Psychological Disorder Analysis PSY/270

Table of Contents

Psychological Disorder Analysis
Psychological Disorder Analysis

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Psychological Disorder Analysis

Marla is a 42-year-old Hispanic female who comes to the mental health clinic complaining of having trouble sleeping, feeling “jumpy all of the time,” and experiencing an inability to concentrate. These symptoms are causing problems for her at work, where she is an accountant.   —— Dysthymia Disorder

·         Resources: Appendix A, Fundamentals of Abnormal Psychology, and the Faces of Abnormal Psychology Interactive application at the McGraw Hill Higher Education website

·         Write a 1,400- to 1,750-word paper analyzing Marla’s disorder. Address the following:

·         Decide which disorder Marla may have using the information in the Faces of Abnormal Psychology Interactive Application at

·         The profile introduction will match more than one of the disorders found in the application.

·         You must choose one of the disorders and complete the profile.

·         Include the 10 question from the week Four CheckPoint. (Questions are below)

Clinical Interview Questions

Psychological Disorder Analysis

1)       What made you decide to come to therapy?

2)       What are you expectations and goal you would like to achieve from therapy?

3)       Can you tell me about yourself, your family (mother, father, siblings) and how is your relationship with them? Are you all a close nit family?

4)       Do you have any close friends or a significant other?

5)       How well do you get along with your friends, significant other and co-workers?

6)       Do you have any feelings of anxiety, depression, or suicidal thoughts?

7)       How is your overall physical health?

8)       Does mental illness or depression run in your family?

9)       Are you currently on any medication? Do you drink or use any illegal drugs?

10)   How would you describe yourself and your personality? Do you think you have good morals?

·         Summarize the disorder using the information provided in the interactive application.

·         Explain the origin of the disorder and any potential treatments by using one of the models of abnormality found in Ch. 2 of Fundamentals of Abnormal Psychology. (SEE ATTACHED PDF)

·         Format your paper consistent with APA guidelines.

Final Project Overview

Psychological Disorder Analysis

The final project for this course is comprehensive, designed to allow you to analyze a psychological disorder by reviewing a short profile of Marla, a 42-year-old accountant. This assignment provides you with a greater understanding of and ability to recognize abnormal behavior. Once you identify a possible disorder, probe deeper by asking questions and completing Marla’s profile. Once you have completed Marla’s profile, suggest possible treatments based on the models of abnormality in Ch. 2. This project reflects the culmination of your knowledge gathered through the readings, discussion questions, CheckPoints, and assignments.

•               Suggested in Week Two: Review the McGraw Hill Higher Education Web site,, which will be used for your final project.

•               Due in Week Four: Review the requirements for your final project and pp. 69-70 of the text. Draft ten probing questions to learn more about the patient’s background.

•               Suggested in Week Eight: Familiarize yourself with the DSM-IV to make a decision regarding a possible disorder.


Please review my grading expectations for the Psychological Disorder Analysis Final Project Assignment:

Presentation Grading Form for the Psychological Disorder Analysis Final Project, Due in Week Nine

Content and Development  

175 Points             Points Earned


                Additional Comments:

All key elements of the assignment are covered in a substantive way.

•               Student identifies Marla’s disorder and completes the profile.

•               Student summarizes and includes the 10 questions from week four checkpoint.  

•               Student summarizes the disorder using information provided in the interactive application.  

•               Student explains the origin of the disorder and any potential treatments by using one of the models of abnormality.

•               The paper is 1,400 to 1,750 words in length.

The content is comprehensive, accurate, and persuasive.        

The paper develops a central theme or idea, directed toward the appropriate audience.  

The paper links theory to relevant examples and uses the vocabulary of the theory correctly.         

Major points are stated clearly; are supported by specific details, examples, or analysis; and are organized logically.              

The introduction provides sufficient background on the topic and previews major points. 

The conclusion is logical, flows from the body of the paper, and reviews the major points.              

Readability and Style  

10 Points               Points Earned


                Additional Comments:

Paragraph transitions are present, logical, and maintain the flow throughout the paper.   

The tone is appropriate to the content and assignment.            

Sentences are complete, clear, and concise.               

Sentences are well constructed, with consistently strong, varied sentences.        

Sentence transitions are present and maintain the flow of thought.        


15 Points               Points Earned


                Additional Comments:

The paper, including the title page, reference page, tables, and appendixes, follows APA formatting guidelines.      

Citations of original works within the body of the paper follow APA guidelines.   

The paper is laid out with effective use of headings, font styles, and white space.              

Rules of grammar, usage, and punctuation are followed.         

Spelling is correct.              


200 Points             Points Earned


Overall Comments:

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P hilip Berman, a 25-year-old single unemployed former copy editor for a large publishing house, . . . had been hospitalized after a suicide attempt in which he deeply gashed his 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 have 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, “I’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 an 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 I 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

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32 ://CHAPTER 2

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 (Sharf, 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.

•model•A set of assumptions and concepts that help scientists explain and interpret observations. Also called a paradigm.

•neuron•A nerve cell.

•synapse•The tiny space between the nerve ending of one neuron and the den- drite of another.

•neurotransmitter•A chemical that, released by one neuron, crosses the syn- aptic space to be received at receptors on the dendrites of neighboring neurons.


Famous Psych Lines from the Movies: Take 2 “Do you have any idea how crazy you are?” (No Country for Old Men, 2007) <<

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

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

“Insanity runs in my family. . . . It practically gallops.” (Arsenic and Old Lace, 1944) <<

“Ah, but the strawberries! That’s where I had them!” (The Caine Mutiny, 1954) <<

“I won’t be ignored!” (Fatal Attraction, 1987) <<

“I’ve wrestled with reality for thirty-five years, doctor, and I’m happy to state I fi- nally won out over it.” (Harvey, 1950) <<

“I begged you to get therapy.” (Tootsie, 1982) <<

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Models of Abnormality :// 33

jjThe 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 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.



