975, 1974). Many patients still live in foster homes there, interacting with other residents, until they recover.
Unfortunately, these improvements in care began to fade by the mid- sixteenth century. Government officials discovered that private homes and
8 ://CHAPTER
Abnormal Psychology: Past and Present :// 9
community residences could house only a small percentage of those with severe mental disorders and that medical hospitals were too few and too small. More and more, they converted hospitals and monasteries into asylums, in- stitutions whose primary purpose was to care for people with mental illness. These institutions began with every intention of providing good care. Once the asylums started to overflow; however, they became virtual prisons where patients were held in filthy conditions and treated with unspeakable cruelty.
In 1547, for example, Bethlehem Hospital was given to the city of Lon- don by Henry VIII for the sole purpose of confining the mentally ill. In this asylum patients bound in chains cried out for all to hear.The hospital actually became a popular tourist attraction; people were eager to pay to look at the howling and gibbering inmates.The hospital's name, pronounced "Bedlam" by the local people, has come to mean a chaotic uproar.
The Nineteenth Century: Reform and Moral Treatment As 1800 approached, the treatment of people with mental disorders began to improve once again (Maher & Maher, 2003). Historians usually point to La Bic6tre, an asylum in Paris for male patients, as the first site of asylum reform. In 1793, during the French Revolution, Philippe Pinel (1745-1826) was named the chief physician there. He ar- gued that the patients were sick people whose illnesses should be treated with sympathy and kindness rather than chains and beatings (van Walsum, 2004). He allowed them to move freely about the hospital grounds, replaced the dark dungeons with sunny, well- ventilated rooms, and offered support and advice. Pinel's approach proved remarkably successful. Many patients who had been shut away for decades improved greatly over a short period of time and were released. Pinel later brought similar reforms to a mental hospital in Paris for female patients, La Salpetriere.
Meanwhile, an English Quaker named William Tuke (1732-1819) was bringing similar reforms to northern England. In 1796 he founded theYork Retreat, a rural estate where about 30 mental patients lived as guests in quiet country houses and were treated with a combination of rest, talk, prayer, and manual work (Charland, 2007).
The Spread of Mor i Tref trnent The methods of Pinel and Tuke, called moral treatment because they emphasized moral guidance and humane and respectful tech- niques, caught on throughout Europe and the United States. Patients with psychologi- cal problems were increasingly perceived as potentially productive human beings whose mental functioning had broken down under stress.They were considered deserv- ing of individual care, including discussions of their prob- lems, useful activities, work, companionship, and quiet.
The person most responsible for the early spread of moral treatment in the United States was Benjamin Rush (1745-1813), an eminent physician at Pennsylvania Hospital who is now considered the father of American psychiatry. Limiting his practice to mental illness, Rush developed humane approaches to treatment (Whitaker, 2002). For example, lie required that the hospital hire intelligent and sensitive attendants to work closely with patients, reading and talking to them and taking them on regular walks. He also suggested that it would be therapeutic for doctors to give small gifts to their patients now and then.
Rush's work was influential, but it was a Boston schoolteacher named Dorothea Dix (1802-1887) who made humane care a public concern in the United States. From 1841 to 1881 Dix went from state legislature to
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state legislature and to Congress speaking of the horrors she had observed at asylums and calling for reform. Dix's campaign led to new laws and greater government funding to improve the treatment of people with mental disorders. Each state was made responsible for developing effective public mental hospitals, or state hospitals, all of which intended to offer moral treatment (Boardman & Makari, 2007). Similar hospitals were established throughout Europe.
The Decline of Moral Treatment By the 1850s, a number of mental hospitals throughout Europe and America reported success using moral approaches. By the end of that century, however, several factors led to a reversal of the moral treatment movement (Bockoven, 1963). One factor was the speed with which the movement had spread. As mental hospitals multiplied, severe money and staffing shortages developed, and recovery rates declined.Another factor was the assump- tion behind moral treatment that all patients could be cured if treated with humanity and dignity. For some, this was indeed sufficient. Others, however, needed more effective treatments than any that had yet been developed. An additional factor contributing to the decline of moral
treatment was the emergence of a new wave of prejudice against people with mental disorders. As more and more patients disappeared into large, distant mental hospitals, the public came to view them as strange and dangerous. In turn, people were less open- handed when it came to making donations or allocating government funds.
By the early years of the twentieth century, the moral treatment movement had ground to a halt in both the United States and Europe. Public mental hospitals were providing only custodial care and ineffective medical treatments and were becoming more overcrowded every year. Long-term hospitalization became the rule once again.
• state hospitals•State-run public mental institutions in the United States.
• somatogenic perspective•The view that abnormal psychological Functioning has physical causes.
spsychoenic perspective•The view that the chief causes of abnormal func- tioning are psychological.
The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives As the moral movement was declining in the late 1800s, two opposing perspectives emerged and began to compete for the attention of clinicians: the somatogenic per- spective, the view that abnormal psychological functioning has physical causes, and the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. These perspectives came into full bloom during the twentieth century.
The Sornatogenic Perspective The somatogenic perspective has at least a 2,400- year history—remember Hippocrates' view that abnormal behavior resulted from brain disease and an imbalance of humors? Not until the late nineteenth century, however, did this perspective make a triumphant return and begin to gain wide acceptance.
Two factors were responsible for this rebirth. One was the work of an eminent German researcher, Emil Kraepelin (1856-1926). In 1883 Kraepelin published an influ- ential textbook arguing that physical factors, such as fatigue, are responsible for mental dysfunction. In addition, as you will see in Chapter 3, he developed the first modern system for classifying abnormal behavior (de Vries et al., 2008; Engstrom et al., 2006).
New biological discoveries also triggered the rise of the somatogenic perspective. One of the most important discoveries was that an organic disease, syphilis, led to gen- eral paresis, an irreversible disorder with both physical and mental symptoms, including paralysis and delusions of grandeur. In 1897 Richard von Krafft-Ebing (1840-1902), a German neurologist, injected matter from syphilis sores into patients suffering from general paresis and found that none of the patients developed symptoms of syphilis. Their immunity could have been caused only by an earlier case of syphilis. Since all patients with general paresis were now immune to syphilis, Krafft-Ebing theorized that syphilis had been the cause of their general paresis.
The work of Kraepelin and the new understanding of general paresis led many researchers and practitioners to suspect that physical factors were responsible for many
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mental disorders, perhaps all of them. These theories and the possibility of quick medi- cal solutions for mental disorders were especially welcomed by those who worked in mental hospitals, where patient populations were now growing at an alarming rate.
Despite the general optimism, biological approaches yielded mostly disappointing results throughout the first half of the twentieth century. Although many medical treat- ments were developed for patients in mental hospitals during that time, most of the techniques failed to work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy (alternating hot and cold baths), and lobotomy, a surgical cutting of certain nerve fibers in the brain. Even worse, biological views and claims led, in some circles, to proposals for immoral solutions such as eugenic sterilization, the elimination (through medical or other means) of individuals' ability to reproduce (see Table 1-1). Not until the 1950s, when a number of effective medications were finally discovered, did the somatogenic perspective truly begin to pay off for patients.
The Psychogenic Perspective The late nineteenth century also saw the emer- gence of the psychogenic perspective, the view that the chief causes of abnormal func- tioning are often psychological. This view, too, had a long history, but it did not gain much of a following until studies of hypnotism demonstrated its potential.
Hypnotism is a procedure that places people in a trancelike mental state during which they become extremely suggestible. It was used to help treat psychological dis- orders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734-1815) started a clinic in Paris. His patients suffered from hysterical disorders, mys- terious bodily ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room filled with music; then he appeared, dressed in a colorful costume, and touched the troubled area of each patient's body with a special rod. A surprising number of patients seemed to be helped by this treatment, called mesmerism. Their pain, numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients and that this state was causing their symptoms to disap- pear (Marcel, 2009; Lynn & Kirsch, 2006).The treatment was so controversial, however, that eventually Mesmer was banished from Paris.
Eugenics and Mental Disorders
Year Event 1896 Connecticut became the first state in the United States to prohibit
persons with mental disorders from marrying.
1896-1933 Every state in the United States passed a law prohibiting marriage by persons with mental disorders.
1907 Indiana became the first state to pass a bill calling for people with mental disorders, as well as criminals and other "defectives," to undergo sterilization.
1927 The U.S. Supreme Court ruled that eugenic sterilization was constitutional.
1907-1945 Around 45,000 Americans were sterilized under eugenic sterilization laws; 21,000 of them were patients in state mental hospitals.
1929-1932 Denmark, Norway, Sweden, Finland, and Iceland passed eugenic sterilization laws.
1933 Germany passed a eugenic sterilization law, under which 375,000 people were sterilized by 1940.
1940 Nazi Germany began to use "proper gases" to kill people with mental disorders; 70,000 or more people were killed in less than two years.
Source: Whitaker, 2002. 1
abnormal psychopathology psychiatric
maladjustment
insanity distressed disturbed unbalanced unstable freak-out
mental illness
"nuts" (slang)
mentally handicapped
deviant
psychological
buts , use words like "abnormal" and
' I "mental disorder" so often that it is easy to forget that there was a time not
that long ago when these terms did not exist. When did these and similar words (including slang terms) make their debut in
print as expressions of psychological dys- functioning? The Oxford English Dictionary offers the following dates.
1300 1400
madness
1600
"crazy" (slang)
1700 1800 1900 2000
dysfunctional
1500 1200
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It was not until years after Mesmer died that many researchers had the courage to investigate his procedure, later called hypnotism (from hypnos, the Greek word for "sleep"), and its effects on hysteri- cal disorders. The experiments of two physicians practicing in the city of Nancy in France, Hippolyte-Marie Bernheim (1840-1919) and Ambroise-Auguste Liebault (1823-1904), showed that hysterical dis- orders could actually be produced in otherwise normal people while they were under the influence of hypnosis.That is, the physicians could make normal people experience deafness, paralysis, blindness, or numb- ness by means of hypnotic suggestion—and they could remove these artificial symptoms by the same means. Thus they established that a mental process—hypnotic suggestion—could both cause and cure even a physical dysfunction. Leading scientists concluded that hysterical disorders were largely psychological in origin, and the psychogenic perspective rose in popularity.
Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer (1842-1925) of Vienna. This physician discovered that his patients sometimes awoke free of hysterical symptoms after speaking candidly under hypnosis about past upsetting events. During the 1890s Breuer was joined in his work by another Viennese physician, Sigmund Freud (1856-1939). As you will see in Chapter 2, Freud's work eventually led him to develop the theory of psychoanalysis, which holds that many forms of abnormal and normal psychological functioning are psychogenic. In particular, he believed that unconscious psychological processes are at the root of such functioning.
Freud also developed the technique of psychoanalysis, a form of discussion in which clinicians help troubled people gain insight into their unconscious psychological pro- cesses. He believed that such insight, even without hypnotic procedures, would help the patients overcome their psychological problems.
Freud and his followers offered psychoanalytic treatment primarily to those patients who did not typically require hospitalization. These patients visited therapists in their offices for sessions of approximately an hour and then went about their daily activities— a format of treatment now known as outpatient therapy. By the early twentieth century, psychoanalytic theory and treatment were widely accepted throughout the Western world.
12 :41/CHAPTER
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Abnormal Psychology: Past and Present :1/ 13
•psychoanalysis.Either the theory or the treatment of abnormal mental func- tioning that emphasizes unconscious psychological forces as the cause of psychopathology.
•psychotropic medications• Drugs that mainly affect the brain and reduce many symptoms of mental dysfunctioning.
How Was Abnormality Viewed and Treated in the Past?
The history of psychological disorders stretches back to ancient times. Prehistoric societies apparently viewed abnormal behavior as the work of evil spirits. There is evidence that Stone Age cultures used trephination, a primitive form of brain surgery, to treat abnormal behavior. People of early societies also sought to drive out evil spirits by exorcism.
Physicians of the Greek and Roman empires offered more enlightened explana- tions of mental disorders. Hippocrates believed that abnormal behavior was caused by an imbalance of the four bodily fluids, or humors.
Unfortunately, throughout history each period of enlightened thinking about psychological functioning has been followed by a period of backward thinking. In the Middle Ages, for example, Europeans returned to demonological explanations of abnormal behavior. The clergy was very influential and held that mental disorders were the work of the devil. As the Middle Ages drew to a close, such explana- tions and treatments began to decline, and care of people with mental disorders improved during the early part of the Renaissance. Certain religious shrines offered humane treatment. Unfortunately, this enlightened approach was short-lived, and by the middle of the sixteenth century persons with mental disorders were being warehoused in asylums.
Care of people with mental disorders started to improve again in the nine- teenth century. Moral treatment began in Europe and spread to the United States, where Dorothea Dix's national campaign helped lead to the establishment of state hospitals. Unfortunately, the moral treatment movement disintegrated by the late nineteenth century, and public mental hospitals again became warehouses where inmates received minimal care.
The turn of the twentieth century saw the return of the somatogenic perspective, the view that abnormal psychological functioning is caused primarily by physical factors. The same period saw the rise of the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. Sigmund Freud's psychogenic approach, psychoanalysis, eventually gained wide acceptance and influenced future generations of clinicians.
",`Current Trends It would hardly be accurate to say that we now live in a period of great enlightenment about or dependable treatment of mental disorders. In fact, surveys have found that 43 percent of respondents believe that people bring mental disorders on themselves and that 35 percent consider such disorders to be caused by sinful behavior (Stanford, 2007; NMHA, 1999). Nevertheless, the past 50 years have brought major changes in the ways clinicians understand and treat abnormal functioning. More theories and types of treatment exist, as do more research studies, more information, and, perhaps for these reasons, more disagreements about abnormal functioning today than at any time in the past. In some ways the study and treatment of psychological disorders have come a long way, but in other respects clinical scientists and practitioners are still struggling to make a difference.
How Are People with Severe Disturbances Cared For? In the 1950s researchers discovered a number of new psychotropic medications— drugs that primarily affect the brain and reduce many symptoms of mental dysfunction- ing. They included the first antipsychotic drugs, which correct extremely confused and
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distorted thinking; antidepressant drugs, which lift the mood of depressed people; and antianxiety drugs, which reduce tension and worry.
When given these drugs, many patients who had spent years in mental hospitals began to show signs of improvement. Hospital ad- ministrators, encouraged by these results and pressured by a growing public outcry over the terrible conditions in public mental hospitals, began to discharge patients almost immediately.
