Fundamentals of Abnormal Psychology ninth edition

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RONALD J. COMER

Princeton University

JONATHAN S. COMER

Florida International University

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Worth Publishers

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With boundless love and appreciation, to Marlene Comer and Jami Furr, who fill our lives with love

and joy.

About the Authors

RONALD J. COMER has been a professor in Princeton University’s Department of Psychology

for the past 44 years, serving also as director of Clinical Psychology Studies and as chair of the

university’s Institutional Review Board. He has recently transitioned to emeritus status at the

university. He has received the President’s Award for Distinguished Teaching at Princeton,

where his various courses in abnormal psychology have been among the university’s most

popular.

Professor Comer is also Clinical Associate Professor of Family Medicine and Community

Health at Rutgers Robert Wood Johnson Medical School. He is a practicing clinical psychologist

and a consultant to Eden Autism Services and to hospitals and family practice residency

programs throughout New Jersey.

In addition to writing the textbooks Fundamentals of Abnormal Psychology (ninth edition),

Abnormal Psychology (tenth edition), Psychology Around Us (second edition), and Case Studies in

Abnormal Psychology (second edition), Professor Comer has published a range of journal articles

and produced numerous widely used educational video programs, including The Higher

Education Video Library Series, The Video Anthology for Abnormal Psychology, Video Segments in

Neuroscience, Introduction to Psychology Video Clipboard, and Developmental Psychology Video

Clipboard.

Professor Comer was an undergraduate at the University of Pennsylvania and a graduate

student at Clark University. He currently lives in Lawrenceville, New Jersey, with his wife

Marlene. From there he can keep a close eye on the often-frustrating Philadelphia sports teams

with whom he grew up.

JONATHAN S. COMER is a professor of psychology at Florida International University,

where he also directs the Mental Health Interventions and Technology (MINT) Program. He is –

President of the Society of Clinical Psychology (Division 12 of the American Psychological

Association) and a leader in the field of clinical child and adolescent psychology. The author of

130 scientific papers and chapters, he has received career awards from the American

Psychological Association, the Association for Psychological Science, and the Association for

Behavioral and Cognitive Therapies for his research on innovative treatment methods, childhood

anxiety and disruptive behaviors, and the impact of traumatic stress, disasters, and terrorism on

children. His current work also focuses on ties between psychopathology, neurocircuitry, and the

intergenerational transmission of psychological problems.

In addition to Fundamentals of Abnormal Psychology (ninth edition), Professor Comer has

authored Abnormal Psychology (tenth edition) and Childhood Disorders (second edition) and

edited The Oxford Handbook of Research Strategies for Clinical Psychology, among other books. He

serves as Associate Editor of the journal Behavior Therapy and is on the Board of Directors of the

Society of Clinical Child and Adolescent Psychology. He is a Fellow of the American

Psychological Association, the Society of Clinical Psychology, and the Society for Child and

Family Policy and Practice. He is also a practicing clinical psychologist.

Professor Comer was an undergraduate at the University of Rochester and a graduate student

at Temple University. He currently lives in South Florida with his wife Jami and their children

Delia and Emmett. He loves music—both playing and listening—and enjoys keeping an eye on

the often-frustrating Philadelphia sports teams that his father taught him to love/hate.

Brief Contents Abnormal Psychology in Science and Clinical Practice

1 Abnormal Psychology: Past and Present

2 Models of Abnormality

3 Clinical Assessment, Diagnosis, and Treatment

Problems of Anxiety and Mood

4 Anxiety, Obsessive-Compulsive, and Related Disorders

5 Disorders of Trauma and Stress

6 Depressive and Bipolar Disorders

7 Suicide

Problems of the Mind and Body

8 Disorders Featuring Somatic Symptoms

9 Eating Disorders

10 Substance Use and Addictive Disorders

11 Sexual Disorders and Gender Variations

Problems of Psychosis

12 Schizophrenia and Related Disorders

Life-Span Problems

13 Personality Disorders

14 Disorders Common Among Children and Adolescents

15 Disorders of Aging and Cognition

Conclusion

16 Law, Society, and the Mental Health Profession

Contents Preface

CHAPTER 1

Abnormal Psychology: Past and Present

What Is Psychological Abnormality?