Cerebral cortex

Basal ganglia

Corpus callosum

Figure 2-1 The cerebrum Some psychological disorders can be traced to abnormal functioning of neurons in the cerebrum, which includes brain structures such as the basal ganglia, hippocampus, amygdala, corpus callosum, and cerebral cortex.


In Their Words “My brain? That’s my second favorite organ.” <<

Woody Allen

“I am a brain, Watson. The rest of me is a mere appendix.” <<

Sherlock Holmes, in Arthur Conan Doyle’s “The Adventure of the Mazarin Stone”

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34 ://CHAPTER 2

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).


Cell body

Electrical impulse


Nerve ending


Release of neurotransmitters

Receptor sites on receiving neuron Receptor sites on receiving neuron


More than coincidence? Studies of twins suggest that some aspects of behavior and personality are influenced by genetic factors. Many identical twins, like these musicians, are found to have similar tastes, behave in similar ways, and make similar life choices. Some even develop similar abnormal behaviors.

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Figure 2-2 A neuron communicating information A message in the form of an electrical impulse travels down the sending neuron’s axon to its nerve ending, where neuro- transmitters are released and carry the message across the synaptic space to the dendrites of a receiving neuron.

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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 (Fábrega, 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 infections. 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).

Biological 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 1950s, researchers discovered several effective psychotropic medications, drugs that mainly affect emotions and thought processes. These drugs have greatly changed the outlook for a number of mental disorders and today are used widely, ei- ther alone or with other forms of therapy. However, the psychotropic drug revolution

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The brain bank At Cornell University’s “brain bank,” researcher Barbara Finlay holds the brain of a person who had schizophrenia. There are currently more than 100 brain banks, each preserving dozens of brains for study by researchers around the world ( Kennedy, 2004).

•hormones•The chemicals released by endocrine glands into the bloodstream.

•gene•Chromosome segments that control the characteristics and traits we inherit.

•psychotropic medications•Drugs that primarily affect the brain and reduce many symptoms of mental dysfunctioning.

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36 ://CHAPTER 2

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 drugs 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 far back as trephining, the prehistoric practice of chipping a hole in the skull of a person who behaved strangely. Modern procedures are derived from a 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).

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.

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“Don’t judge me until you’ve walked a mile on my medication.”

•electroconvulsive therapy (ECT)• 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.

•psychosurgery•Brain surgery for men- tal disorders. Also called neurosurgery.


Whose Brain Has the Most Neurons? Human 100,000,000,000 neurons <<

Octopus 300,000,000 neurons <<

Rat 21,000,000 neurons <<

Frog 16,000,000 neurons <<

Cockroach 1,000,000 neurons <<

Honey bee 850,000 neurons <<

Fruit fly 100,000 neurons <<

Ant 10,000 neurons <<

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Models of Abnormality :// 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.

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: $20 million

Clinical Phase III: Final Testing (3–5 years) Investigators conduct controlled studies

to fully determine drug’s efficacy and important side effects.

• Number of subjects: 300–30,000 • Typical cost: $45 million

Review by FDA (1–5 years) Research is reviewed by FDA, and drug

is approved or disapproved.

Postmarketing Surveillance (10 years) Long after the drug is on the market-

place, testing continues and doctors’ reports are gathered. Manufacturer must report any unexpected long-term effects and side effects.

Preclinical Phase (5 years) New drug is developed and identified. Drug is tested on animals, usually rats,

to help determine its safety and efficacy.

Clinical Phase I: Safety Screening (1.5 years) Investigators test drug on human

subjects to determine its safety. • Number of subjects: 10–100 • Typical cost: $10 million

SUMMING UP 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.

jjThe 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.

Figure 2-3 How does a new drug reach the market- place? It takes an average of 14 years and tens of millions of dollars for a pharma- ceutical company in the United States to bring a newly discovered drug to market. The company must carefully follow steps that are specified by law. (Adapted from Lemonick & Goldstein, 2002; Zivin, 2000.)

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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

table: 2-1

The Defense Never Rests: Defense Mechanisms to the Rescue

Defense Operation Example Repression Person avoids anxiety by simply not

allowing painful or dangerous thoughts to become conscious.

An executive’s desire to run amok and attack 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.

•id•According to Freud, the psychologi- cal force that produces instinctual needs, drives, and impulses.

•ego•According to Freud, the psycho- logical force that employs reason and operates in accordance with the reality principle.

•ego defense mechanisms•According to psychoanalytic theory, strategies devel- oped by the ego to control unacceptable id impulses and to avoid or reduce the anxiety they arouse.

•superego•According to Freud, the psychological force that represents a per- son’s values and ideals.

•fixation•According 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.

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Models of Abnormality :// 39

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

“Luke, I am your father.” This light-saber fight between Luke Skywalker and Darth Vader highlights the most famous, and contentious, father-son relationship in movie history. According to Freud, however, all fathers and sons experience significant tensions and conflicts that they must work through, even in the absence of the special pressures faced by Luke and his father in the Star Wars series.

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Critical training Freud believed that toilet training is a critical developmental experience. Children whose training is too harsh may become “fixated” at the anal stage and develop an “anal character”—stubborn, contrary, stingy, or controlling.

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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 (Luborsky et al., 2008; Kernberg, 2005, 2001, 1997).

Psychodynamic Therapies 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 New Yorker 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. I get a funny feeling over my skin, tingly-like. It’s a strange feeling, like a blindness, like not seeing something. My mind blurs and spreads over anything I look at. I’ve had this feeling off and on since I walked in the park. My mind seems to blank off like I can’t think or ab- sorb anything.

(Wolberg, 1967, p. 662)

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


ho to

Freud takes a closer look at Freud Sigmund Freud, founder of psychoanalytic theory and therapy, examines a sculptured bust of himself in 1931 at his village home near Vienna. As Freud and the bust go eyeball to eyeball, one can only imagine what conclusions each is drawing about the other.