After the discovery of these medications, mental health profession- als in most of the developed nations of the world followed a policy of deinstitutionalization, releasing hundreds of thousands of patients from public mental hospitals. On any given day in 1955, close to 600,000 people lived in public mental institutions across the United States (see Figure 1-1). Today the daily patient population in the same kinds of hospitals is around 60,000 (Torrey, 2006, 2001).
In short, outpatient care has now become the primary mode of treatment for people with severe psychological disturbances as well as for those with more moderate problems. Today when very disturbed people do need institutionalization, they are usually given short-term hospitalization. Ideally, they are then given outpatient psychotherapy and medication in community programs and residences (McEvoy & Richards, 2007).
Chapters 2 and 12 will look more closely at this recent emphasis on cornmu- nity care for people with severe psychological disturbances—a philosophy called the community mental health approach. The approach has been helpful for many patients, but too few community programs are available to address current needs in the United States (Rosenberg & Rosenberg, 2006). As a result, hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth be- tween 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. In fact, only 40 percent of persons with severe psychological disturbances currently receive treatment of any kind (Wang et al., 2007, 2005). At least 100,000 individuals with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons (Bonin et al., 2009; Cutler et al., 2002). Their abandonment is truly a national disgrace.
14 ://CHAPTER 1
How Are People with Less Severe Disturbances Treated? The treatment picture for people with moderate psychological disturbances has been more positive than that for people with severe disorders. Since the 1950s, outpatient
care has continued to be the preferred mode of treatment for them,
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and the number and types of facilities that offer such care have expanded to meet the need.
Before the 1950s, almost all outpatient care took the form of private psychotherapy, an arrangement by which an individual directly pays a psychotherapist for counseling services.This tended to be an expensive form of treatment, available only to the wealthy. Since the 1950s, however, most health insurance plans have expanded coverage to include private psychotherapy, so that it is now also widely available to people with more modest incomes. In addition, outpatient therapy is now offered in a number of less expensive set- tings, such as community mental health centers, crisis intervention centers, family service centers, and other social service agencies. The new settings have spurred a dramatic increase in the number of persons seeking outpatient care for psychological problems. Surveys suggest that nearly 1 of every 5 adults in the United States receives treatment for psychological disorders in the course of a year (Wang
Abnormal Psychology: Past and Present 1 5
_rn Pressures: Modern Problems he twenty-first century, like each of the centuries before it, has spawned
new fears that are tied to its unique techno- logical advances, community threats, and environmental dangers. These fears have received little study. They may or may not reflect abnormal functioning. Indeed, we could argue that some of them represent appropriate concerns about very real problems. Either way, they have caught the attention of the media and clinical observ- ers and, perhaps most importantly, have received catchy names.
"Ea:I-Anxiety" People who suffer from this problem are tormented by concern and a sense of doom over our polluted and endangered environment. They often complain of panic attacks, loss of appe- tite, irritability, and unexplained bouts of weakness and sleeplessness. These fears are fueled by abundant media cover- age of crises such as global warming, collapsed fisheries, and food shortages (Nobel, 2007). A treatment approach called ecopsychology is now practiced by hundreds of therapists to help reduce the anxiety of such individuals (Glaser, 2008).
"Terrorism Terror" Global terrorism is a major source of anxiety in contem- porary society, particularly since the Sep- tember 11, 2001, attacks on the World Trade Center in New York City and the Pentagon in Washington, DC. Everyday hassles of the past have turned into po- tential threats by their association with the actions of terrorists (Furedi, 2007). When boarding planes, subway cars, or buses, for example, many travelers
who formerly worried only about the low risks of flying or the possibility of being late for work may now find themselves worrying that the transporting vehicles are about to become targets or tools of terrorist actions.
"Crime Phobia" People today have become increasingly anxious about crime. Some observers note that the fear of crime—predominantly armed violence—has restructured the lives of Americans. Says political scientist Jona- than Simon, "Fear of crime governs us in our choices of where to live, where to work, where to send our children to school" (quoted in Bergquist, 2002). Many theorists point to disproportionate media coverage of violent crimes as a major cause of crime phobia, particu- larly given that crime anxiety seems to
keep rising even while actual crime rates are falling (Stearns, 2006).
"Cyber Fear" Some people, particu- larly individuals in the workplace, are literally afraid of their computers. They fear that they will break the computers or be unable to learn new computer tasks. Among more sophisticated computer users, many live in fear of computer crashes, server overloads, or computer viruses. And some, stricken by a combi- nation of crime phobia and cyber fear, worry constantly about e-crimes, such as computer hoaxes or scams, computer- identity theft, or cyberterrorism. The flip side of cyber fear is Internet addiction, the uncontrollable need to be online—yet another technology-driven problem that you'll be coming across in Chapter 13.
et al., 2007, 2005). The majority of clients are seen for fewer than five sessions during the year.
Outpatient treatments are also becoming available for more and more kinds of problems. When Freud and his colleagues first began to practice, most of their patients suffered from anxiety or depression.Almost half of today's clients suffer from those same problems, but people with other kinds of disorders are also receiving therapy. In addition, at least 20 percent of clients enter therapy because of problems in living—problems with marital, family, job, peer, school, or community relationships (Druss et al., 2007).
•cieinstitutionaiization•The practice, begun in the 1960s, of releasing hun- dreds of thousands of patients from public mental hospitals.
16 ://CHAPTER 1
• prevention•Interventions aimed at deterring disorders before they develop.
•positive psychology•The study and enhancement of positive feelings, traits, and abilities.
•multicultural psychology•The field that examines the impact of culture, race, gender, and similar factors on our behav- iors and focuses on how such factors may influence abnormal behavior.
•managed care program•A system of health care coverage in which the insurance company largely controls the nature, scope, and cost of services.
Yet another change in outpatient care since the 1950s has been the development of programs devoted exclusively to one kind of psychological problem. We now have, for example, suicide prevention centers, substance abuse programs, eating disorder programs, phobia clinics, and sexual dysfunction programs. Clinicians in these programs have the kind of expertise that can be acquired only by concentration in a single area.
A Growing Emphasis on Preventing Disorders and Promoting Mental Health Although the community mental health approach often has failed to address the needs of people with severe disorders, it has given rise to an important principle of mental health care—prevention (Evans, 2009; Bond & Hauf, 2007). Rather than wait for psychological disorders to occur, many of today's community programs try to correct the social conditions that give rise to psychological problems (poverty or community violence, for example) and to help individuals who are at risk for developing emotional problems (for example, teenage mothers or the children of people with severe psycho- logical disorders). As you will see later, community prevention programs are not always successful and they often suffer from limited funding, but they have grown in number throughout the United States and Europe, offering great promise as the ultimate form of intervention.
Psychology: Happiness Is All Around Us 6udging from many websites, TV news
:gshows, and the spread of self-help
books, you might think that happiness is
rare. But there's good news. Research indicates that people's lives are, in gen- eral, more upbeat than we think. In fact,
most people around the world say they're happy—including most of those who are poor, unemployed, elderly, and disabled (Becchetti & Santoro, 2007; Pugno, 2007). Men and women are equally likely to declare themselves sat- isfied or very happy. Wealthy people appear only slightly hap- pier than those of modest means (Easterbrook, 2005; Diener et al., 1993). Overall, only 1 person in 10 reports being "not too happy" (Myers, 2000; Myers & Diener, 1996), and only 1 in 7 reports waking up unhappy (Wallis, 2005).
Of course, some people are indeed happier than others. Particularly happy people seem to remain happy from decade to decade, regardless of job changes, moves, and family changes (Becchetti & Santoro, 2007; Diener et al., 2000). Such people adjust to negative events and return to their usual cheerful state within a few months (Diener et al., 2009, 2006, 1992). Conversely, unhappy people are not cheered in the long term even by posi- tive events.
Some research indicates that happiness is linked to personality characteristics and interpretive styles (Diener et al., 2006; Stewart et al., 2005). Happy people are, for example, generally optimistic, outgoing, curious, and tender-minded; they also tend to persevere, have several close friends, possess high self-esteem, be spiritual, and have a sense of control over their lives (Peterson et al., 2007; Sahoo et al., 2005).
A better understanding of the roots of happiness is likely to emerge from the cur- rent flurry of research. In the meantime, we can take comfort in the knowledge that the human condition isn't quite as unhappy as news stories (and textbooks on abnormal psychology) may make it seem.
Abnormal Psychology: Past and Present :1/ 17
Prevention programs have been further energized in the past few years by the field of psychology's growing interest in positive psychology (Seligman, 2007). Positive psychology is the study and encouragement of positive feelings such as optimism and happiness; positive traits like hard work and wisdom; positive abilities such as social skills; and group-directed virtues, including generosity and tolerance.
In the clinical arena, positive psychology suggests that practitioners can help people best by promoting positive development and psychological wellness. While researchers study and learn more about positive psychology in the laboratory, clinicians with this orientation teach people coping skills that help protect them from stress and adversity and encourage them to become more involved in meaningful activities and relationships (Bond & Hauf, 2007). In this way, the clinicians are trying to promote mental health and prevent mental disorders.
Multicultural Psychology We are, without question, a society of multiple cultures, races, and languages. Indeed, in the coming decades, members of racial and ethnic minority groups in the United States will, collectively, outnumber white Americans (Gordon, 2005; U.S. Census Bureau, 2000). This change is partly because of shifts in immigration trends and partly because of higher birth rates among minority groups in the United States.The majority of new immigrants to this country are Hispanic (34 percent) or Asian (34 percent). Moreover, while the average number of children born to white Americans is 1.7, the number born to African Americans and Hispanic Americans is 2.4 and 2.9, respectively.
In response to this growing diversity, a new area of study called multicultural psychology has emerged. Multicultural psychologists seek to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders may differ psychologically (Alegria et al., 2009, 2007, 2004). As you will see throughout this book, the field of multicultural psychology has begun to have a powerful effect on our understanding and treatment of abnormal behavior.
The Growing Influence of Insurance Coverage So many people now seek therapy that private insurance companies have changed their coverage for mental health patients.Today the leading form of coverage is the managed care program—a program in which the insurance company determines such key issues as which therapists its clients may choose, the cost of sessions, and the number of sessions for which a client may be reimbursed (Shore, 2007; Reed & Eisman, 2006).
At least 75 percent of all privately insured persons in the United States are cur- rently enrolled in managed care programs (Deb et al., 2006; Kiesler, 2000).The coverage for mental health treatment under such programs follows the same basic principles as coverage for medical treatment, including a limited pool of practitioners from which patients can choose, preapproval of treatment by the insurance company, strict standards for judging whether problems and treatments qualify for reimbursement, and ongoing reviews and assessments. In the mental health realm, both therapists and clients typically dislike managed care programs (Cutler, 2007). They fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments whose results are not always lasting (for example, drug therapy), pose a special hardship for those with severe mental disorders, and put control of therapy into the hands of the insurance companies rather than the therapists (Whitaker, 2007).
A key problem with insurance coverage—both managed care and other kinds of insurance programs—is that reimbursements for mental disorders tend to be lower than those for medical disorders. This places persons with psychological difficulties at a dis- tinct disadvantage. Recently the federal government and 35 states passed so-called parity laws that direct insurance companies to provide equal coverage for mental and medical problems (Pear, 2008; Steverman, 2007). It is not yet clear, however, whether these laws will indeed lead to improved coverage or better treatment (Busch et al., 2006).
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Profiles of Mental Health Professionals in the United States
Degree Began to Practice
Current Number
Percent Female
Psychiatrists M.D., D.O. 1840s 33,000 25
Psychologists Ph.D., Psy.D., Ed.D. Late 1940s 152,000 52
Social workers M.S.W., D.S.W. Early 1950s 405,000 77
Counselors Various Early 1950s 375,000 50
Source: U.S. Bureau of Labor Statistics, 2008, 2002; AMA, 2007; APA, 2005; Weissman, 2000.
18 ://CHAPTER 1
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What Are Today's Leading Theories and Professions? One of the most important developments in the clinical field has been the growth of numerous theoretical perspectives that now coexist in the clinical field. Before the 1950s, the psychoanalytic perspective, with its emphasis on unconscious psychological problems as the cause of abnormal behavior, was dominant. Then the discovery of effective psychotropic drugs inspired new respect for the somatogenic, or biological, view. As you will see in Chapter 2, other influential perspectives that have emerged since the 1950s are the behavioral, cognitive, humanistic-existential, and sociocultural schools of thought. At present no single viewpoint dominates the clinical field as the psychoanalytic perspective once did. In fact, the perspectives often conflict and compete with one another, yet in some instances they complement each other and together provide
more complete explanations and treatments for psychological disorders. In addition, a variety of professionals now offer help to people with psychological
problems (Wang et al., 2006). Before the 1950s, psychotherapy was offered only by psy- chiatrists, physicians who complete three to four additional years of training after medical school (a residency) in the treatment of abnormal mental functioning. After World War II, however, with millions of soldiers returning home to countries throughout North America and Europe, the demand for mental health services expanded so rapidly that other professional groups had to step in to fill the need.
Among those other groups are clinical psychologists—professionals who earn a doc- torate in clinical psychology by completing four to five years of graduate training in abnormal functioning and its treatment and also complete a one-year internship at a mental health setting. Psychotherapy and related services are also provided by counseling psychologists, educational and school psychologists, psychiatric nurses, marriage therapists, family therapists, and—the largest group psychiatricsocial workers (see Table 1-2). Each of these specialties has its own graduate training programs. Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the various specialties often use similar techniques.
One final key development in the study and treatment of mental disorders since World War II has been a growing appreciation of the need for effective research (Goodwin, 2007, 2002). Clinical researchers have tried to determine which concepts best
explain and predict abnormal behavior, which treatments are most effective, and what kinds of changes may be required. Today well-trained clinical researchers conduct stud- ies in universities, medical schools, laboratories, mental hospitals, mental health centers, and other clinical settings throughout the world.
Abnormal Psychology: Past and Present :1/ 19
•scientific method•The process of systematically gathering and evaluating information through careful observa- tions to gain an understanding of a phenomenon.