Deviance

Distress

Dysfunction

Danger

The Elusive Nature of Abnormality

What Is Treatment?

How Was Abnormality Viewed and Treated in the Past?

Ancient Views and Treatments

Greek and Roman Views and Treatments

Europe in the Middle Ages: Demonology Returns

The Renaissance and the Rise of Asylums

The Nineteenth Century: Reform and Moral Treatment

The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives

Recent Decades and Current Trends

How Are People with Severe Disturbances Cared For?

How Are People with Less Severe Disturbances Treated?

A Growing Emphasis on Preventing Disorders and Promoting Mental Health

Multicultural Psychology

The Increasing Influence of Insurance Coverage

What Are Today’s Leading Theories and Professions?

Technology and Mental Health

What Do Clinical Researchers Do?

The Case Study

The Correlational Method

The Experimental Method

Alternative Research Designs

What Are the Limits of Clinical Investigations?

Protecting Human Participants

Moving Forward

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Verbal Debuts

PSYCHWATCH Marching to a Different Drummer: Eccentrics

INFOCENTRAL Happiness

MINDTECH The Use and Misuse of Social Media

CHAPTER 2

Models of Abnormality

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 Cognitive-Behavioral Model

The Behavioral Dimension

The Cognitive Dimension

The Cognitive-Behavioral Interplay

Assessing the Cognitive-Behavioral Model

The Humanistic-Existential Model

Rogers’ 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

Integrating the Models: The Developmental Psychopathology Perspective

Key Terms

Quick Quiz

LaunchPad

… TRENDING TV Drug Ads Come Under Attack

INFOCENTRAL Mindfulness

MINDTECH Have Your Avatar Call My Avatar

CHAPTER 3

Clinical Assessment, Diagnosis, and Treatment

Clinical Assessment: How and Why Does the Client Behave Abnormally?

Characteristics of Assessment Tools

Clinical Interviews

Clinical Tests

Clinical Observations

Diagnosis: Does the Client’s Syndrome Match a Known Disorder?

Classification Systems

DSM-5

Is DSM-5 an Effective Classification System?

Call for Change

Can Diagnosis and Labeling Cause Harm?

Treatment: How Might the Client Be Helped?

Treatment Decisions

The Effectiveness of Treatment

What Lies Ahead for Clinical Assessment?

Key Terms

Quick Quiz

LaunchPad

MINDTECH Psychology’s WikiLeaks?

… TRENDING The Truth, the Whole Truth, and Nothing but the Truth

INFOCENTRAL DSM: The Bigger Picture

CHAPTER 4

Anxiety, Obsessive-Compulsive, and Related Disorders

Generalized Anxiety Disorder

The Sociocultural Perspective: Societal and Multicultural Factors

The Psychodynamic Perspective

The Humanistic Perspective

The Cognitive-Behavioral Perspective

The Biological Perspective

Phobias

Specific Phobias

Agoraphobia

What Causes Phobias?

How Are Phobias Treated?

Social Anxiety Disorder

What Causes Social Anxiety Disorder?

Treatments for Social Anxiety Disorder

Panic Disorder

The Biological Perspective

The Cognitive-Behavioral Perspective

Obsessive-Compulsive Disorder

What Are the Features of Obsessions and Compulsions?

The Psychodynamic Perspective

The Cognitive-Behavioral Perspective

The Biological Perspective

Obsessive-Compulsive-Related Disorders

Integrating the Models: The Developmental Psychopathology Perspective

Key Terms

Quick Quiz

LaunchPad

… TRENDING Separation Anxiety Disorder, Not Just For Kids Anymore

INFOCENTRAL Fear

MINDTECH Social Media Jitters

CHAPTER 5

Disorders of Trauma and Stress

Stress and Arousal: The Fight-or-Flight Response

Acute and Posttraumatic Stress Disorders

What Triggers Acute and Posttraumatic Stress Disorders?

Why Do People Develop Acute and Posttraumatic Stress Disorders?

How Do Clinicians Treat Acute and Posttraumatic Stress Disorders?