•free association•A psychodynamic technique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.

•resistance•An unconscious refusal to participate fully in therapy.

•transference•According 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.

•dream•A series of ideas and images that form during sleep.

•catharsis•The reliving of past repressed feelings in order to settle inter- nal conflicts and overcome problems.

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Models of Abnormality :// 41

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: I get so excited by what is happening here. I feel 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. I 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, “I told you so.” I was put in a cast and kept in bed for months.

(Wolberg, 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.

Catharsis 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 time, often years.

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A cultural phenomenon The psychodynamic model’s impact has extended far beyond the clinical field. In 1955 a comic book series named Psychoanalysis hit the marketplace. Its first caption read, “This is a psychiatrist! Into his peaceful, tastefully-decorated, subdued office come the tormented and the driven.”

Every night 14%Never 6%

Rarely 24%

Occasionally 33%

Frequently 23%

Figure 2-4 Remembering our dreams Although most adults dream several times each night, only 14 percent of them are able to remember their dreams every night. In contrast, 30 per- cent rarely or never recall any of their dreams. (Adapted from Kantrowitz & Springen, 2004; Strauch, 2004.)

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Contemporary Trends in Psychodynamic Therapy The past 30 years have witnessed substantial changes in the way many psychodynamic therapists conduct ses- sions. An increased demand for focused, time-limited 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-

On an August day in 1996, a 3-year-old 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-old 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

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.

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


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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).

SUMMING UP The Psychodynamic 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.

jjThe 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.


All About Freud Freud’s fee for one session of therapy was $20—$160 in today’s dollars. <<

For almost 40 years Freud treated patients 10 hours per day, five or six days per week. <<

Freud’s parents often favored the pre- cociously intelligent Sigmund over his siblings—for example, by giving him his own room in which to study in peace. <<

(Gay, 2006, 1999; Jacobs, 2003; Asimov, 1997; Schwartz, 1993)


In Their Words “We are molded and remolded by those who have loved us.” <<

François Mauriac

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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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See and do Modeling may account for some forms of abnormal behavior. A famous study by Albert Bandura and his colleagues (1963) demonstrated that children learned to abuse a doll by observing an adult hit it. Children who had not been exposed to the adult model did not mistreat the doll.

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).

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BEFORE CONDITIONING AFTER CONDITIONING CS: Tone → No response CS: Tone → CR: Salivation US: Meat → UR: 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

Figure 2-5 Working for Pavlov In Ivan Pavlov’s experimental device, the dog’s saliva was collected in a tube as it was secreted, and the amount was recorded on a revolving cylinder. The experimenter observed the dog through a one-way glass window.

•conditioning•A simple form of learning.

•operant conditioning•A process of learning in which behavior that leads to satisfying consequences is likely to be repeated.

•modeling•A process of learning in which an individual acquires responses by observing and imitating others.

•classical conditioning•A process of learning by temporal association in which two events that repeatedly occur close together in time become fused in a person’s mind and produce the same response.

•systematic desensitization•A 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.

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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).

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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Conditioning for fun and profit Pet owners have discovered that they can teach animals a wide assortment of tricks by using the principles of conditioning. Only 3 percent of all dogs have learned to “sing,” while 21 percent know how to sit.

Behavioral 10%

Interpersonal 4%

Family systems 3%

Existential 1%

Other 8%

Client-centered 1%

Gestalt 1%

Psychodynamic 15%

Eclectic 29% Cognitive 28%

Figure 2-6 Theoretical orientations of today’s clinical psychologists In one survey, 29 percent of clinical psychologists labeled themselves as “eclectic,” 28 percent considered themselves “cognitive,” and 15 percent called their orientation “psychodynamic.” (Adapted from Prochaska & Norcross, 2007.)

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Models of Abnormality :// 47

jjThe 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).

SUMMING UP The Behavioral 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.

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A clinical pioneer Aaron Beck proposes that many forms of abnormal behavior can be traced to cognitive factors, such as upsetting thoughts and illogical thinking.


In Their Words “Life itself still remains a very effective therapist.” <<

Karen Horney, Our Inner Conflicts, 1945

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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.

Today, 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; Mortley 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

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.

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.


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•cognitive therapy•A therapy devel- oped by Aaron Beck that helps people recognize and change their faulty think- ing processes.

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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 al., 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 determined. The cognitions seen in psychologically troubled people could well be a


Top Nonfiction Books Recommended by Therapists An Unquiet Mind (K. R. Jamison) <<

Nobody Nowhere: The Autobiography of an Autistic (D. Williams) <<

Darkness Visible: A Memoir of Madness (W. Styron) <<

Out of the Depths: An Autobiographical Study of Mental Disorder and Religious Experience (A. T. Boisen) <<

Girl, Interrupted (S. Kaysen) <<

Undercurrents: A Therapist’s Reckoning with Depression (M. Manning) <<

Getting Better: Inside Alcoholics Anony- mous (N. Robertson) <<

A Brilliant Madness (P. Duke) <<

Divided Minds: Twin Sisters and Their Journey through Schizophrenia (P. S. Wagner & C. Spiro) <<

Daughter of the Queen of Sheba (J. Lyden) <<

Imagining Robert: My Brother, Madness, and Survival (J. Neugeboren) <<

Conquering Schizophrenia: A Father, His Son, and a Medical Breakthrough (P. Wyden) <<

The Years of Silence Are Past: My Father’s Life with Bipolar Disorder (S. Hinshaw) <<

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50 ://CHAPTER 2

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? Can such changes make a general and lasting difference in the way people feel and behave? Moreover, a growing body of research suggests that the kinds of cognitive changes proposed by Beck and other cogni- tive therapists are not always possible to achieve (Sharf, 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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SUMMING UP 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.

jjThe 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


When Humanism and Neuroscience Cross Paths When participants in a study conducted at the University of Oregon were led to believe that their research money was going to charity, the pleasure centers in their brains—the caudate nucleus and the nucleus accumbens—became more active. When the participants actually chose to give the money to charity, brain scans indicated that the pleasure centers were particularly active (Mayr, 2007). <<

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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 I 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.