Current Trends
In the 1950s, researchers discovered a number of new psychotropic medications, drugs that mainly affect the brain and reduce many symptoms of mental dysfunc- tioning. Their success contributed to a policy of deinstitutionalization, under which hundreds of thousands of patients were released from public mental hospitals. In addition, outpatient treatment has become the main approach for most persons with mental disorders, both mild and severe; prevention programs are growing in number and influence; the field of multicultural psychology has begun to influence how clinicians view and treat abnormality; and insurance coverage is having a significant impact on the way treatment is conducted. Finally, a variety of perspec- tives and professionals have come to operate in the field of abnormal psychology, and many well-trained clinical researchers now investigate the field's theories and treatments.
*What Do Clinical Researchers Do? Research is the key to accuracy in all fields of study; it is particularly important in abnormal psychology because wrong beliefs in this field can lead to great suffering. At the same time, clinical researchers, also called clinical scientists, face certain challenges that make their work very difficult. They must figure out how to measure such elusive concepts as unconscious motives, private thoughts, mood changes, and human potential; they must consider the different cultural backgrounds, races, and genders of the people they choose to study; and they must always ensure that the rights of their research participants, both human and animal, are not violated (Barnard, 2007; Kazdin, 2003). Let us examine the leading methods used by today's researchers so that we can better understand their work and judge their findings.
Clinical researchers try to discover broad laws, or principles, of abnormal psycho- logical functioning. They search for a general, or nomothetic, understanding of the the nature, causes, and treatments of abnormality (Harris, 2003).They do not typically assess, diagnose, or treat individual clients; that is the job of clinical practitioners.To gain broad insights, clinical researchers, like scientists in other fields, use the scientific method— that is, they collect and evaluate information through careful observations.These obser- vations in turn enable them to pinpoint and explain relationships between variables.
Simply stated, a variable is any characteristic or event that can vary, whether from time to time, from place to place, or from person to person.Age, sex, and race are human variables. So are eye color, occupation, and social status. Clinical researchers are interested in variables such as childhood upsets, present life experiences, moods, social functioning, and responses to treatment. They try to deter- mine whether two or more such variables change together and whether a change in one variable causes a change in another.Will the death of a parent cause a child to become depressed? If so, will a given treatment reduce that depression?
Such questions cannot be answered by logic alone because scientists, like all human beings, frequently make errors in thinking. Thus clinical research- ers rely mainly on three methods of investigation: the case study, which typi- cally focuses on one individual, and the correlational method and experimental method, approaches that usually gather information about many individuals. Each is best suited to certain kinds of circumstances and questions (Martin & Hull, 2007). As a group, these methods enable scientists to form and test hypotheses, or hunches, that certain variables are related in certain ways—and to draw broad conclusions as to why.
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The Case Study A case study is a detailed description of one person's life and psychological problems. It describes the person's history, present circumstances, and symptoms. It may also specu- late about why the problems developed, and it may describe the person's treatment. One of the field's best known case studies, called The Three Faces of Eve, describes a woman with dissociative identity disorder; or multiple personality disorder. The case study focuses on the woman's three alternating personalities, each having a distinct set of memories, preferences, and personal habits (Thigpen & Cleckley, 1957).
Most clinicians take notes and keep records in the course of treating their patients, and some further organize those notes into a formal case study to be shared with other professionals.The clues offered by a case study may help a clinician better understand or treat the person under discussion (Stricker & Trierweiler, 1995). In addition, case stud- ies may play nomothetic roles that go far beyond the individual clinical case (Martin Sc Hull, 2007).
How Are Case Studies Helpful? Case studies can be a source of new ideas about behavior and "open the way for discoveries" (Bolgar, 1965). Freud's theory of psycho- analysis was based mainly on the patients he saw in private practice. In addition, a case study may offer tentative support for a theory. Freud used case studies in this way as well, regarding them as evidence for the accuracy of his ideas. Conversely, case studies may serve to challenge a theory's assumptions (Elms, 2007).
Case studies may also show the value of new therapeutic techniques or unique applica- tions of existing techniques. And, finally, case studies may offer opportunities to study unusual problems that do not occur often enough to permit a large number of obser- vations (Martin & Hull, 2007). Investigators of problems such as multiple personality disorder once relied entirely on case studies for information.
What Are the Limitations of Case Studies? Case studies also have limita- tions. First, they are reported by biased observers, that is, by therapists who have a personal stake in seeing their treatments succeed (Markin & Kivlighan, 2007).The therapists must choose what to include in a case study, and their choices may at times be self-serving. Second, case studies rely upon subjective evidence. Is a client's problem really caused by the events that the therapist or client says are responsible? After all, those are only a fraction of the events that may be contributing to the situation. Finally, case studies provide little basis
for generalization. Events or treatments that seem important in one case may be of no help at all in efforts to understand or treat others.
The limitations of the case study are largely addressed by two other methods of investigation: the correlational method and the experimental method. They do not offer the rich detail that makes case studies so interesting, but they do help investigators draw broad conclusions about abnormality in the population at large. Thus they are now the preferred methods of clinical investigation.
Three features of the correlational and experimental methods enable clinical inves- tigators to gain general insights: (1) The researchers typically observe many individuals; (2) the researchers apply procedures uniformly, and can thus repeat, or replicate, their investigations; and (3) the researchers use statistical tests to analyze the results of a study.
The Correlational Method Correlation is the degree to which events or characteristics vary with each other.The correlational method is a research procedure used to determine this "co-relationship" between variables. This method can, for example, answer the question, "Is there a cor- relation between the amount of stress in people's lives and the degree of depression they experience?" That is, as people keep experiencing stressful events, are they increasingly likely to become depressed?
To test this question, researchers have collected life stress scores (for example, the number of threatening events experienced during a certain period of time) and de- pression scores (for example, scores on a depression survey) from individuals and have
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Abnormal Psychology: Past and Present :// 21
correlated these scores. The people who are chosen for a study are its subjects, or participants, the term preferred by today's investigators. Typically, investigators have found that the life stress and depression variables increase or decrease together (Monroe et al., 2007). That is, the greater someone's life stress score, the higher his or her score on the depression scale. When variables change the same way, their cor- relation is said to have a positive direction and is referred to as a positive correlation.
Alternatively, correlations can have a negative rather than a positive direction. In a negative correlation, the value of one variable increases as the value of the other vari- able decreases. Researchers have found, for example, a negative correlation between depression and activity level. The greater one's depression, the lower the number of one's activities.
There is yet a third possible outcome for a correlational study.The variables may be unrelated, meaning that there is no consistent relationship between them. As the measures of one variable increase, those of the other variable sometimes increase and sometimes decrease. Studies have found, for example, that depression and intel- ligence are unrelated.
In addition to knowing the direction of a correlation, researchers need to know its magnitude, or strength.That is, how closely do the two variables correspond? Does one always vary along with the other, or is their relationship less exact? When two variables are found to vary together very closely in person after person, the correla- tion is said to be high, or strong.
The direction and magnitude of a correlation are often calculated numerically and expressed by a statistical term called the correlation coefficient. The correlation coefficient can vary from +1.00, which indicates a perfect positive correlation between two vari- ables, down to -1.00, which represents a perfect negative correlation. The sign of the coefficient (+ or -) signifies the direction of the correlation; the number represents its magnitude. The closer the correlation coefficient is to .00, the weaker, or lower in mag- nitude, it is. Thus correlations of +.75 and -.75 are of equal magnitude and are equally strong, whereas a correlation of +.25 is weaker than either.
Everyone's behavior is changeable, and many human responses can be measured only approximately. Most correlations found in psychological research, therefore, fall short of a perfect positive or negative correlation. For example, one study of life stress and depression in 68 adults found a correlation of +.53 (Miller, Ingham, & Davidson, 1976). Although hardly perfect, a correlation of this magnitude is considered large in psychological research.
When C n Correlations Be Trusted? Scientists must decide whether the cor- relation they find in a given group of participants accurately reflects a real correlation in the general population. Could the observed correlation have occurred by mere chance? They can test their conclusions with a statistical analysis of their data, using principles of probability_ In essence, they calculate how likely it is that the study's particular findings have occurred by chance. If the statistical analysis indicates that chance is unlikely to ac- count for the correlation they found, researchers may conclude that their findings reflect a real correlation in the general population.
What Are the Merits of the Correlational Method? The correlational method has certain advantages over the case study (see Table 1-3 on the next page). Be- cause researchers measure their variables, observe many participants, and apply statistical analyses, they are in a better position to generalize their correlations to people beyond the ones they have studied. Furthermore, researchers can easily repeat correlational stud- ies using new groups of participants to check the results of earlier studies.
Although correlations allow researchers to describe the relationship between two variables, they do not explain the relationship (Proctor & Capaldi, 2006). When we look at the positive correlation found in many life stress studies, we may be tempted to conclude that increases in recent life stress cause people to feel more depressed. In fact, however, the two variables may be correlated for any one of three reasons: (1) Life stress may cause depression; (2) depression may cause people to experience more life stress
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•case study•A detailed account of a person's life and psychological problems.
•correlation•The degree to which events or characteristics vary along with each other.
•correlational methocl•A research procedure used to determine how much events or characteristics vary along with each other.
Relative Strengths and Weaknesses of Research Methods
Provides Individual
Information
Provides General
Information
Provides Causal
Information
Statistical Analysis Possible Replicable
Case study Yes No No No No
Correlational method No Yes No Yes Yes
Experimental method No Yes Yes Yes Yes
22 ://CHAPTER 1
•epidemiological studrA study that measures the incidence and prevalence of a disorder in a given population,
• longitudinal studrA study that observes the same participants on many occasions over a long period of time.
(for example, a depressive approach to life may cause people to mismanage their money or may interfere with social relationships); or (3) depression and life stress may each be caused by a third variable, such as financial problems (Monroe & Reid, 2009).
Special Forms of Correlational Rese rch Epidemiological studies and longitu- dinal studies are two kinds of correlational research used widely by clinical investigators. Epidemiological studies reveal the incidence and prevalence of a disorder in a par- ticular population. Incidence is the number of new cases that emerge during a given pe- riod of time. Prevalence is the total number of cases in the population during a given time period; prevalence includes both existing and new cases.
Over the past 30 years clinical researchers throughout the United States have worked on the largest epidemiological study ever con- ducted, the Epiderniologic Catchment Area Study.They have interviewed more than 20,000 people in five cities to determine the preva- lence of many psychological disorders and the treatment programs used (Eaton et al., 2007; Narrow et al., 2002). Two other large-scale epidemiological studies in the United States, the National Comorbidity Survey and the Na- tional Comorbidity Survey Replication, have questioned more than 9,000 individuals (Druss et al., 2007; Kessler et al., 2007, 2005). All of these studies have been further compared with
epidemiological studies of specific groups, such as Hispanic and Asian American popula- tions, or with epidemiological studies conducted in other countries, to see how rates of mental disorders and treatment programs vary from group to group and from country to country (Alegria et al., 2007, 2004, 2000).
Such epidemiological studies have helped researchers detect groups at risk for particular disorders. Women, it turns out, have a higher rate of anxiety disorders and depression than men, while men have a higher rate of alcoholism than women. Elderly people have a higher rate of suicide than young people. Hispanic Americans experience posttraumatic stress disorder more than other racial and ethnic groups in the United States. And people in some countries have higher rates of certain mental disorders than those in other countries.
In longitudinal studies, correlational studies of another kind, researchers observe the same individuals on many occasions over a long period of time (Donnellan & Conger, 2007). In one such study, investigators have observed the progress over the years of normally functioning children whose mothers or fathers suffered from schizophrenia (Schiffman et al., 2006, 2005; Mednick, 1971).The researchers have found, among other things, that the children of the parents with the most severe cases of schizophrenia were particularly likely to develop a psychological disorder and to commit crimes at later points in their development.
Abnormal Psychology: Past and Present :1/ 23
HOME SEND 1°— EXPLORE ) ---------
On Facebook, Scholars Link Up with Data BY STEPHANIE ROSENBLOOM, NEW YORK TIMES, DECEMBER 17, 2007
...
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inch day about 1,700 juniors at an East Coast college log on to Facebook.corn to accumulate "friends," compare
movie preferences, share videos and exchange cybercocktails and kisses. Unwittingly, these students have become the subjects of academic research.
To study how personal tastes, habits and values affect the formation of social relationships (and how social relationships affect tastes, habits and values), a team of researchers from Harvard and the University of California, Los Angeles, are moni- toring the Facebook profiles of an entire class of students at one college, which they declined to name because it could compro- mise the integrity of their research. . . .
In other words, Facebook—where users rate one another as "hot or not," play games like "Pirates vs. Ninjas" and throw virtual sheep at one another—is helping scholars explore funda- mental social science questions.
"We're on the cusp of a new way of doing social science," said Nicholas Christakis, a Harvard sociology professor who is also part of the research. "Our predecessors could only dream of the kind of data we now have."
Social scientists at Indiana, Northwestern, Pennsylvania State, Tufts, the University of Texas and other institutions are mining Facebook to test traditional theories in their fields about relation- ships, identity, self-esteem, popularity, collective action, race and political engagement.. .. In a few studies, the Facebook users do not know they are being examined. A spokeswoman for Facebook says the site has no policy prohibiting scholars from studying profiles of users who have not activated certain privacy settings. .
. . . The site's users have mixed feelings about being put under the microscope. [One student] said she found it "fascinat- ing that professors are using [Facebook]," but [another] said,
"I don't feel like academic research has a place on a Web site like Facebook." He added that if that if it was going to happen, professors should ask students' permission.
Although federal rules govern academic study of human sub- jects, universities, which approve professors' research methods, have different interpretations of the guidelines. "The rules were made for a different world, a pre-Facebook world," said Samuel D. Gosling, an associate professor of psychology at the University of Texas, Austin, who uses Facebook to explore perception and identity. "There is a rule that you are allowed to observe public behavior, but it's not clear if online behavior is public or not." .. .
Copyright Cll 2007 The NewYork Times. All rights reserved. Used by permission and protected by the Copyright laws of the United States.
The printing, copying, redistribution, or retransmission of the material without express written permission is prohibited.
V ',
The Experimental Method An experiment is a research procedure in which a variable is manipulated and the manipulation's effect on another variable is observed.The manipulated variable is called the independent variable, and the variable being observed is called the dependent variable.
One of the questions that clinical scientists ask most often is, "Does a particular therapy relieve the symptoms of a particular disorder?" (Nathan, 2007). Because this question is about a causal relationship, it can be answered only by an experiment. That is, experimenters must give the therapy in question to people who are suffering from a disorder and then observe whether they improve. Here the therapy is the independent variable, and psychological improvement is the dependent variable.