Dissociative Disorders

Dissociative Amnesia

Dissociative Identity Disorder

How Do Theorists Explain Dissociative Amnesia and Dissociative Identity Disorder?

How Are Dissociative Amnesia and Dissociative Identity Disorder Treated?

Depersonalization-Derealization Disorder

Getting a Handle on Trauma and Stress

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Sexual Assault

MINDTECH Virtual Reality Therapy: Better than the Real Thing?

PSYCHWATCH Repressed Childhood Memories or False Memory Syndrome?

PSYCHWATCH Peculiarities of Memory

CHAPTER 6

Depressive and Bipolar Disorders

Unipolar Depression: The Depressive Disorders

How Common Is Unipolar Depression?

What Are the Symptoms of Depression?

Diagnosing Unipolar Depression

Stress and Unipolar Depression

The Biological Model of Unipolar Depression

The Psychological Models of Unipolar Depression

The Sociocultural Model of Unipolar Depression

Integrating the Models: The Developmental Psychopathology Perspective

Bipolar Disorders

What Are the Symptoms of Mania?

Diagnosing Bipolar Disorders

What Causes Bipolar Disorders?

What Are the Treatments for Bipolar Disorders?

Making Sense of All That Is Known

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Sadness at the Happiest of Times

INFOCENTRAL Exercise and Dietary Supplements

MINDTECH Texting: A Relationship Buster?

PSYCHWATCH Abnormality and Creativity: A Delicate Balance

CHAPTER 7

Suicide

What Is Suicide?

How Is Suicide Studied?

Patterns and Statistics

What Triggers a Suicide?

Stressful Events and Situations

Mood and Thought Changes

Alcohol and Other Drug Use

Mental Disorders

Modeling: The Contagion of Suicide

What Are the Underlying Causes of Suicide?

The Psychodynamic View

Durkheim’s Sociocultural View

The Interpersonal View

The Biological View

Is Suicide Linked to Age?

Children

Adolescents

The Elderly

Treatment and Suicide

What Treatments Are Used After Suicide Attempts?

What Is Suicide Prevention?

Do Suicide Prevention Programs Work?

Psychological and Biological Insights Lag Behind

Key Terms

Quick Quiz

LaunchPad

… TRENDING Internet Horrors

INFOCENTRAL The Right to Die by Suicide

CHAPTER 8

Disorders Featuring Somatic Symptoms

Factitious Disorder

Conversion Disorder and Somatic Symptom Disorder

Conversion Disorder

Somatic Symptom Disorder

What Causes Conversion and Somatic Symptom Disorders?

How Are Conversion and Somatic Symptom Disorders Treated?

Illness Anxiety Disorder

Psychophysiological Disorders: Psychological Factors Affecting Other Medical Conditions

Traditional Psychophysiological Disorders

New Psychophysiological Disorders

Psychological Treatments for Physical Disorders

Relaxation Training

Biofeedback

Meditation

Hypnosis

Cognitive-Behavioral Interventions

Support Groups and Emotion Expression

Combination Approaches

Expanding the Boundaries of Abnormal Psychology

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Munchausen Syndrome by Proxy

MINDTECH Can Social Media Spread “Mass Hysteria”?

INFOCENTRAL Sleep and Sleep Disorders

CHAPTER 9

Eating Disorders

Anorexia Nervosa

The Clinical Picture

Medical Problems

Bulimia Nervosa

Binges

Compensatory Behaviors

Bulimia Nervosa Versus Anorexia Nervosa

Binge-Eating Disorder

What Causes Eating Disorders?

Psychodynamic Factors: Ego Deficiencies

Cognitive-Behavioral Factors

Depression

Biological Factors

Societal Pressures

Family Environment

Multicultural Factors: Racial and Ethnic Differences

Multicultural Factors: Gender Differences

How Are Eating Disorders Treated?