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Actualizing the self Humanists suggest that self- actualized people also show concern for the welfare of humanity. This 89-year-old social services volunteer (right), for example, has participated for the past 20 years as a companion to elderly persons with mental retardation and developmental disabilities.

•self-actualization•The humanistic pro- cess by which people fulfill their potential for goodness and growth.

•client-centered therapy•The 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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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.

Perls 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; Strümpfel, 2006, 2004).

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“Just remember, son, it doesn’t matter whether you win or lose— unless you want Daddy’s love.”

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Beating the blues Gestalt therapists often guide clients to express their feelings in their full intensity by banging on pillows, crying out, kicking, or pounding things. Building on these tech- niques, a new approach, drum therapy, teaches clients, such as this woman, how to beat drums to help release traumatic memories, change beliefs, and feel more liberated.

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Models of Abnormality :// 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; Helmeke & 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 dysfunctioning 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.

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Religion and mental health A Thai Buddhist monk speaks during a psycho- logical session at a school in Bang Niang Camp. In Thailand, people recovering from personal problems often go to their local temple seeking comfort through prayer and meditation.

•gestalt therapy•The humanistic ther- apy developed by Fritz Perls in which clinicians actively move clients toward self-recognition and self-acceptance by using techniques such as role playing and self-discovery exercises.

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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 I 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 same thing over and over, too. Patient: Maybe I’ll 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: I 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

•existential therapy•A therapy that encourages clients to accept responsibil- ity for their lives and to live with greater meaning and values.


Charitable Acts $150 billion Amount contributed to

charity each year in the United States <<

57% Percentage of charitable donations contributed to religious organizations <<

43% Percentage of donations directed to education, human services, health, and the arts <<

75% Percentage of incoming college freshmen who have done volunteer work in the past year <<

(Kate, 1998; Reese, 1998)

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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; Strümpfel, 2006). This newfound interest in research should lead to important insights about the merits of this model in the coming years.

SUMMING UP The Humanistic-Existential Model

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 acceptingly, 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.

jjThe 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 light 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.


Gender Issues in the Workplace According to the Bureau of Labor Statis- tics, women today earn 76¢ for every $1 earned by a man. <<

Around 42 percent of young adult women believe that women have to outperform men at work to get the same rewards; only 11 percent of young adult men agree. <<

(Yin, 2002)


Prayer and Health 84% Percentage of Americans who

believe that praying for the sick im- proves their chance of recovery <<

65% Percentage of prayers about health that relate to mental health <<

(Sheler, 2004; Kalb, 2003)

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56 ://CHAPTER 2

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.

Social 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 communication patterns of some families actually force individual members to behave in a way that oth- erwise seems abnormal. If the members were to behave normally, they would severely strain the family’s usual manner 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 personal 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.


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Today’s TV families Unlike television viewers of the 1950s, when problem-free families like the Nelsons (of Ozzie & Harriet) ruled the airwaves, today’s viewers prefer more complex, sometimes dysfunctional, families, like the Henricksons—Bill, his three wives, their eight children, and their extended family— whose difficulties are on display in HBO’s popular series Big Love.


Pressures of Poverty 90 Number of victims of violent crime

per 1,000 poor persons <<

50 Number of victims per 1,000 mid- dle-income people <<

40 Number of victims per 1,000 wealthy people <<

(U.S. Bureau of Justice Statistics)

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Family-Social Treatments The family-social perspective has helped spur the growth of several treatment ap- proaches, including group therapy, family and couple therapy, and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models. However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.

Group Therapy Thousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. Indeed, one survey of clinical psychologists revealed that almost one-third of them devoted some portion of their practice to group therapy (Norcross & Goldfried, 2005). Typically, mem- bers of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice (Cox et al., 2008). Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.

Research suggests that group therapy is of help to many clients, often as helpful as individual therapy (Shaughnessy et al., 2007; Kösters et al., 2006). The group format also has been used for purposes that are educational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.

A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (for example, bereavement, substance abuse, illness, unemployment, or divorce) come together to help and support one another without the direct leadership of a professional clinician (Mueller et al., 2007). According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by 3 to 4 percent of the population.

Family Therapy Family therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change its ways (Goldenberg & Goldenberg, 2008; Bowen, 1960). Here, the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:

Tommy sat motionless in a chair gazing out the window. He was fourteen and a bit small for his age. . . . Sissy was eleven. She was sitting on the couch between her Mom and Dad with a smile on her face. Across from them sat Ms. Fargo, the family therapist.

Ms. Fargo spoke. “Could you be a little more specific about the changes you have seen in Tommy and when they came about?”

Mrs. Davis answered first. “Well, I guess it was about two years ago. Tommy started getting in fights at school. When we talked to him at home he said it was none of our business. He became moody and disobedient. He wouldn’t do anything that we wanted him to. He began to act mean to his sister and even hit her.”

“What about the fights at school?” Ms. Fargo asked.

This time it was Mr. Davis who spoke first. “Ginny was more worried about them than I was. I used to fight a lot when I was in school and I think it is normal. . . . But I was very respectful to my parents, especially my Dad. If I ever got out of line he would smack me one.”

“Have you ever had to hit Tommy?” Ms. Fargo inquired softly.

“Sure, a couple of times, but it didn’t seem to do any good.”

•family systems theory•A theory that views the family as a system of interact- ing parts whose interactions exhibit consistent patterns and unstated rules.

•group therapy•A therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.

•self-help group•A group made up of people with similar problems who help and support one another without the direct leadership of a clinician. Also called a mutual help group.