•experiment•A research procedure in which a variable is manipulated and the effect of the manipulation is observed.
• independent variable•The variable in an experiment that is manipulated to determine whether it has an effect on another variable.
•dependent variable•The variable in an experiment that is expected to change as the independent variable is manipulated.
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'control group•In an experiment, a group of participants who are not exposed to the independent variable.
•experimental group•In an experi- ment, the participants who are exposed to the independent variable.
'random assignment•A selection procedure that ensures that participants are randomly placed either in the control group or in the experimental group.
•blind desir•An experiment in which participants do not know whether they are in the experimental or the control condition.
•quasi-experiment•An experiment in which investigators make use of control and experimental groups that already exist in the world at large. Also called a mixed design.
•natural experiment•An experiment in which nature, rather than an experi- menter, manipulates an independent variable.
As with correlational studies, investigators must then do a sta- tistical analysis on their data and find out how likely it is that the observed differences are the result of chance.Again, if the likelihood is very low, the observed differences are considered to be statistically significant, and the experimenter may conclude with some confi- dence that they are caused by the independent variable.
If the true cause of changes in the dependent variable cannot be separated from other possible causes, then an experiment gives very little information. Thus, experimenters must try to eliminate all con founds from their studies—variables other than the indepen- dent variable that may also be affecting the dependent variable. When there are confounds in an experiment, they, rather than the independent variable, may be causing the observed changes.
For example, situational variables, such as the location of the therapy office (say, a quiet country setting) or soothing music piped into the office, may have a therapeutic effect on participants
in a therapy study. Or perhaps the participants are unusually motivated or have high expectations that the therapy will work, factors that thus account for their improve- ment. To guard against confounds, researchers include three important features in their experiments—a control group, random assignment, and a blind design.
The Control Group A control group is a group of research participants who are not exposed to the independent variable under investigation but whose experience is similar to that of the experimental group, the participants who are exposed to the independent variable. By comparing the two groups, an experimenter can better deter- mine the effect of the independent variable.
To study the effectiveness of a particular therapy, for example, experimenters typi- cally divide participants into two groups. The experimental group may come into an office and receive the therapy for an hour, while the control group may simply come into the office for an hour. If the experimenters find later that the people in the experi- mental group improve more than the people in the control group, they may conclude that the therapy was effective above and beyond the effects of time, the office setting, and any other confounds. To guard against confounds, experimenters try to provide all participants, both control and experimental, with experiences that are identical in every way—except for the independent variable.
Random Assignment Researchers must also watch out for differences in the makeup of the experimental and control groups, since those differences may also confound a study's results. In a therapy study, for example, the experimenter may unintentionally put wealthier participants in the experimental group and poorer ones in the control group. This difference, rather than their therapy, may be the cause of the greater improvement later found among the experimental participants.To reduce the effects of preexisting dif- ferences, experimenters typically use random assignment.This is the general term for any selection procedure that ensures that every participant in the experiment is as likely to be placed in one group as the other. Researchers might, for example, select people by flipping a coin or picking names out of a hat.
Blind Design A final confound problem is bias. Participants may bias an experiment's results by trying to please or help the experimenter (Fritsche & Linneweber, 2006). In a therapy experiment, for example, if those participants who receive the treatment know the purpose of the study and which group they are in, they might actually work harder to feel better or fulfill the experimenter's expectations. If so, subject, or participant, bias rather than therapy could be causing their improvement.
To avoid this bias, experimenters can prevent participants from finding out which group they are in. This experimental strategy is called a blind design because the in- dividuals are blind as to their assigned group. In a therapy study, for example, control participants could be given a placebo (Latin for "I shall please"), something that looks or
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Abnormal Psychology: Past and Present :1/ 25
tastes like real therapy but has none of its key ingredients. This "imitation" therapy is called placebo therapy. If the experimental (true therapy) participants then improve more than the control (placebo therapy) participants, experimenters have more confidence that the true therapy has caused their improvement.
An experiment may also be confounded by experimenter bias (Kazdin, 2003)—that is, experimenters may have expectations that they unintentionally transmit to the partici- pants in their studies. In a drug therapy study, for example, the experimenter might smile and act confident when providing real medications to the experimental participants but frown and appear hesitant when offering placebo drugs to the control participants.This kind of bias is sometimes referred to as the Rosenthal effect, after the psychologist who first identified it (Rosenthal, 1966). Experimenters can eliminate their own bias by ar- ranging to be blind themselves. In a drug therapy study, for example, an aide could make sure that the real medication and the placebo drug look identical. The experimenter could then administer treatment without knowing which participants were receiving true medications and which were receiving false medications. While either the partici- pants or the experimenter may be kept blind in an experiment, it is best that both be blind—a research strategy called a double -blind design. In fact, most medication experi- ments now use double-blind designs to test promising drugs (Marder et al., 2007).
Alternative Experimental Designs Clinical researchers often must settle for experimental designs that are less than ideal. The most common such variations are the quasi-experimental design, the natural experiment, the analogue experiment, and the single- subject experiment.
In quasi-experiments, or mixed designs, investigators do not randomly assign participants to control and experimental groups but instead make use of groups that already exist in the world at large (Wampold, 2006). For example, because investigators of the effects of child abuse cannot abuse a randomly chosen group of children, they must instead compare children who already have a history of abuse with children who do not.To make this comparison as valid as possible, they may further use matched control participants. That is, they match the experimental participants with control participants who are similar in age, sex, race, socioeconomic status, type of neighborhood, or other characteristics. For every abused child in the experimental group, they choose a child who is not abused but who has similar characteristics to be included in the control group (Widow et al., 2007).
In natural experiments nature itself manipulates the independent variable, and the experimenter observes the effects. Natural experiments must be used for studying the psychological effects of unusual and unpredictable events, such as floods, earthquakes,
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plane crashes, and fires. Because the participants in these studies are selected by an ac- cident of fate rather than by the investigators' design, natural experiments are actually a kind of quasi-experiment.
On December 26, 2004, an earthquake occurred beneath the Indian Ocean off the coast of Sumatra, Indonesia. The earthquake triggered a series of massive tsunamis that inundated the ocean's coastal communities, killed more than 225,000 people, and injured and left millions of survivors homeless.Within months of this disaster, research- ers conducted natural experiments in which they collected data from several hundred survivors and from control groups of people who lived in areas not directly affected by the tsunamis.The disaster survivors scored significantly higher on anxiety and depression measures (dependent variables) than the controls did. The survivors also experienced more sleep problems, feelings of detachment, difficulties concentrating, and guilt feelings than the controls did (Bhushan & Kumar, 2007; Tang, 2007, 2006).
Experimenters often run analogue experiments. Here they induce laboratory participants—either animals or humans—to behave in ways that seem to resemble real- life abnormal behavior and then conduct experiments on the participants in the hope of shedding light on the real-life abnormality. For example, as you'll see in Chapter 7, investigator Martin Seligman has produced depression-like symptoms in laboratory par- ticipants—both animals and humans—by repeatedly exposing them to negative events (shocks, loud noises, task failures) over which they have no control. In these "learned helplessness" analogue studies, the participants seem to give up, lose their initiative, and become sad.
Finally, scientists sometimes do not have the luxury of experimenting on many participants. They may, for example, be investigating a disorder so rare that few par- ticipants are available. Experimentation is still possible, however, with a single-subject experimental design. Here a single participant is observed both before and after the manipulation of an independent variable.
For example, using a particular single-subject design called an ARAB, or reversal, design, one researcher sought to determine whether the systematic use of rewards would reduce a teenage boy's habit of disrupting his special education class with loud talk (Deitz, 1977). He rewarded the boy, who suffered from mental retardation, with extra teacher time whenever he went 55 minutes without interrupting the class more than three times. In condition A, the student was observed prior to receiving any reward, and he was found to disrupt the class frequently with loud talk. In condition B, the boy was given a series of teacher reward sessions (introduction of the independent variable); as
•analogue experiment•A research method in which the experimenter produces abnormal-like behavior in labo- ratory participants and then conducts experiments on the participants.
•single-subject experimental design. A research method in which a single participant is observed and measured both before and after the manipulation of an independent variable.
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Abnormal Psychology. Past and Present :1,1 27
expected, his loud talk decreased dramatically. Then the rewards from the teacher were stopped (condition A again), and the student's loud talk increased once again. Appar- ently the independent variable had indeed been the cause of the improvement. To be still more confident about this conclusion, the researcher had the teacher apply reward sessions yet again (condition B again). Once again the student's behavior improved.
What Are the Limits of Clinical Investigations? We began this section by noting that clinical scientists look for general laws that will help them understand, treat, and prevent psychological disorders. As we have seen, how- ever, circumstances can interfere with their progress.
Each method of investigation that we have observed addresses some of the problems involved in studying human behavior, but no one approach overcomes them all. Thus, it is best to view each research method as part of a team of approaches that together may shed considerable light on abnormal human functioning.When more than one method has been used to investigate a disorder, it is important to ask whether all the results seem to point in the same direction. If they do, clinical scientists are probably making prog- ress toward understanding and treating that disorder. Conversely, if the various methods seem to produce conflicting results, the scientists must admit that knowledge in that particular area is still limited.
F.
What Do Clinical Researchers Do?
Clinical researchers use the scientific method to uncover general principles of abnor- mal psychological functioning. They depend primarily on three methods of investiga- tion: the case study, the correlational method, and the experimental method.
A case study is a detailed account of one person's life and psychological problems.
Correlational studies systematically observe the degree to which events or char- acteristics vary together. This method allows researchers to draw broad conclusions about abnormality in the population at large. Two widely used forms of the correla- tion method are epidemiological studies and longitudinal studies.
In experiments, researchers manipulate suspected causes to see whether ex- pected effects will result. This method allows researchers to determine the causes of various conditions or events. Clinical experimenters must often settle for experi- mental designs that are less than ideal, including the quasi-experiment, the natural experiment, the analogue experiment, and the single-subject experiment.
PUTTING IT... together A Work in Progress
Since ancient times, people have tried to explain, treat, and study abnormal behavior. By examining the way past societies responded to such behaviors, we can better un- derstand the roots of our present views and treatments. In addition, a look backward helps us appreciate just how far we have come—how humane our present views are, how impressive our recent discoveries are, and how important our current emphasis on research is.
At the same time we must recognize the many problems in abnormal psychology today.The field has yet to agree on one definition of abnormality. It is currently made up of conflicting schools of thought and treatment whose members are often unimpressed by the claims and accomplishments of the others. Clinical practice is carried out by a
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variety of professionals trained in different ways. And current research methods each have flaws that limit our knowledge and use of clinical information.
As you proceed through the topics in this book and look at the nature, treatment, and study of abnormal functioning, keep in mind the field's current strengths and weak- nesses, the progress that has been made, and the journey that lies ahead. Perhaps the most important lesson to be learned from our look at the history of this field is that our current understanding of abnormal behavior represents a work in progress. The clinical field stands at a crossroads, with some of the most important insights, investigations, and changes yet to come.
\\\ nPITIrAL THOUr.;HITS///
,-, 1. Why are movies and novels with
fj themes of abnormal functioning so popular? pp. 1 -2
/7- 2. What behaviors might fit the criteria
:7A of deviant, distressful, dysfunctional, 7j,-. or dangerous but would not be con- • sidered abnormal by most people? /7.7. • pp. 2-4
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gists to develop an interest in positive psychology? p. 17
5. Even when there are well-known research findings to the contrary, many people hold on to false beliefs about human behavior, particularly abnormal behavior. Why does research fail to change their views?
you think it took so long for psycholo- pp. 19, 27
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3. What episodes of "mass madness" have occurred in recent times? How might the Internet, cable television, or other forms of modern technology contribute to new forms of mass mad- ness? p. 8
4. Positive behaviors have been around as long as negative ones. Why do
abnormal psychology, p. 2
deviance, p. 2
norms, p. 2
culture, p. 2
distress, p. 3
dysfunction, p. 3
danger, p. 3
treatment, p. 4
trephination, p. 7
humors, p. 7
asylum, p. 9
moral treatment, p. 9
state hospitals, p. 10
somatogenic perspective,
psychogenic perspective,
general paresis, p. 10
hypnotism, p. 12
psychoanalysis, p. 12
psychotropic medications, p. 13
deinstitutioncrlization, p. 14
private psychotherapy, p. 14
prevention, p. 16
positive psychology, p. 17
multicultural psychology, p. 17
managed care program, p. 17
scientific method, p. 19
case study, p. 20
correlation, p. 20
10 correlational method, p. 20
10
incidence, p. 22
prevalence, p. 22
longitudinal study, p. 22
experiment, p. 23
independent variable, p. 23
dependent variable, p. 23
control group, p. 24
experimental group, p. 24
random assignment, p. 24
blind design, p. 24
quasi-experiment, p. 25
natural experiment, p. 25
analogue experiment, p. 26
single-subject experimental design, p. 26
P.
P.
(3;;02;,M /71/0/:49.;;Z:,;„.„;: • epidemiological study, p. 22
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Abnormal Psychology: Past and Present :11 29
7 7
3. Give examples of the somatogenic view of psychological abnormality
7•,A from Hippocrates, the Renaissance, the nineteenth century, and the recent past. pp. 7- 14
.o4/7 4. Discuss the rise and fall of moral
treatment. pp. 9- 10
5. Describe the role of hypnotism and hysterical disorders in the develop- ment of the psychogenic view. pp, 1 1 - 12
6. How did Sigmund Freud come to develop the theory and technique of psychoanalysis? p. 12
7. Describe the major changes that have occurred since the 1950s in the treatment of people with mental disorders. pp. 13-18
8. What are the advantages and disadvantages of the case study,
correlational method, and experi- mental method? pp. 20-27
9. What techniques do researchers include in experiments to guard against the influence of confounds? pp. 24-25
10. Describe four alternative kinds of experiements that researchers often use. pp. 25-27
1. What features are common to abnormal psychological function- ing? pp. 2-4
2. Name two forms of past treatments that reflect a demonological view of abnormal behavior. pp. 7-9
4 .4` e
Search the Fundamentals of Abnormal Psychology Video Tool Kit www.worthpublishers.com/apvtk
A Chapter 1 Video Cases Benjamin Rush's Moral Treatments Early Hospital Treatments for Severe Mental Disorders Shameful Past Institutions for Persons with Developmental Disabilities Experimental Design in Action Genetic Research: Violating One's Privacy? A Tragic Consequence of Research Misconduct
A Video case discussions, study guides, and questions
Log on to the Corner Web Page www.worthpublishers.com/comer
A Chapter 1 outline, learning objectives, research exercises, study tools, and practice test questions
A Additional Chapter 1 case studies, Web links, and FAQs
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MODELS OF ABNORMALITY CHAPTER
hilip Berman, a 25-year-old single unemployed former copy editor fora large publishing house, . . . had been hospitalized after a suicide attempt in which he deeply gashed his
1 wrist with a razor blade. He described (to the therapist] how he had sat on the bathroom floor and watched the blood drip into the bathtub for some time before he telephoned
his father at work for help. He and his father went to the hospital emergency room to have the gash stitched, but he convinced himself and the hospital physician that he did not need hospitalization. The next day when his father suggested he needed help, he knocked his dinner to the floor and angrily stormed to his room. When he was calm again, he allowed his father to take him back to the hospital.