Treatments for Anorexia Nervosa

Treatments for Bulimia Nervosa

Treatments for Binge-Eating Disorder

Prevention of Eating Disorders: Wave of the Future

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Body Dissatisfaction

MINDTECH Dark Sites of the Internet

… TRENDING Shame on Body Shamers

CHAPTER 10

Substance Use and Addictive Disorders

Depressants

Alcohol

Sedative-Hypnotic Drugs

Opioids

Stimulants

Cocaine

Amphetamines

Stimulant Use Disorder

Hallucinogens, Cannabis, and Combinations of Substances

Hallucinogens

Cannabis

Combinations of Substances

What Causes Substance Use Disorders?

Sociocultural Views

Psychodynamic Views

Cognitive-Behavioral Views

Biological Views

The Developmental Psychopathology View

How Are Substance Use Disorders Treated?

Psychodynamic Therapies

Cognitive-Behavioral Therapies

Biological Treatments

Sociocultural Therapies

Other Addictive Disorders

Gambling Disorder

Internet Gaming Disorder: Awaiting Official Status

New Wrinkles to a Familiar Story

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH College Binge Drinking: An Extracurricular Crisis

… TRENDING The Opioid Crisis

INFOCENTRAL Smoking, Tobacco, and Nicotine

CHAPTER 11

Sexual Disorders and Gender Variations

Sexual Dysfunctions

Disorders of Desire

Disorders of Excitement

Disorders of Orgasm

Disorders of Sexual Pain

Treatments for Sexual Dysfunctions

What Are the General Features of Sex Therapy?

What Techniques Are Used to Treat Particular Dysfunctions?

What Are the Current Trends in Sex Therapy?

Paraphilic Disorders

Fetishistic Disorder

Transvestic Disorder

Exhibitionistic Disorder

Voyeuristic Disorder

Frotteuristic Disorder

Pedophilic Disorder

Sexual Masochism Disorder

Sexual Sadism Disorder

Gender Variations

Transgender Functioning

Gender Dysphoria

Personal Topics Draw Public Attention

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Sex Throughout the Life Cycle

PSYCHWATCH Sexism, Viagra, and the Pill

MINDTECH “Sexting”: Healthy or Pathological?

CHAPTER 12

Schizophrenia and Related Disorders

The Clinical Picture of Schizophrenia

What Are the Symptoms of Schizophrenia?

What Is the Course of Schizophrenia?

How Do Theorists Explain Schizophrenia?

Biological Views

Psychological Views

Sociocultural Views

Developmental Psychopathology View

How Are Schizophrenia and Other Severe Mental Disorders Treated?

Institutional Care in the Past

Institutional Care Takes a Turn for the Better

Antipsychotic Drugs

Psychotherapy

The Community Approach

An Important Lesson

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Hallucinations

PSYCHWATCH Postpartum Psychosis: A Dangerous Syndrome

PSYCHWATCH Lobotomy: How Could It Happen?

MINDTECH Putting a Face on Auditory Hallucinations

CHAPTER 13

Personality Disorders

“Odd” Personality Disorders

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

“Dramatic” Personality Disorders

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

“Anxious” Personality Disorders

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Multicultural Factors: Research Neglect

Are There Better Ways to Classify Personality Disorders?

The “Big Five” Theory of Personality and Personality Disorders

“Personality Disorder—Trait Specified”: DSM-5’s Proposed Dimensional Approach

Rediscovered, Then Reconsidered

Key Terms

Quick Quiz

LaunchPad

… TRENDING Mass Murders: Where Does Such Violence Come From?

MINDTECH Selfies: Narcissistic or Not?

INFOCENTRAL The Dark Triad

CHAPTER 14

Disorders Common Among Children and Adolescents

Childhood and Adolescence

Childhood Anxiety Disorders

Separation Anxiety Disorder and Selective Mutism

Treatments for Childhood Anxiety Disorders

Depressive and Bipolar Disorders During Childhood

Major Depressive Disorder

Bipolar Disorder and Disruptive Mood Dysregulation Disorder

Oppositional Defiant Disorder and Conduct Disorder

What Are the Causes of Conduct Disorder?

How Do Clinicians Treat Conduct Disorder?