•family therapy•A therapy format in which the therapist meets with all members of a family and helps them to change in therapeutic ways.


Attitudes toward Therapy 19% People who believe that psycho-

therapy is primarily for “people with serious psychological difficulties” <<

13% Those who think psychotherapy is “a waste of time” <<

49% Those who have positive feelings when they find out that an ac- quaintance is seeing a therapist <<

10% Those who have negative feelings when they find out that an ac- quaintance is seeing a therapist <<

(Fetto, 2002)

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58 ://CHAPTER 2

All at once Tommy seemed to be paying attention, his eyes riveted on his father. “Yeah, he hit me a lot, for no reason at all!”

“Now, that’s not true, Thomas.” Mrs. Davis has a scolding expression on her face. “If you behaved yourself a little better you wouldn’t get hit. Ms. Fargo, I can’t say that I am in favor of the hitting, but I understand sometimes how frustrating it may be for Bob.”

“You don’t know how frustrating it is for me, honey.” Bob seemed upset. “You don’t have to work all day at the office and then come home to contend with all of this. Some- times I feel like I don’t even want to come home.”

Ginny gave him a hard stare. “You think things at home are easy all day? I could use some support from you. You think all you have to do is earn the money and I will do every- thing else. Well, I am not about to do that anymore.” . . .

Mrs. Davis began to cry. “I just don’t know what to do anymore. Things just seem so hopeless. Why can’t people be nice in this family anymore? I don’t think I am asking too much, am I?”

Ms. Fargo . . . looked at each person briefly and was sure to make eye contact. “There seems to be a lot going on. . . . I think we are going to need to understand a lot of things to see why this is happening.”

(Sheras & Worchel, 1979, pp. 108–110)

Family therapists may follow any of the major theoretical models, but more and more of them are adopting the principles of family systems theory. Today 3 percent of all clinical psychologists, 13 percent of social workers, and 1 percent of psychiatrists identify themselves mainly as family systems therapists (Prochaska & Norcross, 2007).

As you read earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, struc- tural family therapy, therapists try to change the family power structure, the roles each person plays, and the relationships between members (Goldenberg & Goldenberg, 2008; Minuchin, 1997, 1987, 1974). In another, conjoint family therapy, therapists try to help members recognize and change harmful patterns of communication (Sharf, 2008; Satir, 1987, 1967, 1964).

Family therapies of various kinds are often helpful to individuals, although research has not yet clarified how helpful (Goldenberg & Goldenberg, 2008). Some studies have found that as many as 65 percent

of individuals treated with family approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others (Alexander et al., 2002).

Couple Therapy In couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns occurring in the re- lationship (Baucom et al., 2009, 2006, 2000). A couple approach may also be used when a child’s psychological problems are traced to problems in the parents’ relationship.

Although some degree of conflict exists in any long-term relationship, many adults in our society experience serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate (Marshall & Brown, 2008). Many couples who live together without marrying apparently have similar levels of difficulty (Harway, 2005).

Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Behavioral couple therapy, for example, uses many techniques from the behavioral perspective (Shadish & Baldwin, 2005; Gurman, 2003). Therapists


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The virtual family dinner Many systems theorists are concerned that as family members spread out geographi- cally, key family dynamics are lost. To help maintain valuable family interactions, two researchers have developed “The Virtual Family Dinner,” a video-conferencing device that enables family members to share meals and other experiences even from great distances.

•couple therapy•A therapy format in which the therapist works with two peo- ple who share a long-term relationship. Also called marital therapy.

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Models of Abnormality :// 59

Sunday 12:00 noon Cocaine Anonymous, main floor 5:30 p.m. Survivors of Incest, main floor 6:00 p.m. Al-Anon, 2nd floor 6:00 p.m. Alcoholics Anonymous, basement

Monday 5:30 p.m. Debtors Anonymous, basement 6:30 p.m. Codependents of Sex Addicts Anonymous,

2nd floor 7:00 p.m. Adult Children of Alcoholics,

2nd floor 8:00 p.m. Alcoholics Anonymous, basement 8:00 p.m. Al-Anon, 2nd floor 8:00 p.m. Alateen, basement 8:00 p.m. Cocaine Anonymous, main floor

Tuesday 8:00 p.m. Survivors of Incest Anonymous,


Self-help groups are widely accepted in our society by consumers and clini- cians alike (Isenberg et al., 2004). Indeed, one survey of mental health professionals revealed that almost 90 percent of all thera- pists in the United States often recommend such groups to their clients as a supplement to therapy (Clifford et al., 1998).

Small wonder that the number, range, and appeal of such groups have grown rap- idly over the past several decades and that 25 million people in the United States alone are estimated to attend self-help groups over the course of their lives. And this number does not even include the millions of chat group participants who seek online support, information, and help from fellow sufferers. The self-help group movement and its impact on our society are brought to life in the fol- lowing notice that was posted in a Colorado church, listing support groups that would be meeting at the church during the coming week (Moskowitz, 2008, 2001):

Wednesday 5:30 p.m. Sex & Love Addicts Anonymous, basement 7:30 p.m. Adult Children of Alcoholics, 2nd floor 8:00 p.m. Cocaine Anonymous, main floor

Thursday 7:00 p.m. Codependents of Sex Addicts Anonymous,

2nd floor 7:00 p.m. Women’s Cocaine Anonymous, main floor

Friday 5:30 p.m. Sex & Love Addicts Anonymous, basement 5:45 p.m. Adult Overeaters Anonymous, 2nd floor 7:30 p.m. Codependents Anonymous, basement 7:30 p.m. Adult Children of Alcoholics, 2nd floor 8:00 p.m. Cocaine Anonymous, main floor

Saturday 10:00 a.m. Adult Children of Alcoholics, main floor 12:00 p.m. Self-Abusers Anonymous, 2nd floor

Self-Help Groups: Too Much of a Good Thing?