The immediate precipitant for his suicide attempt was that he had run into one of his former girlfriends with her new boyfriend. The patient stated that they had a drink together, but all the while he was with them he could not help thinking that "they were dying to run off and jump in bed." He experienced jealous rage, got up from the table, and walked out of the restaurant. He began to think about how he could "pay her back."
Mr. Berman had felt frequently depressed for brief periods during the previous several years. He was especially critical of himself for his limited social life and his inability to hove managed to have sexual intercourse with a woman even once in his life. As he related this to the therapist, he lifted his eyes from the floor and with a sarcastic smirk said, "l'm a 25-year-old virgin. Go ahead, you can laugh now." He has had several girlfriends to date, whom he described as very attractive, but who he said had lost interest in him. On further questioning, however, it became apparent that Mr. Berman soon became very critical of them and demanded that they always meet his every need, often to their own detriment. The women then found the relationship very unrewarding and would soon find someone else.
During the past two years Mr. Berman had seen three psychiatrists briefly, one of whom had given him a drug, the name of which he could not remember, but that had precipitated some sort of unusual reaction for which he had to stay in a hospital overnight. . . . Concerning his hospitalization, the patient said that "It was a dump," that the staff refused to listen to what he had to say or to respond to his needs, and that they, in fact, treated all the patients "sadisti- cally." The referring doctor corroborated that Mr. Berman was a difficult patient who demanded that he be treated as special, and yet was hostile to most staff members throughout his stay. After one angry exchange with an aide, he left the hospital without leave, and subsequently signed out against medical advice.
Mr. Berman is one of two children of a middle-class family. His father is 55 years old and employed in a managerial position for on insurance company. He perceives his father as weak and ineffectual, completely dominated by the patient's overbearing and cruel mother. He states that he hates his mother with "a passion l can barely control." He claims that his mother used to call him names like "pervert" and "sissy" when he was growing up, and that in an argument she once "kicked me in the balls." Together, he sees his parents as rich, powerful, and selfish, and, in turn, thinks that they see him as lazy, irresponsible, and a behavior problem. When his parents called the therapist to discuss their son's treatment, they stated that his problem began with the birth of his younger brother, Arnold, when Philip was 10 years old. After Arnold's birth Philip apparently became an "ornery" child who cursed a lot and was difficult to discipline. Philip recalls this period only vaguely. He reports that his mother once was hospitalized for depression, but that now she doesn't believe in psychiatry."
TOPIC OVERVIEW The Biological Model How Do Biological Theorists Explain Abnormal Behavior?
Biological Treatments
Assessing the Biological Model
The Psychodynamic Model How Did Freud Explain Normal and Abnormal Functioning?
How Do Other Psychodynamic Explanations Differ from Freud's?
Psychodynamic Therapies
Assessing the Psychodynamic Model
The Behavioral Model How Do Behaviorists Explain Abnormal Functioning?
Behavioral Therapies
Assessing the Behavioral Model
The Cognitive Model How Do Cognitive Theorists Explain Abnormal Functioning?
Cognitive Therapies
Assessing the Cognitive Model
The Humanistic-Existential Model Rogers's Humanistic Theory and Therapy
Gestalt Theory and Therapy
Spiritual Views and Interventions
Existential Theories and Therapy
Assessing the Humanistic-Existential Model
The Sociocultural Model: Family- Social and Multicultural Perspectives How Do Family-Social Theorists Explain Abnormal Functioning?
Family-Social Treatments
How Do Multicultural Theorists Explain Abnormal Functioning?
Multicultural Treatments
Assessing the Sociocultural Model
Putting It Together: Integration of the Models
Famous Psych Linos from ihe Movies: Take 2
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Mr. Berman had graduated from college with average grades. Since graduating he had worked at three different publishing houses, but at none of them for more than one year. He always found some justifica- tion for quitting. He usually sat around his house doing very little for two or three months after quitting a job, until his parents prodded him into getting a new one. He described innumerable interactions in his life with teachers, friends, and employers in which he felt offended or unfairly treated, . . . and frequent arguments that left him feeling bitter . . . and spent most of his time alone, "bored." He was unable to commit himself to any person, he held no strong convictions, and he felt no allegiance to any group.
The patient appeared as a very thin, bearded, and bespectacled young man with pale skin who main- tained little eye contact with the therapist and who had an air of angry bitterness about him. Although he complained of depression, he denied other symptoms of the depressive syndrome. He seemed preoccupied with his rage at his parents, and seemed particularly invested in conveying a despicable image of himself . . .
(Spitzer et al., 1983, pp. 59- 61)
Philip Berman is clearly a troubled person, but how did he come to be that way? How do we explain and correct his many problems? To answer these questions, we must first look at the wide range of complaints we are trying to understand: Philip's depression and anger, his social failures, his lack of employment, his distrust of those around him, and the problems within his family. Then we must sort through all kinds of potential causes—internal and external, biological and interpersonal, past and present.
Although we may not realize it, we all use theoretical frameworks as we read about Philip. Over the course of our lives, each of us has developed a perspective that helps us make sense of the things other people say and do. In science, the perspectives used to explain events are known as models, or paradigms. Each model spells out the scientist's basic assumptions, gives order to the field under study, and sets guidelines for its investigation (Kuhn, 1962). It influences what the investigators observe as well as the questions they ask, the information they seek, and how they interpret this information
2008).To understand how a clinician explains or treats a specific set of symptoms, such as Philip's, we must know his or her preferred model of abnormal functioning.
Until recently, clinical scientists of a given place and time tended to agree on a single model of abnormality—a model greatly influenced by the beliefs of their culture. The demonological model that was used to explain abnormal functioning during the Middle Ages, for example, borrowed heavily from medieval society's concerns with religion, superstition, and warfare. Medieval practitioners would have seen the devil's guiding hand in Philip Berman's efforts to commit suicide and his feelings of depres- sion, rage, jealousy, and hatred. Similarly, their treatments for him—from prayers to whippings—would have sought to drive foreign spirits from his body.
Today several models are used to explain and treat abnormal functioning. This va- riety has resulted from shifts in values and beliefs over the past half-century, as well as improvements in clinical research. At one end of the spectrum is the biological model, which sees physical processes as key to human behavior. In the middle are four mod- els that focus on more psychological and personal aspects of human functioning: The psychodynamic model looks at people's unconscious internal processes and conflicts, the behavioral model emphasizes behavior and the ways in which it is learned, the cognitive model concentrates on the thinking that underlies behavior, and the humanistic-existential model stresses the role of values and choices. At the far end of the spectrum is the socio- cultural model, which looks to social and cultural forces as the keys to human functioning. This model includes the family-social perspective, which focuses on an individual's family and social interactions, and the multicultural perspective, which emphasizes an individual's culture and the shared beliefs, values, and history of that culture.
Given their different assumptions and concepts, the models are sometimes in conflict. Those who follow one perspective often scoff at the "naive" interpretations, investigations, and treatment efforts of the others.Yet none of the models is complete in itself. Each focuses mainly on one aspect of human functioning, and none can explain all aspects of abnormality.
32 :41/CHAPTER 2
Cerebral cortex
,Basal ganglia
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-H ippocam pus
Models of Abnormality :1/ 33
one Biological Model Philip Berman is a biological being. His thoughts and feelings are the results of bio- chemical and bioelectrical processes throughout his brain and body. Proponents of the biological model believe that a full understanding of Philip's thoughts, emotions, and behavior must therefore include an understanding of their biological basis. Not surpris- ingly, then, they believe that the most effective treatments for Philip's problems will be biological ones.
How Do Biological Theorists Explain Abnormal Behavior? Adopting a medical perspective, biological theorists view abnormal behavior as an ill- ness brought about by malfunctioning parts of the organism. Typically, they point to problems in brain anatomy or brain chemistry as the cause of such behavior (Garrett, 2009; Lambert & Kinsley, 2005).
Brain Anatomy and Abnormal Behavior The brain is made up of approxi- mately 100 billion nerve cells, called neurons, and thousands of billions of support cells, called glia (from the Greek meaning "glue").Within the brain large groups of neurons form distinct areas, or brain regions. Toward the top of the brain, for example, is a cluster of regions, collectively referred to as the cerebrum, which includes the cortex, corpus cal- losum, basal ganglia, hippocampus, and amygdala (see Figure
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2-1).The neurons in each of these brain regions control important functions. The cortex is the outer layer of the brain, the corpus callosum connects the brain's two ce- rebral hemispheres, the basal ganglia plays a crucial role in planning and producing movement, the hippocampus helps control emotions and memory, and the amygdala plays a key role in emotional memory. Clinical research- ers have discovered connections between certain psy- chological disorders and problems in specific areas of the brain. One such disorder is Huntington's disease, a disorder marked by violent emotional outbursts, memory loss, suicidal thinking, involuntary body movements, and ab- surd beliefs. This disease has been traced to a loss of cells in the basal ganglia.
Brain Chemistry and Abnormal Behavior Biological researchers have also learned that psychologi- cal disorders can be related to problems in the transmis- sion of messages from neuron to neuron. Information is communicated throughout the brain in the form of electrical impulses that travel from one neuron to one or more others. An impulse is first received by a neuron's dendrites, antenna-like extensions located at one end of the neuron. From there it travels down the neuron's axon, a long fiber extending from the neuron's body. Finally, it is transmit- ted through the nerve ending at the end of the axon to the dendrites of other neurons (see Figure 2-2 on the next page).
But how do messages get from the nerve ending of one neuron to the dendrites of another? After all, the neurons do not actually touch each other.A tiny space, called the synapse, separates one neuron from the next, and the message must somehow move across that space.When an electrical impulse reaches a neuron's ending, the nerve ending is stimulated to release a chemical, called a neurotransmitter, that travels across the synaptic space to receptors on the dendrites of the neighboring neurons. After binding to the receiving neuron's receptors, some neurotransmitters tell the receiving neurons to "fire," that is, to trigger their own electrical impulse. Other neurotransmitters carry an inhibitory message; they tell receiving neurons to stop all firing. Obviously, neurotrans- mitters play a key role in moving information through the brain.
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34 //CHAPTER 2
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Researchers have identified dozens of neurotransmitters in the brain, and they have learned that each neuron uses only certain kinds. Studies indicate that abnormal activity by certain neurotransmitters can lead to specific mental disorders (Sarter et al., 2007). Depression, for example, has been linked to low activity of the neurotransmitters serotonin and norepinephrine. Perhaps low se- rotonin activity is partly responsible for Philip Berman's pattern of depression and rage.
In addition to focusing on neurons and neurotransmitters, researchers have learned that mental disorders are sometimes related to abnormal chemical activity in the body's endocrine system. Endocrine glands, located throughout the body, work along with neurons to control such vital activities as growth, reproduction, sexual activity, heart rate, body temperature, energy, and responses to stress. The glands release chemicals called hormones into the bloodstream, and these chemicals then propel body organs into action. During times of stress, for example, the adrenal glands, located on top of the kidneys, secrete the hor- mone cortisol. Abnormal secretions of this chemical have been tied to anxiety and mood disorders.
Sources of Biological Abnormalities Why do some people have brain structures or biochemical activities that differ from the norm? Three factors have received particular attention in recent years—genetics, evolution, and viral infections.
GENETICS AND ABNORMAL BEHAVIOR Abnormalities in brain anatomy or chemistry are sometimes the result of genetic inheritance. Each cell in the human brain and body contains 23 pairs of chromosomes, with each chromosome in a pair inherited from one of the person's parents. Every chromosome contains numer- ous genes—segments that control the characteristics and traits a person inherits. Altogether, each cell contains between 30,000 and 40,000 genes (Andreasen, 2005, 2001). Scientists have known for years that genes help determine such physical characteristics as hair color, height, and eyesight. Genes can make people more prone to heart disease, cancer, or diabetes, and perhaps to possess-
ing artistic or musical skill. Studies suggest that inheritance also plays a part in mood disorders, schizophrenia, and other mental disorders.
The precise contributions of various genes to mental disorders have become clearer in recent years, thanks in part to the completion of the Human Genome Project in 2000. In this major undertaking, scientists used the tools of molecular biology to map, or sequence, all of the genes in the human body in great detail. With this information in hand, researchers hope eventually to be able to prevent or change genes that help cause medical or psychological disorders (Holman et al., 2007).
Models of Abnormality :// 35
EVOLUTION AND ABNORMAL BEHAVIOR Genes that contribute to mental disorders are typi- cally viewed as unfortunate occurrences—almost mistakes of inheritance. The respon- sible gene may be a mutation, an abnormal form of the appropriate gene that emerges by accident_ Or the problematic gene may be inherited by an individual after it has initially entered the family line as a mutation. According to some theorists, however, many of the genes that contribute to abnormal functioning are actually the result of normal evolutionary principles (Fabrega, 2007, 2006, 2002).
In general, evolutionary theorists argue that human reactions and the genes respon- sible for them have survived over the course of time because they have helped individu- als to thrive and adapt. Ancestors who had the ability to run fast, for example, or the craftiness to hide were most able to escape their enemies and to reproduce. Thus, the genes responsible for effective walking, running, or problem solving were particularly likely to be passed on from generation to generation to the present day.