Elimination Disorders

Enuresis

Encopresis

Neurodevelopmental Disorders

Attention-Deficit/Hyperactivity Disorder

Autism Spectrum Disorder

Intellectual Disability

Clinicians Discover Childhood and Adolescence

Key Terms

Quick Quiz

LaunchPad

INFOCENTRAL Child and Adolescent Bullying

PSYCHWATCH Child Abuse

PSYCHWATCH Reading and ’Riting and ’Rithmetic

CHAPTER 15

Disorders of Aging and Cognition

Old Age and Stress

Depression in Later Life

Anxiety Disorders in Later Life

Substance Misuse in Later Life

Psychotic Disorders in Later Life

Disorders of Cognition

Delirium

Alzheimer’s Disease and Other Neurocognitive Disorders

Issues Affecting the Mental Health of the Elderly

Clinicians Discover the Elderly

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH The Oldest Old

INFOCENTRAL The Aging Population

MINDTECH Remember to Tweet; Tweet to Remember

… TRENDING Damaging the Brain: Football and CTE

CHAPTER 16

Law, Society, and the Mental Health Profession

Law and Mental Health

How Do Clinicians Influence the Criminal Justice System?

How Do the Legislative and Judicial Systems Influence Mental Health Care?

In What Other Ways Do the Clinical and Legal Fields Interact?

What Ethical Principles Guide Mental Health Professionals?

Mental Health, Business, and Economics

Bringing Mental Health Services to the Workplace

The Economics of Mental Health

Technology and Mental Health

The Person Within the Profession

Within a Larger System

Key Terms

Quick Quiz

LaunchPad

PSYCHWATCH Famous Insanity Defense Cases

PSYCHWATCH Serial Murderers: Madness or Badness?

… TRENDING Doctor, Do No Harm

INFOCENTRAL Personal and Professional Issues

Glossary

References

Credits

Name Index

Subject Index

Preface Ron Comer

I thought it was cute when my 13-year-old son Jon sometimes sat in on my 400-student

Abnormal Psychology lectures at Princeton, interesting when he took his first psychology course

at the University of Rochester, amusing when his undergraduate abnormal psychology course

used my textbook, troubling when he autographed copies of the book for his classmates,

surprising when he decided to major in psychology, and very satisfying when he entered the

clinical psychology graduate program at Temple University. However, what Jon has

accomplished professionally from that point forward has been nothing short of mind-boggling to

me, and I am not easily mind-boggled.

He has become one of today’s most productive and influential researchers, a leader in the

clinical field, a magnificent teacher, and a deeply caring and wise clinician. Little of this has to do

with me and everything to do with his intellectual gifts and remarkable work ethic, and the giants

in the field who have mentored him over the years—particularly Dave Barlow, Phil Kendall,

Dante Cicchetti, Bill Pelham, Anne Marie Albano, and Mark Olfson. Nevertheless, I’ll take it.

At some point during Jon’s flourishing career at Boston University and now Florida

International University, an unstated question began to emerge: Should he join me as co-author

on my abnormal psychology textbooks Fundamentals of Abnormal Psychology and Abnormal

Psychology? I had never entertained the possibility of having a co-author during my 35 years of

writing these textbooks; and anyway, I believed Jon was too busy making his mark on the field,

receiving multiple career awards from the American Psychological Association and other

organizations, being elected President of the APA’s Society of Clinical Psychology, writing over

130 scientific papers, and the like. But, as the saying goes, “If you want to make God laugh, tell

Him your future plans.” Lo and behold, Jon and I are now co-authors of these books.

Ultimately, the decision to ask Jon to join me in this endeavor was a natural one. As textbook

authors grow older, publishers seek out possible co-authors (for reasons that shall go unstated in

order to protect my fragile ego and growing sense of mortality). It was clear to me that the ideal

co-author would have to be a highly accomplished researcher and writer who would complement

my particular areas of expertise and bring special knowledge in such areas as the developmental

psychopathology perspective, technology-driven and novel treatment interventions, cognitive-

behavioral approaches, brain circuitry, and more. And it was obvious that Jon was that person.