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60 ://CHAPTER 2

help spouses recognize and change problem behaviors largely by teaching specific problem- solving and communication skills. A broader, more sociocultural version, called integrative couple therapy, further helps partners accept behaviors that they cannot change and em- brace the whole relationship nevertheless (Christensen et al., 2006). Partners are asked to see such behaviors as an understandable result of basic differences between them.

Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who fail to receive treatment (Fraser & Solovey, 2007), but no one form of couple therapy stands out as superior to others (Snyder et al., 2006; Harway 2005). Although two-thirds of treated couples experience improved marital functioning by the end of therapy, fewer than half of those who are treated achieve “distress-free” or “happy” relationships. Moreover, one-third of success- fully treated couples may relapse within two years after therapy.

Community Treatment Community mental health treatment programs allow clients, particularly those with severe psychological difficulties, to receive treatment in familiar social surroundings as they try to recover. In 1963 President John Kennedy called for such a “bold new approach” to the treatment of mental disorders—a com- munity approach that would enable most people with psychological problems to receive services from nearby agencies rather than distant facilities or institutions. Congress passed the Community Mental Health Act soon after, launching the community mental health movement across the United States. A number of other countries have launched similar movements.

As you read in Chapter 1, a key principle of community treatment is prevention. Here clinicians actively reach out to clients rather than wait for them to seek treatment. Research suggests that such efforts are often very successful (Hage et al., 2007). Com-

munity workers recognize three types of prevention, which they call primary, secondary, and tertiary.

Primary prevention consists of efforts to improve community at- titudes and policies. Its goal is to prevent psychological disorders altogether. Community workers may, for example, consult with a local school board or offer public workshops on stress reduction (Bloom, 2008).

Secondary prevention consists of identifying and treating psycholog- ical disorders in the early stages, before they become serious. Com- munity workers may work with schoolteachers, ministers, or police to help them recognize the early signs of psychological dysfunction and teach them how to help people find treatment (Ervin et al., 2007).

The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Today community agencies across the United States do successfully offer tertiary care for millions of people with moderate psychological problems, but, as we also observed in

Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances. One of the reasons for this failure is lack of funding, an issue that you will read about in later chapters (Weisman, 2004).

How Do Multicultural Theorists Explain Abnormal Functioning? Culture refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next (Matsumoto, 2007, 2001). We are, without question, a society of multiple cultures. Indeed, in the coming decades, members of racial and ethnic minority groups in the United States will, col- lectively, outnumber white Americans (Gordon, 2005; U.S. Census, 2000).

Partly in response to this growing diversity, the multicultural, or culturally diverse, perspective has emerged ( Jackson, 2006). Multicultural psychologists seek

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Secondary prevention in action Community mental health professionals sometimes work with police and other pub- lic servants, teaching them how to address the psychological needs of people who are under extreme stress. This 8-year-old had to call the police when he saw his father attacking his mother with a knife. The child’s rage, frustration, and emotional pain are apparent.


Marital Infidelity: Gender Shift 22% Percentage of married men who

confessed in 1991 to having had an extramarital affair <<

22% Married men who confessed in 2002 to an extramarital affair <<

10% Married women who confessed in 1991 to having had an extramari- tal affair <<

15% Married women who confessed in 2002 to an extramarital affair <<

(National Opinion Research, 2005; Ali & Miller, 2004)

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Models of Abnormality :// 61

to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of differ- ent cultures, races, and genders differ psychologically (Alegria et al., 2009, 2007, 2004). Today’s multicultural view is differ- ent from past—less enlightened—cultural perspectives: It does not imply that members of racial, ethnic, and other minority groups are in some way inferior or culturally deprived in com- parison with a majority population (Sue & Sue, 2003). Rather, the model holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of that individual’s unique cultural context, from the values of that culture to the special external pressures faced by members of the culture.

The groups in the United States that have received the most attention from multicultural researchers are ethnic and racial minority groups (African American, Hispanic American, Native American, and Asian American groups) and groups such as economically disadvantaged persons, homosexual individu- als, and women (although women are not technically a minority group). Each of these groups is subjected to special pressures in American society that may contribute to feel- ings of stress and, in some cases, to abnormal functioning. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is indeed more common among poorer people than among wealthier people (Byrne et al., 2004; Draine et al., 2002). Perhaps the pressures of poverty explain this relationship. Of course, membership in these various groups overlaps. Many members of minority groups, for example, also live in poverty. The higher rates of crime, unemployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities typically experienced by poor persons may place great stress on many members of such minority groups.

Multicultural researchers have also noted that the prejudice and discrimination faced by many minority groups may contribute to certain forms of abnormal functioning (Carter, 2007; Nelson, 2006). Women in Western society receive diagnoses of anxiety and depressive disorders at least twice as often as men (McSweeney, 2004). Similarly, African Americans experience unusually high rates of anxiety disorders (Blazer et al., 1991). Hispanic Americans may have a greater vulnerability to posttraumatic stress disorder than members of other ethnic groups (Koch & Haring, 2008). And Native Americans display exceptionally high alcoholism and suicide rates (Beals et al., 2005). Although many factors may combine to produce these differences, racial and sexual prejudice and the problems they pose may contribute to abnormal patterns of tension, unhappiness, low self-esteem, and escape (Carter, 2007; Nelson, 2006).

Multicultural Treatments Studies conducted throughout the world have found that members of ethnic and racial minority groups tend to show less improvement in clinical treatment (Comas-Diaz, 2006), make less use of mental health services, and stop therapy sooner than members of majority groups (Ward, 2007; Comas-Diaz, 2006; Wang et al., 2006).