Similarly, say evolutionary theorists, the capacity to experience fear was, and in many instances still is, adaptive. Fear alerted our ancestors to dangers, threats, and losses, so that persons could avoid or escape potential problems. People who were particularly sensitive to danger—those with greater fear responses—were more likely to survive catastrophes, battles, and the like and to reproduce, and so to pass on their fear genes. Of course, in today's world pressures are more numerous, subtle, and complex 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 disorders.
The evolutionary perspective is controversial in the clinical field and has been re- jected by many theorists. Imprecise and at times impossible to research, this explanation requires leaps of faith that many scientists find unacceptable.
VIRAL INFECTIONS AND ABNORMAL BEHAVIOR Another possible source of abnor- mal brain structure or biochemical dysfunctioning is viral ittfections. As you will see in Chapter 12, for example, research suggests that schizophrenia, a disorder marked by delusions, hallucinations, or other departures from real- ity, may be related to exposure to certain viruses during childhood or before birth (Meyer et al., 2008; Shirts et al., 2007). Studies have found that the mothers of many individuals with this disorder contracted influenza or re- lated viruses during their pregnancy. This and related pieces of circumstantial evidence suggest that a damaging virus may enter the fetus's brain and remain dormant there until the individual reaches adolescence or young adulthood. At that time, the virus may produce the symptoms of schizophrenia. During the past decade, researchers have sometimes linked viruses to anxiety and mood disorders, as well as to psychotic disorders (Dale et al., 2004).
Bioiogical Treatments Biological practitioners look for certain kinds of clues when they try to understand abnormal behavior. 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 dysfunctioning, they are in a better position to choose a biological course of treatment. The three leading kinds of biological treatments used today are drug therapy, electroconvulsive therapy, and psychosurgery. Drug therapy is by far the most common of these approaches.
In the 1 950s, 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, ei- ther alone or with other forms of therapy. However, the psychotropic drug revolution
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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 (see Figure 2-3).
Four major psychotropic drug groups are used in therapy: antianxiety, antidepressant, antibipolar, and antipsychotic drugs. Antianxiety drugs, also called minor tranquilizers or anxiolytics, help reduce tension and anxiety. Antidepressant dings help improve the mood of people who are depressed. 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 of psychotic disorders, disorders (such as schizophrenia) marked by a loss of contact with reality.
A second form of biological treatment, used primarily on depressed patients, is elec- troconvulsive 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.The treatment is used on tens of thousands of depressed persons annually, particularly those whose depression fails to respond to other treatments (Eschweiler et al., 2007; Pagnin et al., 2004).
A third form of biological treatment is psychosurgery, or neurosurgery, brain surgery for mental disorders. It is thought to have roots as Ear 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 technique first developed in the late 1930s by a Portuguese neuropsychiatrist, Antonio de 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 than the lobotomies of the past. Even so, they are considered experimental and are used only after certain severe disorders have continued for years without responding to any other form of treatment (Sachdev & Chen, 2009).
36 :41/CHAPTER 2
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.
°electroconvulsive therapy (ECT)0 A form of biological treatment, used primarily on depressed patients, in which a brain seizure is triggered as an elec- tric current passes through electrodes attached to the patient's forehead.
opsychosurgery°Brain surgery for men- tal disorders. Also called neurosurgery.
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subjects to determine its safety. • Number of subjects: io—loo • Typical cost: $10 million
Clinical Phase II: Preliminary Testing (2 years) Investigators conduct studies with human
subjects to determine how drug can best be evaluated and to obtain preliminary estimates of correct dosage and treatment procedures.
• Number of subjects: 50-500 • Typical cost: $2o million
Clinical Phase III: Final Testing (3-5 years) Investigators conduct controlled studies
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Models of Abnormality :11 37
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 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.
r. •
The Biological Model
Biological theorists look at the biological processes of human functioning to explain abnormal behavior, pointing to anatomical or biochemical problems in the brain and body. Such abnormalities are sometimes the result of genetic inheritance, evo- lution, or viral infections. Biological therapists use physical and chemical methods to help people overcome their psychological problems. The leading ones are drug therapy, electroconvulsive therapy, and, on rare occasions, psychosurgery.
OThe 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 he or she 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 (Luborsky et al., 2008).
Psychodynamic theorists would view Philip Berman as a person in conflict. They would want to explore his past experiences because, in their view, psychological con- flicts are tied to early relationships and to traumatic experiences that occurred during childhood. Psychodynamic theories rest on the deterministic assumption that no symp- tom 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 weak- ness 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 psycho- logical functioning and 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) and Alfred Adler (1870-1937)—became the most influential clinical theorists in the Western world.
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.
Defense
Repression
Operation
Person avoids anxiety by simply not allowing painful or dangerous thoughts to become conscious.
Example
An executive's desire to run amok and attack his boss and colleagues at a board meeting is denied access to his 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 own unacceptable impulses, motives, or desires to other individuals.
The executive who repressed his destructive desires may project his anger onto his 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.
After your parking spot is taken, you release your pent-up anger by starting an argument with your roommate.
Intellectualization Person represses emotional reactions in favor of overly logical response 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 at which no one is expected to behave maturely or responsibly.
A boy who cannot cope with the anger he feels toward his rejecting mother regresses to infantile behavior, soiling his clothes and no longer taking care of his basic needs.
The Defense Never Rests: Defense Mechanisms to the Rescue
eideAccording to Freud, the psychologi- cal force that produces instinctual needs, drives, and impulses.
oegooAccording to Freud, the psycho- logical force that employs reason and operates in accordance with the reality principle.
eego defense mechanismsoAccording to psychoanalytic theory, strategies devel- oped by the ego to control unacceptable id impulses and to avoid or reduce the anxiety they arouse.
esuperegooAccording to Freud, the psychological force that represents a per- son's values and ideals.
efixationoAccording to Freud, a condi- tion in which the id, ego, and superego do not mature properly and are frozen at an early stage of development.
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 en- gaging 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 mother, for example, is not always available to do our bidding. A part of the id separates off and becomes the ego. Like the id, the ego un- consciously 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 can- not 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 most basic defense mechanism, repression, prevents unacceptable impulses from ever reaching con- sciousness.There are many other ego defense mechanisms, and each of us tends to favor some over others (see Table 2-1).
The Superego The superego grows from the ego, just as the ego grows out of the id. As we learn from our parents that many of our id impulses are unacceptable, we un- consciously 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
38 : //CHAPTER 2
Models of Abnormality :// 39
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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 control his id im- pulses, which lead him repeatedly to act in impulsive and often dangerous ways—suicide gestures, jealous rages, job resignations, outbursts of temper, 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. During this stage, children fear that the mother who feeds and com- forts 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.
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, Alfred Adler, 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.
Three of today's most influential psychodynamic theories are ego theory, self theory, and object relations theory. Ego theorists emphasize the role of the ego and consider it a more independent and powerful force than Freud did (Sharf, 2008). Self theorists, in contrast, give the greatest attention to the role of the self—the unified personality. They
40 ://CHAPTER 2
believe that the basic human motive is to strengthen the whole- ness of the self (Luborsky et al., 2008; Kohut, 2001, 1977). Object relations theorists 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 (Luhorsky et al., 2008; Kernberg, 2005, 2001, 1997).
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°free association0A psychodynamic technique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.
oresistanceoAn unconscious refusal to participate fully in therapy.
etransferenceoAccording to psychody- namic theorists, the redirection toward the psychotherapist of feelings associated with important figures in a patient's life, now or in the past.
odreamoA series of ideas and images that form during sleep.
ocatharsisoihe reliving of past repressed feelings in order to settle inter- nal conflicts and overcome problems.
Psychodynarnic Therapoes Psychodynamic therapies range from Freudian psychoanalysis to modern therapies based on self theory or object relations theory. All seek to uncover past traumas and the inner conflicts that have resulted from them. All 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.
Free Association In psychodynamic therapies, the patient is responsible for starting and leading each discussion.The therapist tells the patient to describe any thought, feel- ing, 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 un- cover unconscious events. Notice how free association helps this NewYorker to discover threatening impulses and conflicts within herself:
Patient: So I started walking, and walking, and decided to go behind the museum and walk through Central Park. So I walked and went through a back field and felt very excited and wonderful. 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. I think of an erect penis. This is connected with my father. 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. 1 get a funny feeling over my skin, tingly-like. ft'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. My mind seems to blank off like I can't think or ab- sorb anything.
(Wolberg, 1967, p. 662)
Therapist Onterpretation 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 particu- larly important—resistance, transference, and dreams.
Patients are showing resistance, an unconscious refusal to participate fully in ther- apy, when they suddenly cannot free associate or when they change a subject to avoid
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Models of Abnormality Al
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:
Patient get so excited by what is happening here. I fee/ I'm being held back by needing to be nice. I'd like to blast loose sometimes, but i don't dare.
Therapist: Because you fear my reaction? Patient: The worst thing would be that you wouldn't like me. You wouldn't speak to me
friendly; you wouldn't smile; you'd feel you can't treat me and discharge me from treatment. But i know this isn't so, I know it.
Therapist: Where do you think these attitudes come from? Patient: When I was nine years old, i read a lot about great men in history. I'd quote
them and be dramatic. I'd want a sword at my side; I'd dress like an Indian. Mother would scold me. Don't frown, don't talk so much. Sit on your hands, over and over again. 1 did all kinds of things. i was a naughty child. She told me I'd be hurt. Then at fourteen I fell off a horse and broke my back. I had to be in bed. Mother told me on the day I went riding not to, that I'd get hurt because the ground was frozen. I was a stubborn, self-willed child. Then i went against her will and suffered an accident that changed my life, a fractured back. Her attitude was, "1 told you so." I was put in a cast and kept in bed for months.
(Wollierg, 1967, p. 662)
Finally, many psychodynamic therapists try to help patients interpret their dreams (see Figure 2-4). 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.
Cash rsis Insight must be an emotional as well as an intellectual process. Psychody- namic therapists believe that patients must experience catharsis, a reliving of past re- pressed 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 dine, often years.
42 ://CHAPTER 2
Instincts
n an August day in 1996, a 3-year- jold boy climbed over a barrier at the
Brookfield Zoo in Illinois and fell 24 feet onto the cement floor of the gorilla com- pound. An 8-year-oid 160-pound gorilla named Binti-Jua picked up the child and cradled his limp body in her arms. The child's mother, fearing the worst, screamed out, "The gorilla's got my baby!" But Binti protected the boy as if he were her own. She held off the other gorillas, rocked him gently, and carried him to the entrance of the gorilla area, where rescue workers were waiting. Within hours, the incident was seen on videotape replays around the world, and Binti was being hailed for her maternal instincts.
When Binti was herself an infant, she had been removed from her mother, Lulu, who did not have enough milk. To make up for this loss, keepers at the zoo worked around the clock to nurture Binti; she was always being held in someone's arms. When Binti became pregnant at age 6, trainers were afraid that the early separa- tion from her mother would leave her ill prepared to raise an infant of her own. So they gave her mothering lessons and taught her to nurse and carry around a stuffed doll.
After the incident at the zoo, clinical theorists had a field day interpreting the gorilla's gentle and nurturing care for the
• • • • • • • • • • " "" " • " °`• " " • • • • •
Contemporary Trends in Psychodynamic TherapyThe past 30 years have witnessed substantial chan ges in the way many psychodynamic therapists conduct ses- sions.An increased demand for focused, time-Iimited psychotherapies has resulted in ef-
forts to make psychodynamic therapy more efficient.Two contemporary 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 (Charman, 2004).The therapist and patient focus on this prob-
lem 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 the approaches are sometimes quite helpful to patients (Present et al., 2008).
RELATIONAL PSYCHOANALYTIC THERAPY Whereas Freud believed that psychodynamic thera- pists should take on the role of a neutral, distant expert during a treatment session, a con-
child, each within his or her preferred theory. Many evolutionary theorists, for example, viewed the behavior as an ex- pression of the maternal instincts that have helped the gorilla species to survive and evolve. Some psychodynamic theorists sug- gested that the gorilla was expressing feel- ings of attachment and bonding, already experienced with her own 17-month-old
daughter. And behaviorists held that the gorilla may have been imitating the nur- turing behavior that she had observed in human models during her own infancy or enacting the parenting training that she had received during her pregnancy. In the meantime, Binti-Jua, the heroic gorilla, returned to her relatively quiet and predict- able life at the zoo.
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Models of Abnormality :// 43
temporary 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 (Luborsky et al., 2008; Levenson, 1982). 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.
Assessing the Psychodynamic Model Freud and his followers have helped change the way abnormal functioning is under- stood (Corey, 2008). 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 nor- mal functioning. Psychological conflict is a common experience; it leads to abnormal functioning only if the conflict becomes excessive.
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 (Nietzel et al., 2003). 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 limited research support over the years, and psychodynamic theorists rely largely on evidence provided by individual case studies. Nevertheless, recent research evidence suggests that long-term psychodynamic therapy may be helpful for many persons with long-term complex disorders (Leichsenring Rabung, 2008), and 15 percent of today's clinical psychologists identify themselves as psychodynamic therapists (Prochaska & Norcross, 2007).
The Psychodynarnic Model
Psychodynamic theorists believe that an individual's behavior, whether normal or abnormal, results from the interaction of underlying psychological forces. They consider psychological conflicts to be rooted in early parent-child relationships and traumatic experiences. The model was first developed by Sigmund Freud, who said that three dynamic forces—the id, ego, and superego—interact to produce thought, feeling, and behavior. Other psychodynamic theories are ego theory, self theory, and object relations theory. Psychodynamic therapists help people uncover past traumas and the inner conflicts that have resulted from them. They use a number of techniques, including free association and interpretations of resistance, transfer- ence, and dreams. Two of the leading contemporary psychodynamic approaches are short-term psychodynamic therapies and relational psychoanalytic therapy.
- !The Behavioral Model Like psychodynamic theorists, behavioral theorists believe that our actions are deter- mined largely by our experiences in life. However, the behavioral model concentrates on behaviors, the responses an organism makes to its environment. Behaviors can be exter- nal (going to work, say) or internal (having a feeling or thought). In turn, behavioral theorists base their explanations and treatments on principles of learning, the processes by which these behaviors change in response to the environment.
44: ,j/CHAPTER 2
Many learned behaviors help people to cope with daily challenges and to lead happy, productive lives. However, abnormal behaviors also can be learned. Behaviorists who try to explain Philip Berman's problems might view him as a man who has received improper training: He has learned behaviors that offend others and repeatedly work against him.