Moreover, Jon was receiving offers from various publishing companies to author their abnormal

psychology textbooks, and the notion of having a Comer textbook competing with another

Comer textbook was simply too much for me to bear (did I mention my fragile ego?). And, of

course, personally, the possibility of collaborating with someone whom I respect deeply and love

greatly was too alluring to pass up. Thus, with the current editions of Fundamentals of Abnormal

Psychology and Abnormal Psychology, Jon and I have begun a new journey, from which, we hope

and believe, readers will learn much and profit greatly.

Jon Comer

Roughly two decades ago, I entered the University of Rochester with the intention of studying

music. But I soon realized that, despite my continuing love of music, the study of clinical

psychology fascinated me most. Two pivotal undergraduate experiences brought the clinical field

to life for me and prompted me to realize that work in this area should eventually be at the center

of my professional life.

The first experience was taking a psychology course with (and later working in the laboratory

of) Dante Cicchetti, the contagiously passionate researcher and professor who introduced me to

developmental psychopathology—his “neurons-to-neighborhoods” perspective that focuses on

how dynamic interactions among psychological, biological, and sociocultural factors unfold

across time to produce both normal and abnormal human functioning. I was excited by the

power of this comprehensive perspective to explain individual differences, embrace interacting

causal factors, and meaningfully inform prevention and treatment interventions. To this day, the

developmental psychopathology perspective explicitly guides much of my research and thinking.

The second influential undergraduate experience was the power of a unique textbook. In the

fall of my sophomore year, I enrolled in an abnormal psychology course and found a familiar

name on the syllabus: “Comer”. . . as in “the required text for this course is Ronald Comer’s

Abnormal Psychology (Second Edition).” At the time I did not have a particularly deep

understanding of my father’s work. I knew he worked very hard writing this book and that a

great many colleges and universities had adopted it, but I had never sat down to read more than a

few paragraphs here or there. But now, his book, cover-to-cover, was on my list of required

readings.

As I read through the chapters for class, I became captivated by the book’s engaging writing

style, empathic descriptions of people with psychological disorders, blend of clinical research and

practice, and strategic incorporation of current events and popular culture. I was also struck by

how the book translated complex ideas into highly readable and easy to digest material. The book

managed to present clinical psychology as a vibrant and evolving science, with many of the

biggest answers still ahead. I was hooked; this was the field for me.

I recognize that it may seem like I was biased to be so favorably disposed toward this

particular textbook, given the family connection. However, I would actually suggest the opposite

—I was in my late teens at the time, and I must confess that I was not exactly looking to give my

father copious credit for much during those years.

Over the past 20 years, from my time as a young undergraduate to my current academic and

professional roles, I have been continually reminded that I am far from alone in my experiences

with this extraordinary text. Countless individuals, from college freshmen to many of the field’s

senior leaders, have approached me to tell me what a special experience they have had with my

father’s textbook—whether as a student, as an instructor, or (like myself) as both.

When the opportunity arose to join Fundamentals of Abnormal Psychology and Abnormal

Psychology as a co-author, it was a no-brainer for me. It has been a privilege to bring my particular

background and areas of expertise to help expand these already outstanding books. For example,

together my father and I have worked to incorporate the increasingly influential developmental

psychopathology perspective throughout the books, along with a contemporary emphasis on

biopsychosocial accounts of abnormality. As an instructor in psychology, I have always taken

seriously my role as an ambassador for this field, someone who can introduce a captivating field

to students, excite them about it, and provide them with insights that can influence their

continued intellectual and professional development. Co-authoring the new editions of

Fundamentals of Abnormal Psychology and Abnormal Psychology has provided me with a special

opportunity to expand this ambassadorship and to reach a greater number of students than I

could have previously imagined. I am very appreciative.

On a more personal note, the greatest joy of undertaking this project has been to do so under

the mentorship of my father, Ronald Comer—a peerless educator and writer who has helped

teach and cultivate so many individuals over the years. Working with him has given me a coveted

front row seat to learn from the “master” about how to best communicate the complexities of the

field and how to respectfully portray mental dysfunction and human suffering, all with his

unique blend of empathy, dignity, and humor. He has mentored me on this project—as he has

throughout so many experiences of my life—with great wisdom, common sense, patience,

selflessness, and love. This field has no shortage of individuals who feel fortunate to have been

touched by his inimitable gifts. But no one more so than me.