A number of studies suggest that two features of treatment can increase a therapist’s effectiveness with minority clients: (1) greater sensitivity to cultural issues and (2) inclu- sion of cultural morals and models in treatment, especially in therapies for children and adolescents (Castro, Holm-Denoma, & Buckner, 2007; Lee & Sue, 2001). Given such findings, some clinicians have developed culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups (Carten, 2006; Mio et al., 2006). Therapies geared to the pressures of being female in Western society, called gender-sensitive, or feminist, therapies, follow similar principles.

Culture-sensitive approaches typically include the following elements (Prochaska & Norcross, 2007; Wyatt & Parham, 2007):

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Victims of hate This memorial service for Matthew Shepard, brutally beaten to death in 1998 because he was gay, is a powerful reminder of the prejudice, discrimination, and even dan- ger that members of minority groups can confront in our society. Culture- sensitive therapies seek to address the special impact of such stressors, as well as other psycho- logical issues, upon individuals.

•community mental health treat- ment• A treatment approach that emphasizes community care.

•multicultural perspective•The view that each culture has a set of values and beliefs, as well as special external pres- sures, that help account for the behavior of its members. Also called culturally diverse perspective.

•culture-sensitive therapies• Approaches that seek to address the unique issues faced by members of minority groups.

•gender-sensitive therapies• Approaches geared to the pressures of being a woman in Western society. Also called feminist therapies.

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62 ://CHAPTER 2

1. Special cultural instruction of therapists in their graduate training programs

2. Awareness by the therapist of a client’s cultural values

3. Awareness by the therapist of the stress, prejudices, and stereotypes to which minority clients are exposed

4. Awareness by therapists of the hardships faced by the children of immigrants

5. Helping clients recognize the impact of both their own culture and the dominant culture on their self-views and behaviors

6. Helping clients identify and express suppressed anger and pain

7. Helping clients achieve a bicultural balance that feels right for them

8. Helping clients raise their self-esteem—a sense of self-worth that has often been damaged by generations of negative messages

Assessing the Sociocultural Model The family-social and multicultural perspectives have added greatly to the understand- ing and treatment of abnormal functioning. Today most clinicians take family, cultural,

social, and societal issues into account, factors that were overlooked just 35 years ago. In addition, clinicians have become more aware of the impact of clinical and social roles. Finally, the treatment formats offered by the socio- cultural model sometimes succeed where traditional ap- proaches have failed.

At the same time, the sociocultural model has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Indeed, research may reveal a relationship between certain family or cultural factors and a particular disorder yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not nec- essarily mean that family dysfunction causes schizophrenia. It is equally possible that family functioning is disrupted by the tension and conflict created by the psychotic behavior of a family member.

Another limitation of the sociocultural model is its in- ability to predict abnormality in specific individuals. If, for example, social conditions such as prejudice and discrimination are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?

Given these limitations, most clinicians view the family-social and multicultural ex- planations as operating in conjunction with the biological or psychological explanations. They agree that family, social, and cultural factors may create a climate favorable to the development of certain disorders. They believe, however, that biological or psychological conditions—or both—must also be present for the disorders to evolve.


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Community mental health: Argentine style Staff members and patients from Buenos Aires’s Neuropsychiatric Hospital set up a laptop and begin broadcasting on the popular radio station Radio La Colifata (colifa is slang for “crazy one”). The station was started 15 years ago to help patients pursue therapeutic activities and reach out to the community.

SUMMING UP The Sociocultural Model

The sociocultural model looks outward to the social and cultural forces that affect members of a society. One of this model’s perspectives, the family-social perspective, points to three kinds of factors in its explanations of abnormal functioning: social labels and roles, social networks and supports, and the family system. Clinicians from the family-social perspective may practice group, family, or couple therapy or community treatment.

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Models of Abnormality :// 63

PUTTING IT… together Integration of the Models Today’s leading models vary widely (see Table 2-2). Yet none of the models has proved consistently superior. Each helps us appreciate a key aspect of human functioning, and each has important strengths as well as serious limitations.

With all their differences, the conclusions and techniques of the various models are often compatible. Certainly our understanding and treatment of abnormal behavior are more complete if we appreciate the biological, psychological, and sociocultural aspects of a person’s problem rather than only one of them. Not surprisingly, then, a growing number of clinicians favor explanations of abnormal behavior that consider more than one kind of cause at a time. These explanations, sometimes called biopsychosocial theories, state that abnormality results from the interaction of genetic, biological, developmen- tal, emotional, behavioral, cognitive, social, cultural, and societal influences (Olson & Sameroff, 2009). A case of depression, for example, might best be explained by pointing collectively to an individual’s inheritance of unfavorable genes, traumatic losses during childhood, negative ways of thinking, and social isolation.

Some biopsychosocial theorists favor a diathesis-stress explanation of how the various factors work together to cause abnormal functioning (“diathesis” means a predisposed

The multicultural perspective, another perspective from the sociocultural model, holds that an individual’s behavior, whether normal or abnormal, is best under- stood when examined in the light of his or her unique cultural context, including the values of that culture and the special external pressures faced by members of the culture. Practitioners of this perspective may employ culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups.

table: 2-2

Comparing the Models

Family- Biological Psychodynamic Behavioral Cognitive Humanistic Existential Social Multicultural

Cause of Biological Underlying Maladaptive Maladaptive Self-deceit Avoidance of Family or External dysfunction malfunction conflicts learning thinking responsibility social pressures or stress cultural conflicts

Research Strong Modest Strong Strong Weak Weak Moderate Moderate support

Consumer Patient Patient Client Client Patient or Patient Client Client designation client or client

Therapist Doctor Interpreter Teacher Persuader Observer Collaborator Family/ Cultural role social advocate/ facilitator teacher

Key therapist Biological Free association Conditioning Reasoning Reflection Varied Family/ Culture- technique intervention and interpretation social sensitive intervention intervention

Therapy Biological Broad Functional Adaptive Self- Authentic Effective Cultural goal repair psychological behaviors thinking actualization life family or awareness change social and comfort system