Whereas the psychodynamic model had its beginnings in the clinical work of phy- sicians, the behavioral model began in laboratories where psychologists were running experiments on conditioning, simple forms of learning. The researchers manipulated stimuli and rewards, then observed how their manipulations affected the responses of their research participants.
During the 1950s, many clinicians became frustrated with what they viewed as the vagueness and slowness of the psychodynamic model. Some of them began to apply the principles of learning to the study and treatment of psychological problems. Their efforts gave rise to the behavioral model of abnormality.
How Do Behaviorists Explain Abnormal Functioning? Learning theorists have identified several forms of conditioning, and each may produce abnormal behavior as well as normal behavior. In operant conditioning, for example, humans and animals learn to behave in certain ways as a result of receiving rewards-- any satisfying consequences—whenever they do so. In modeling, individuals learn responses simply by observing other individuals and repeating their behaviors.
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In a third form of conditioning, classical conditioning, learning occurs by tem- poral association. When two events repeatedly occur close together in time, they become fused in a person's mind, and before long the person responds in the same way to both events. If one event produces a response of joy, the other brings joy as well; if one event brings feelings of relief, so does the other. A closer look at this form of conditioning illustrates how the behavioral model can account for abnormal functioning.
Ivan Pavlov (1849-1936), a famous Russian physiologist, first demonstrated classi- cal conditioning with animal studies. He placed a bowl of meat powder before a dog, producing the natural response that all dogs have to meat: They start to salivate (see Figure 2-5). Next Pavlov added a step: just before presenting the dog with meat pow- der, he sounded a bell. After several such pairings of bell tone and presentation of meat powder, Pavlov noted that the dog began to salivate as soon as it heard the bell.The dog had learned to salivate in response to a sound.
In the vocabulary of classical conditioning, the meat in this demonstration is an unconditioned stimulus (US). It elicits the unconditioned response (UR) of salivation, that is, a natural response with which the dog is born. The sound of the bell is a conditioned stimulus (CS), a previously neutral stimulus that comes to be linked with meat in the dog's mind. As such, it too produces a salivation response. When the salivation response is produced by the conditioned stimulus rather than by the unconditioned stimulus, it is called a conditioned response (CR).
Models of Abnormality :1/ 45
BEFORE CONDITIONING
CS:Tone No response
US: Meat -+ UR: Salivation
AFTER CONDITIONING
CS: Tone -* CR: Salivation
US: Meat UR: Salivation
Classical conditioning explains many familiar behaviors. The ro- mantic feelings a young man experiences when he smells his girl- friend's perfume, say, may represent a conditioned response. Initially, this perfume may have had little emotional effect on him, but because the fragrance was present during several romantic encounters, it came to elicit a romantic response.
Abnormal behaviors, too, can be acquired by classical conditioning. Consider a young boy who is repeatedly frightened by a neighbor's large German shepherd dog. Whenever the child walks past the neigh- bor's front yard, the dog barks loudly and lunges at him, stopped only by a rope tied to the porch. In this unfortunate situation, the boy's parents are not surprised to discover that he develops a fear of dogs. They are stumped, however, by another intense fear the child displays, a fear of sand. They cannot understand why he cries whenever they take him to the beach and screams in fear if sand even touches his skin.
Where did this fear of sand come from? Classical conditioning. It turns out that a big sandbox is set up in the neighbor's front yard for the dog to play in. Every time the dog barks and lunges at the boy, the sandbox is there too. After repeated pairings of this kind, the child comes to fear sand as much as he fears the dog.
Behavioral Therapies Behavioral therapy aims to identify the behaviors that are causing a person's problems and then tries to replace them with more appropriate ones by applying the principles of classical conditioning, operant conditioning, or modeling (Wilson, 2008).The therapist's attitude toward the client is that of teacher rather than healer.
Classical conditioning treatments, for example, may be used to change abnormal reactions to particular stimuli. Systematic desensitization is one such method, often applied in cases of phobia—a specific and unreasonable fear. In this step-by-step procedure, clients learn to react calmly instead of with intense fear to the objects or situations they dread (Farmer & Chapman, 2008; Wolpe, 1997, 1995, 1990). First, they are taught the skill of relaxation over the course of several sessions. Next, they construct a fear hierarchy, a list of feared objects or situations, starting with those that are less feared and ending with the ones that are most dreaded. Here is the hierarchy developed by a man who was afraid of criticism, especially about his mental stability:
1. Friend on the street: "Hi, how are you?"
2. Friend on the street: "How are you feeling these days?"
3. Sister: "You've got to be careful so they don't put you in the hospital."
4. Wife: "You shouldn't drink beer while you are taking medicine."
5. Mother: "What's the matter, don't you feel good?"
6. Wife: "It's just you yourself, it's all in your head."
7. Service station attendant: "What are you shaking for?"
8. Neighbor borrows rake: "Is there something wrong with your leg? Your knees are shaking."
9. Friend on the job: "Is your blood pressure okay?"
10. Service station attendant: "You are pretty shaky, are you crazy or something?"
(Marquis & Morgan, 1969, p. 28)
Desensitization therapists next have their clients either imagine or actually confront each item on the hierarchy while in a state of relaxation. In step-by-step pairings of
oconditioning0A simple form of learning.
°operant conditioning0A process of learning in which behavior that leads to satisfying consequences is likely to be repeated.
omodelingoA process of learning in which an individual acquires responses by observing and imitating others.
°classical conditioningeA process of learning by temporal association in which two events that repeatedly occur close together in time became fused in a person's mind and produce the same response.
°systematic desensitization0A behav- ioral treatment in which clients with phobias learn to react calmly instead of with intense fear to the objects or situa- tions they dread.
Behavioral 10%
Other 8%
Interpersonal 4%
Family systems 3%
Client-centered 1%
-4.--"" Existential i%
Gestalt 2%
46 : //CHAPTER 2
feared items and relaxation, clients move up the hierarchy until at last they can face every one of the items without experiencing fear. As you will read in Chapter 4, research has shown systematic desensitization and other clas- sical conditioning techniques to be effective in treating phobias (Buchanan & Houlihan, 2008).
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Assessing the Behavioral Model The behavioral model has become a powerful force in the clinical field. Various behavioral theories have been proposed over the years, and many treatment techniques have been developed. As you can see in Figure 2-6, approximately 10 percent of today's clinical psychologists report that their approach is mainly behavioral (Prochaska & Norcross, 2007).
Perhaps the greatest appeal of the behavioral model is that it can be tested in the laboratory, whereas psychodynamic theories generally cannot. The behaviorists' basic concepts—stimulus, response, and reward—can be observed and measured. Experimenters have, in fact, successfully used the principles of learning to create clinical symptoms in laboratory participants, suggesting that psychological disorders may indeed develop in the same way. In addition, research has found that behavioral treatments can be help- ful to people with specific fears, compulsive behavior, social deficits, mental retardation, and other problems (Wilson, 2008).
At the same time, research has also revealed weaknesses in the model. Certainly behav- ioral researchers have produced specific symptoms in participants. But are these symptoms ordinarily acquired in this way? There is still no indisputable evidence that most people with psychological disorders are victims of improper conditioning. Similarly, behavioral therapies have limitations.The improvements noted in the therapist's office do not always extend to real life. Nor do they necessarily last without continued therapy.
Finally, some critics hold that the behavioral view is too simplistic, that its con- cepts fail to account for the complexity of behavior. In 1977 Albert Bandura, a leading behaviorist, argued that in order to feel happy and function effectively people must develop a positive sense of self-efficacy. That is, they must know that they can master and perform needed behaviors whenever necessary. Other behaviorists of the 1960s and 1970s similarly recognized that human beings engage in cognitive behaviors, such as anticipating or interpreting—ways of thinking that until then had been largely ignored in behavioral theory and therapy. These individuals developed cognitive-behavioral expla- nations that took unseen cognitive behaviors into greater account (Meichenbaum, 1993; Goldiamond, 1965) and cognitive-behavioral therapies that helped clients to change both counterproductive behaviors and dysfunctional ways of thinking. Cognitive-behavioral theorists and therapists bridge the behavioral model and the cognitive model, the view to which we turn next.
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Models of Abnormality :// 47
The Bel civioral Model
Behaviorists focus on behaviors and propose that the behaviors develop in accordance
with the principles of learning. They hold that three types of conditioning—classical
conditioning, operant conditioning, and modeling—account for all behavior, whether normal or dysfunctional. The goal of the behavioral therapies is to identify
the client's problematic behaviors and replace them with more appropriate ones,
using techniques based on one or more of the principles of learning. The classical conditioning approach of systematic desensitization, for example, has been effec-
tive in treating phobias.
*The Cognitive Model 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 experiences in ways that lead to poor decisions, maladaptive responses, and painful emotions.
In the early 1960s two clinicians,Albert Ellis (1962) and Aaron Beck (1967), proposed that cognitive processes are at the center of behaviors, thoughts, and emotions and that we can best understand abnormal functioning by looking to cognition—a perspective known as the cognitive model. Ellis and Beck claimed that clinicians must ask questions about the assumptions and attitudes that color a client's perceptions, the thoughts run- ning through that person's mind, and the conclusions to which they are leading. Other theorists and therapists soon embraced and expanded their ideas and techniques.
How Do Cognitive Theorists Explain Abnormal Functioning? According to cognitive theorists, abnormal functioning can result from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes that are dis- turbing and inaccurate (Beck &Weishaar, 2008; Ellis, 2008). Philip Berman, for example, often seems to assume that his past history has locked him in his present situation. He believes that he was victimized by his parents and that he is now forever doomed by his past. He seems to approach all new experiences and relationships with expectations of failure and disaster.
Illogical thinking processes are another source of abnormal functioning, ac- cording to cognitive theorists. Beck, for example, has found that some people consistently think in illogical ways and keep arriving at self-defeating conclu- sions (Beck & Weishaar, 2008). As you will see in Chapter 7, he has identified a number of illogical thought processes regularly found in depression, such as overgeneralization, the drawing of broad negative conclusions on the basis of a single insignificant event. One depressed student couldn't remember the date of Columbus's third voyage to America during a history class. Overgeneralizing, she spent the rest of the day in despair over her wide-ranging ignorance.
Cognitive Therapies According to cognitive therapists, people with psychological disorders can overcome their problems by developing new, more functional ways of thinking. Because different forms of abnormality may involve different kinds of cogni- tive dysfunctioning, cognitive therapists have developed a number of strategies. Beck, for example, has developed an approach that is widely used, particularly in cases of depression (Beck & Weishaar, 2008; Beck, 2002, 1967).
Sur:ii j for Help oday, computers and the Internet affect just about every area of life.
Thus it is not surprising that the growth of cybertherapy has closely paralleled devel- opments in computer technology.
The clinical field's first excursion into the digital world took the form of computer software therapy programs (Tantum, 2006; Moriley et al., 2004). These programs seek to reduce emotional distress through typed conversations between human users and computer "therapists." The computer programs try to capture the basic prin- ciples of actual therapy. One program, for example, helps people state their problems in "if-then" statements, a technique similar to that used by cognitive therapists.
Advocates of computer software therapy programs have argued that many people find it easier to disclose sensitive personal information to a computer than to a thera- pist. Research indicates that some of the programs are indeed helpful to at least a modest degree (Lange et al., 2004; Rochlen et al., 2004). Computer experts currently are working to develop programs for recognizing clients' faces and emotions and on programs that emulate emotion in computer-generated animation, develop- ments that will likely increase the versatility and appeal of computer therapy programs.
Another form of cybertherapy, online counseling, has exploded in popular- ity over the past decade. Thousands of therapists have set up online services that invite persons with problems to e-mail their questions and concerns (Chester & Glass, 2006; Rosen, 2005). Such services, often called e-therapy, can cost as much as $2 per minute. Services of this kind have
raised concerns about the quality of care and about confidentiality. Many e-thera- pists do not even have advanced clinical training. Nevertheless, the use of e-therapy continues to grow by leaps and bounds.
Less common, but on the rise, is audio- visual e-therapy. This kind of offering more closely mimics the conventional therapy experience. A client sets up an appoint- ment with a therapist, and, with the aid of a camera, microphone, and proper computer tools, the two proceed to have a face-to-face session. The advantage? Clients can receive counseling conveniently while sitting at home or in their office, and they can have access to a counselor who is located even thousands of miles away. The key disadvantage? Once again, qual- ity control.
Still more common than either online counseling or audiovisual e-therapies are Internet chat groups and "virtual" support groups. Tens of thousands of these groups are currently "in session" around the clock for everything from depression to substance abuse, anxiety, and eating disorders (Moskowitz, 2008, 2001). Like in-person self-help groups, the online chat groups pro- vide opportunities for people with similar problems to communicate with each other, freely trading information, advice, and empathy (Griffiths & Christensen, 2006). Of course, unlike members of in-person self- help groups, people who choose Internet chat group therapy do not know who is on the other end of the computer connection or whether the advice they receive is well intentioned or at all appropriate.
48 ://CHAPTER 2
°cognitive therapy®A therapy devel- oped by Aaron Beck that helps people recognize and change their faulty think- ing processes.
In Beck's approach, called simply cognitive therapy, therapists help clients rec- ognize the negative thoughts, biased interpretations, and errors in logic that dominate their thinking and, according to Beck, cause them to feel depressed.Therapists also guide clients to challenge their dysfunctional thoughts, try out new interpretations, and ulti- mately apply the new ways of thinking in their daily lives. As you will see in Chapter 7, people with depression who are treated with Beck's approach improve much more than those who receive no treatment.
Models of Abnormality 49
In the excerpt that follows, a cognitive therapist guides a depressed 26-year-old graduate student to see the link between the way she interprets her experiences and the way she feels and to begin questioning the accuracy of her interpretations:
Therapist: How do you understand it? Patient: I get depressed when things go wrong. Like when I fail a test.
Therapist: How can failing a test make you depressed? Patient Well, if I fail I'll never get into law school.
Therapist: So failing the test means a lot to you. But if failing a test could drive people into clinical depression, wouldn't you expect everyone who failed the test to have a depression? ... Did everyone who failed get depressed enough to require treatment?
Patient No, but it depends on how important the test was to the person. Therapist Right, and who decides the importance?
Patient: I do. Therapist And so, what we have to examine is your way of viewing the test (or the way
that you think about the test) and how it affects your chances of getting into law school. Do you agree?