Ron & Jon Comer

Between Fundamentals of Abnormal Psychology and Abnormal Psychology, the current textbook

represents the nineteenth edition of one or the other of the books. This textbook journey has

been a labor of love, but also one in which each edition is accompanied by an enormous amount

of work and ridiculous pressure, not to mention countless sleepless nights. We mention these

labors not only because we are world-class whiners but also to emphasize that we approach each

edition as a totally new undertaking rather than as a superficial update of past editions. Our goal

is to make each edition fresh by approaching our content coverage and pedagogical offerings as if

we were writing a completely new book. As a result, each edition includes cutting-edge content

reflecting new developments in the field, as well as in the world around us, delivered to readers

via innovative and enlightening pedagogical techniques.

With this in mind, and with the addition of Jon’s areas of expertise, we have added much new

material and many exciting new features for this edition of Fundamentals of Abnormal Psychology

—while at the same time retaining the successful themes, material, and techniques that have been

embraced enthusiastically by past students and instructors. The result is, we believe, a book that

will excite readers and speak to them and their times. We have tried to convey our passion for the

field of abnormal psychology, and we have built on the generous feedback of our colleagues in

this undertaking—the students and professors who have used this textbook over the years.

New and Expanded Features This edition of Fundamentals of Abnormal Psychology reflects the many changes that have

occurred over the past several years in the fields of abnormal psychology, education, and

publishing, and in the world. Accordingly, we have introduced a number of new features and

changes to the current edition.

•NEW• Developmental Psychopathology Perspective The developmental psychopathology

perspective is introduced and applied throughout the book (for example, pages 68–69, 135–136,

151–152, and 317–318). This cutting-edge perspective—the clinical field’s leading integrative

perspective—uses a developmental framework to bring together the explanations and treatments

of the various models, explaining how biological, psychological, and sociocultural factors may

intersect and interact at key points throughout the life span to help produce both normal and

abnormal functioning. Over the course of our discussions, readers will also come to appreciate

that developmental factors are typically at work in both adult and child psychopathology. They

will also come to recognize this perspective’s principles of prevention, resilience, equifinality, and

multifinality.

•NEW• Brain Circuitry Brain circuits are now at the center of the textbook’s biological

discussions of anxiety, posttraumatic stress, depressive, personality, and other disorders (for

example, pages 38, 111, 125, 132, 149, 180, and 316–317). Over the past decade, researchers

have made striking discoveries about brain circuits—networks of brain structures whose

interconnectivity produces distinct behaviors, cognitions, and emotions. We discuss the

particular kinds of brain circuit dysfunction that contribute to each of the psychological

disorders. At the same time, we clarify how genetic factors, neurotransmitter activity, brain

anatomy, and immune functioning interface with the operation of the brain circuits to produce

psychological dysfunction.

•NEW• The Cognitive-Behavioral Model: Merging the Behavioral and Cognitive

Perspectives We now merge behavioral and cognitive explanations and treatments into a

cohesive and nuanced cognitive-behavioral model, consistent with today’s most prominent point

of view. Previous editions presented behavioral and cognitive discussions separately to help

readers understand the important distinctions between behavior-focused and cognition-focused

principles and research. This edition’s more integrated presentations of the cognitive-behavioral

model enable readers to better appreciate why today’s cognitive-behavioral theorists and

practitioners include both behavioral and cognitive principles in their work and the

complementary and interactive nature of behavioral and cognitive principles.

In addition, in this edition of Fundamentals of Abnormal Psychology we further expand our

coverage of “new wave” cognitive-behavioral theories and therapies, including mindfulness-based

interventions and Acceptance and Commitment Therapy (ACT) (for example, pages 53–54, 110,

195, and 389).