Cultural Oversight Despite the growing cultural diversity throughout the United States, minority group members are remarkably under- represented as participants in psychotro- pic drug treatment studies. A few years back, when UCLA researchers reviewed the best available studies of drugs for mood disorders, schizophrenia, and attention-deficit/hyperactivity disorder, they found that only 8 percent of the patients studied were members of minor- ity groups. Of almost 44,000 patients in antidepressant studies, only 2 were Hispanic; of almost 3,000 patients with schizophrenia, 3 were Asian; and of 825 patients in bipolar disorder drug studies, none were Hispanic or Asian (Vedantam, 2005). <<

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64 ://CHAPTER 2

tendency). According to this theory, people must first have a biological, psychological, or sociocultural predisposition to develop a disorder and must then be subjected to episodes of severe stress. In a case of depression, for example, we might find that unfavorable genes and related biochemical abnormalities predispose the individual to develop the disorder, while the loss of a loved one actually triggers its onset.

In a similar quest for integration, many therapists are now combining treatment techniques from several models. In fact, 29 percent of today’s clinical psychologists, 34 percent of social workers, and 53 percent of psychiatrists describe their approach as “eclectic” or “integrative” (Prochaska & Norcross, 2007). Studies confirm that clinical problems often respond better to combined approaches than to any one therapy alone. For example, as you will see, drug therapy combined with cognitive therapy is some- times the most effective treatment for depression (TADS, 2007).

Given the recent rise in biopsychosocial theories and combination treatments, our examinations of abnormal behavior throughout this book will take two directions. As different disorders are presented, we will look at how today’s models explain each disorder, how clinicians who endorse each model treat people with the disorder, and how well these explanations and treatments are supported by research. Just as important, however, we will also be observing how the explanations and treatments may build upon and strengthen each other, and we will examine current efforts toward integration of the models.

1. What might the enormous popular- ity of psychotropic drugs suggest about the needs and coping styles of individuals today and about problem solving in our technological society? pp. 35–36

2. In Paradise Lost Milton wrote, “The mind . . . can make a heaven of hell, a hell of heaven.” Which model(s) of abnormal functioning would agree with this statement? pp. 37–50

3. Freud’s influence on Western society has extended beyond the clinical realm. Can you think of ways that his theory has affected literature, movies, child-rearing, philosophy, and educa- tion? pp. 37–43

4. Why might positive religious beliefs be linked to mental health? Why have so many clinicians been suspi- cious of religious beliefs for so long? p. 53

5. In Anna Karenina writer Leo Tolstoy wrote, “All happy families resemble one another; every unhappy family is unhappy in its own fashion.” Would family systems theorists agree with Tolstoy? p. 56

6. Group therapy may offer special therapeutic features for clients. What might some of those features be? p. 57

CRITICAL THOUGHTS What might the en ty of psychotropic about the needs an ndividuals today a


of m

3. Freud’s i has exte realm. C theory h

model, p. 32 neuron, p. 33 synapse, p. 33 neurotransmitter, p. 33 endocrine system, p. 34 hormone, p. 34 gene, p. 34 evolution, p. 35 psychotropic medication, p. 35 electroconvulsive therapy (ECT), p. 36 psychosurgery, p. 36

unconscious, p. 37 id, p. 38 ego, p. 38 ego defense mechanism, p. 38 superego, p. 38 fixation, p. 39 ego theory, p. 39 self theory, p. 39 object relations theory, p. 40 free association, p. 40 resistance, p. 40

transference, p. 41 dream, p. 41 catharsis, p. 41 working through, p. 41 short-term psychodynamic therapies, p. 42 relational psychoanalytic therapy, p. 42 conditioning, p. 44 operant conditioning, p. 44 modeling, p. 44 classical conditioning, p. 44

KEY TERMS del, p. 32 ron, p. 33 apse, p. 33



In Their Words “Help! I’m being held prisoner by my heredity and environment.” <<

Dennis Allen

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Models of Abnormality :// 65

systematic desensitization, p. 45 cognitive therapy, p. 48 self-actualization, p. 50 client-centered therapy, p. 51 gestalt therapy, p. 52 existential therapy, p. 54

family systems theory, p. 56 group therapy, p. 57 self-help group, p. 57 family therapy, p. 57 couple therapy, p. 58

community mental health treatment, p. 60 multicultural perspective, p. 60 culture-sensitive therapy, p. 61 gender-sensitive therapy, p. 61 diathesis-stress explanation, p. 63

1. What are the key regions of the brain, and how do messages travel throughout the brain? Describe the biological treatments for psycho- logical disorders. pp. 33–36

2. Identify the models associated with learned responses (p. 44), values (p. 50), responsibility (p. 53), spirituality (p. 53), underlying conflicts (p. 37), and maladaptive assumptions (p. 47).

3. Identify the treatments that use unconditional positive regard (p. 51), free association (p. 40), classical conditioning (p. 45), skill- ful frustration (p. 52), and dream interpretation (p. 41).

4. What are the key principles of the psychodynamic (pp. 37–43), behavioral (pp. 43–47), cognitive (pp. 47–50), and humanistic- existential (pp. 50–55) models?

5. According to psychodynamic theorists, what roles do the id, ego, and superego play in the develop- ment of both normal and abnormal behavior? What are the key tech- niques used by psychodynamic therapists? pp. 37–43

6. What forms of conditioning do behaviorists rely on in their expla- nations and treatments of abnormal behaviors? pp. 44, 45

7. What kinds of cognitive dysfunc- tioning can lead to abnormal behavior? p. 47

8. How do humanistic theories and therapies differ from existential ones? pp. 50–51

9. How might societal labels, social networks, family factors, and culture relate to psychological func- tioning? pp. 55–57, 60–61

10. What are the key features of culture-sensitive therapy, group therapy, family therapy, couple therapy, and community treatment? How effective are these various approaches? pp. 57–60, 61–62


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