Patient Right. . . Therapist Now what did failing mean?
Patient: (Tearful) That I couldn't get into law school. Therapist And what does that mean to you?
Patient That I'm just not smart enough. Therapist Anything else?
Patient That I can never be happy. Therapist And how do these thoughts make you feel?
Patient: Very unhappy. Therapist So it is the meaning of failing a test that makes you very unhappy. In fact, believ-
ing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap—by definition, failure to get into law school equals "I can never be happy."
(Beck et al., 1979, pp, 145-146)
Assessing the Cognitive Model The cognitive model has had very broad appeal. In addition to a large number of cognitive-behavioral clinicians who apply both cognitive and learning principles in their work, many cognitive clinicians focus exclusively on client interpretations, attitudes, as- sumptions, and other cognitive processes. Altogether approximately 28 percent of today's clinical psychologists identify their approach as cognitive (Prochaska & Norcross, 2007).
The cognitive model is popular for several reasons. First, it focuses on a process unique to human beings—the process of human thought—and many theorists from varied backgrounds find themselves drawn to a model_ that considers thought to be the primary cause of normal and abnormal behavior.
Cognitive theories also lend themselves to research. Investigators have found that people with psychological disorders often make the kinds of assumptions and errors in thinking the theorists claim (Ingram et at, 2007).Yet another reason for the popular- ity of this model is the impressive performance of cognitive and cognitive-behavioral therapies. They have proved very effective for treating depression, panic disorder, social phobia, and sexual dysfunctions, for example (Beck & Weishaar, 2008).
Nevertheless, the cognitive model, too, has its drawbacks. First, although disturbed cognitive processes are found in many forms of abnormality, their precise role has yet to be detertnined,The cognitions seen in psychologically troubled people could well be a
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result rather than a cause of their difficulties. Second, although cognitive and cognitive-behavioral therapies are clearly of help to many people, they do not help everyone. Is it enough simply to change cognitions?
Y. oz. 0 v./ N Can such changes make a general and lasting difference in the way TEOlauS THAWS people feel and behave? Moreover, a growing body of research suggests
NEXT 200 MILES that the kinds of cognitive changes proposed by Beck and other cogni- tive therapists are not always possible to achieve (Shall, 2008).
In response to such limitations, a new group of cognitive and cognitive-behavioral therapies, sometimes called the new wave of cog- nitive therapies, has emerged in recent years. These new approaches, such as the widely 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 (Levin & Hayes, 2009). 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.
A final drawback of the cognitive model is that, like the other models you have read about, it is narrow in certain ways. Although cognition is a very special human dimen- sion, it is still only one part of human functioning. Aren't human beings more than the sum of their thoughts, emotions, and behaviors? 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.
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The Cognitive Model
According to the cognitive model, we must understand human thought to under- stand human behavior. When people display abnormal patterns of functioning, cognitive theorists point to cognitive problems, such as maladaptive assumptions and illogical thinking processes. Cognitive therapists try to help people recognize and change their faulty ideas and thinking processes. Among the most widely used cognitive treatments is Beck's cognitive therapy.
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Ti;ghe 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. Ac- cording 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 this 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 (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
Models of Abnormality 51
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 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 humanis- tic 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 (Mendelowitz & Schneider, 2008).
The humanistic and existential theories, and their uplifting implications, were ex- tremely 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.
Rogers's Humanistic Theory and Therapy According to Carl Rogers (2000, 1987, 1951), the road to dysfunction begins in infancy. 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 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 a distorted 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 striv- ing to fulfill his positive human potential, he drifts from job to job and relationship to re- lationship. 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 itself. Rogers would probably link this problem to the critical ways Philip was treated by his mother throughout his childhood.
Clinicians who practice Rogers's client-centered therapy try to create a support- ive climate in which clients feel able to look at themselves honestly and acceptingly (Raskin, Rogers, & Witty, 2008). 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 restatements), and genuineness (sincere com- munication). The following interaction shows the therapist using all these qualities to move the client toward greater self-awareness:
•
Client: Yes, I know I shouldn't worry about it, but I do. Lots of things—money, people, clothes. in classes I feel that everyone's just waiting for a chance to jump on me. . . When I meet somebody l wonder what he's actually thinking of me. Then later on I wonder how I match up to what he's come to think of me.
Therapist: You feel that you're pretty responsive to the opinions of other people. Client: Yes, but it's things that shouldn't worry me.
Gself-actualizationoThe humanistic pro- cess by which people fulfill theft potential for goodness and growth.
°client-centered therapyeThe human- istic therapy developed by Carl Rogers in which clinicians try to help clients by conveying acceptance, accurate empa- thy, and genuineness.
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52 ://CHAPTER 2
Therapist: You feel that it's the sort of thing that shouldn't be upsetting, but they do get you pretty much worried anyway.
Client: Just some of them. Most of those things do worry me because they're true. The ones I told you, that is. But there are lots of little things that aren't true... . Things just seem to be piling up, piling up inside of me. . It's a feeling that things were crowding up and they were going to burst.
Therapist: You feel that it's a sort of oppression with some frustration and that things are just unmanageable.
Client: In a way, but some things just seem illogical. I'm afraid I'm not very clear here but that's the way it comes.
Therapist That's all right. You say just what you think.
(Snyder 1947, pp. 2-24)
In such an atmosphere, clients are expected to feel accepted 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 (Sharf, 2008). 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. All the same, Rogers's therapy has had a positive influence on clinical practice (Raskin et al., 2008). 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 1 percent of today's clinical psychologists, 2 percent of social workers, and 4 percent of counseling psychologists report that they employ the client-centered approach (Prochaska & Norcross, 2007).
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, 2008). But unlike client-centered therapists, they often try to achieve this goal by challenging and even frustrating their clients. Some of Perls's favorite tech- niques were skillful frustration, role playing, and numerous rules and exercises.
In the technique of skillful frustration, gestalt therapists refuse to meet their clients' expectations or demands.This use of frustration is meant to help people see how often they try to manipulate others into meeting their needs. In the technique of role play- ing, the therapists instruct 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. 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.
Peels also developed a list of rules to ensure that clients will look at themselves more closely. In some versions of gestalt therapy, for example, clients may be required to use "I" language rather than "it" language.They must say,"I am frightened" rather than "The situation is frightening."Yet another common rule requires clients to stay in the here and now. They have needs now, are hiding their needs now and must observe them now.
Approximately 1 percent of clinical psychologists and other kinds of clinicians describe themselves as gestalt therapists (Prochaska & Norcross, 2007). 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, 2008; Striimpfel, 2006, 2004).
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Models of Abnormality :1/ 53
Spiritual Views and Interventions For most of the twentieth century, clinical scientists viewed religion as a negative—or at best neutral—factor in mental health (Blanch, 2007; Richards & Bergin, 2005, 2000). In the early 1900s, for example, 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 religion now seems to be ending, however. During the past de- cade, 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 (Richards & Bergin, 2005, 2004). Researchers have learned that spirituality can, in fact, be of psychological benefit to people. 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 (Loewenthal, 2007; Koenig, 2002). Such individuals 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. In line with such findings, many therapists now make a point of including spiritual issues when they treat religious clients (Raab, 2007; Helineke & Sori, 2006), and some further encourage clients to use their spiritual resources to help them cope with current stressors.
Existential Theories and Therapy Like humanists, existentialists believe that psychological dysfunc tinning 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 (Mendelowitz & Schneider, 2008). Such people are left with empty, inauthentic lives. Their dominant emotions are anxiety, frustration, boredom, alienation, and depression.
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 teach- ers, acquaintances, and employers as oppressing. He fails to appreciate his choices in life and his 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.
*gestalt theraprThe humanistic ther- apy developed by Fritz Perk in which clinicians actively move clients toward self-recognition and self-acceptance by using techniques such as role playing and self-discovery exercises.
54 ://CHAPTER 2
°existential theraprA therapy that encourages clients to accept responsibil- ity for their lives and to live with greater meaning and values.
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 (Schneider, 2008, 2003). 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 candor, hard work, and shared learning and growth.
Patient: I don't know why 1 keep coming here. All I do is tell you the same thing over and over. I'm not getting anywhere.
Doctor: I'm getting tired of hearing the some thing over and over, too. Patient Maybe stop coming. Doctor: it's certainly your choice.
Patient: What do you think I should do? Doctor: What do you want to do? Patient: I want to get better. Doctor: don't blame you. Patient If you think I should stay, ok, I will. Doctor: You want me to tell you to stay? Patient: You know what's best; you're the doctor. Doctor: Do I act like a doctor?
(Keen, 1970, p. 200)
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, very little controlled research has been devoted to the effectiveness of this approach (Schneider, 2008). Neverthe- less, around 1 percent of today's therapists use an approach that is primarily existential (Prochaska & Norcross, 2007).
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 (Cain, 2007; Wampold, 2007). 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. Indeed, such optimism meshes quite well with the goals and principles of positive psychology, a current movement described in Chapter 1. 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 ac- complish 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 fulfill- ment 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 antiresearch position is just now beginning to change. Human- istic and existential researchers have conducted several recent studies that use appropriate
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The humanistic-existential model focuses on distinctly human issues such as self- awareness, values, meaning, and choice.
Humanists believe that people are driven to self-actualize. When this drive is interfered with, abnormal behavior may result. One group of humanistic therapists, client-centered therapists, tries to create a very supportive therapy climate in which people can look at themselves honestly and occeptingly, thus opening the door to self-actualization. Another group, gestalt therapists, uses more active techniques to help people recognize and accept their needs. Recently the role of religion as an important factor in mental health and in psychotherapy has caught the attention of researchers and clinicians.
According to existentialists, abnormal behavior results from hiding from life's responsibilities. Existential therapists encourage people to accept responsibility for their lives, to recognize their freedom to choose a different course, and to choose to live with greater meaning.
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control groups and statistical analyses, and they have found that their therapies can be ben- eficial in some cases (Schneider, 2008; Strampfel, 2006) This newfound interest in research should lead to important insights about the merits of this model in the coming years.
•
*The Sociocultural Model: Family-Social and Multicultural Perspectives Philip Berman is also a social and cultural being. He is surrounded by people and by institutions, he is a member of a family and a cultural group, he participates in social relationships, and he holds cultural values. Such forces are always operating upon Philip, setting rules and expectations that guide or pressure him, helping to shape his behaviors, thoughts, and emotions.
According to the sociocultural model, abnormal behavior is best understood in fight of the broad forces that influence an individual. What are the norms of the individual's society and culture? What roles does the person play in the social environment? What kind of family structure or cultural background is the person a part of? And how do other people view and react to him or her? In fact, the sociocultural model is comprised of two major perspectives—the family-social perspective and the multicultural perspective.
How Do Family-Social Theorists Explain Abnormal Functioning? Proponents of the family-social perspective argue that clinical theorists should con- centrate on those broad forces that operate directly on an individual as he or she moves through life—that is, family relationships, social interactions, and community events. They believe that such forces help account for both normal and abnormal behavior, and they pay particular attention to three kinds of factors: social labels and roles, social networks, and family structure and communication.
Social Labels and Roles Abnormal functioning can be influenced greatly by the labels and roles assigned to troubled people (Link & Phelan, 2006; Link et al., 2004, 2001).When people stray from the norms of their society, the society calls them deviant and, in many cases, "mentally ill." Such labels tend to stick. Moreover, when people are viewed in particular ways, reacted to as "crazy," and perhaps even encouraged to act sick, they gradually learn to accept and play the assigned social role. Ultimately the label seems appropriate.
56 ://CHAPTER 2
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A famous study by the clinical investigator David Rosenhan (1973) supports this position. Eight normal people presented themselves at various mental hospitals, com- plaining that they had been hearing voices say the words "empty," "hollow," and "thud." On the basis of this complaint alone, each was diagnosed as having schizophrenia and admitted. In fact, the "pseudopatients" had a hard time convincing others that they were well once they had been given the diagnostic label. Their hospitalizations ranged from 7 to 52 days, even though they behaved normally as soon as they were admitted. In addition, the label kept influencing the way the staff viewed and dealt with them. For example, one pseudopatient who paced the corridor out of boredom was, in clinical notes, described as "nervous." Overall, the pseudopatients came to feel powerless, invis- ible, and bored.
Sod& Networks and Supports Family-social theorists are also concerned with the social networks in which people operate, including their social and professional re- lationships. How well do they communicate with others? What kind of signals do they send to or receive from others? Researchers have often found ties between deficiencies in social networks and a person's functioning (Yen et al., 2007; Paykel, 2006, 2003).They have observed, for example, that people who are isolated and lack social support or inti- macy in their lives are more likely to become depressed when under stress and to remain depressed longer than are people with supportive spouses or warm friendships.
Family Structure and Communication Of course, one of the important social networks for an individual is his or her family. According to family systems theory, the family is a system of interacting parts—the family members—who interact with one another in consistent ways and follow rules unique to each family (Goldenberg & Goldenberg, 2008). Family systems theorists believe that the structure and coinmunication patterns of some families actually force individual members to behave in a way that oth- envise seems abnormal. If the members were to behave normally, they would severely strain the family's usual manlier of operation and would actually increase their own and their family's turmoil.
Family systems theory holds that certain family systems are particularly likely to produce abnormal functioning in individual members. Some families, for example, have an enmeshed structure in which the members are grossly overinvolved in each other's activities, thoughts, and feelings. Children from this kind of family may have great dif- ficulty becoming independent in life (Santiseban et al., 2001). Some families display disengagement, which is marked by very rigid boundaries between the members. Chil- dren from these families may find it hard to function in a group or to give or request support (Corey, 2008, 2004).
Philip Berman's angry and impulsive persona] style might be seen as the product of a disturbed family struc- ture. According to family systems theorists, the whole family—mother, father, Philip, and his brother Arnold— relate in such a way as to maintain Philip's behavior. Family theorists might be particularly interested in the conflict between Philip's mother and father and the imbalance between their parental roles. They might see Philip's behavior as both a reaction to and stimulus for his parents' behaviors. With Philip acting out the role of the misbehaving child, or scapegoat, his parents may have little need or time to question their own relationship.
Family systems theorists would also seek to clarify the precise nature of Philip's relationship with each parent. Is he enmeshed with his mother and/or disengaged from his father? They would look too at the rules governing the sibling relationship in the family, the relationship between the parents and Philip's brother, and the nature of parent- child relationships in previous generations of the family.