•NEW• “Trending” Boxes Throughout this edition, we present Trending boxes in addition to

the PsychWatch boxes and MindTech boxes featured in previous editions. Whereas PsychWatch

boxes explore important topics in the field and MindTech boxes give special attention to

provocative technological issues, the Trending boxes focus on particularly hot topics that are

trending, or current, in abnormal psychology. New Trending boxes include the following:

Separation Anxiety Disorder, Not Just For Kids Anymore (Chapter 4)

Internet Horrors: Live-Streaming of Suicides (Chapter 7)

Shame on Body Shamers (Chapter 9)

The Opioid Crisis (Chapter 10)

Mass Murders: Where Does Such Violence Come From? (Chapter 13)

Damaging the Brain: CTE and Football (Chapter 15)

Doctor Do No Harm: Enhanced Interrogation (Chapter 16)

•NEW• Additional InfoCentrals Our previous edition introduced a feature called InfoCentrals

—numerous lively, full-page infographics on important topics in the field. Given the very

positive reader response to these stimulating visual data offerings, we have included them again in

this edition—updating all of them, substantially changing some, and adding a number of totally

new ones. Brand-new InfoCentrals include the following:

DSM: The Bigger Picture (Chapter 3)

Fear (Chapter 4)

Exercise and Dietary Supplements (Chapter 6)

The Dark Triad (Chapter 13, page 429)

•NEW• Additional and Expanded Topic Coverage Over the past several years, a number of

topics in abnormal psychology have received special attention. In this edition, we have provided

new or expanded sections on these topics, including the impact of changing health care laws (pages

18, 516); transgender issues (pages 356–360); PTSD and the #MeToo movement (page 145); social

media–based research (pages 31, 122); mass murders (page 408); resilience and the Parkland,

Florida, school shootings (page 151); terrorism and mental health (pages 145–146, 514); cognitive

processing therapy (page 154); prolonged exposure therapy (page 154); exercise and mental health

(page 182); the interpersonal theory of suicide (pages 223–224); the implicit association test for

suicidal risk (page 234); teenage eating habits (page 280); body shaming (page 288); motivational

interviewing (page 283); the opioid crisis (page 302); addiction to prescription pain relievers (pages

301–302); community naloxone treatments for drug overdoses (page 321); recreational cannabis laws

(pages 311–312); contingency management treatment (page 320); erotomanic delusions (page 370);

disorders among the offspring of older fathers (pages 205, 389); cognitive remediation for

schizophrenia (page 387); mental health courts (page 392); mentalization (pages 413–414); selective

mutism (pages 439–440); parent management training (page 446); joint attention (page 456);

biomarkers for Alzheimer’s disease (page 486); chronic traumatic encephalopathy (page 488);

outpatient civil commitment (pages 500, 504); and psychologists and enhanced interrogations (page

514).

•NEW• Additional Focus on Technology In this edition we have expanded the previous

edition’s focus on the psychological impact of technology and the use of new technology in

treatment. In text discussions, MindTech boxes, photographs, and figures throughout the book,

we examine many additional technology topics such as telemental health (pages 20, 517–518),

Internet social media–based research (page 31), videoconferencing and parent-management

training (page 446), and live streaming of suicides (page 216).

•NEW• Case Material Over the years, one of the hallmarks of Fundamentals of Abnormal

Psychology has been the inclusion of numerous and culturally diverse clinical examples that bring

theoretical and clinical issues to life. In our continuing quest for relevance to the reader and to

today’s world, we have replaced or revised many of the clinical examples in this edition (for

example, pages 349–350, 410, 415, and 423).

•NEW• Additional Critical Thought Questions Critical thought questions have long been a

stimulating feature of Fundamentals of Abnormal Psychology. These questions pop up within the

text narrative, asking students to pause at precisely the right moment and think critically about

the material they have just read. We have added a number of new such questions throughout this

edition.

•NEW• Additional “Hashtags” This edition retains a fun and thought-provoking feature that

has been very popular among students and professors over the years—reader-friendly Hashtags

(#), previously called Between the Lines. Hashtags consist of surprising facts, current events,

historical notes, interesting lists, and quotes that are strategically placed in the book’s margins.

Numerous new Hashtags have been added to this edition.

•NEW• Thorough Update In this edition we present the most current theories, research, and

events, and include more than 2,000 new references from the years 2017–2019, as well as

numerous new photos, tables, and figures.

•EXPANDED COVERAGE• Prevention and Mental Health Promotion In accord with the

clinical field’s growing emphasis on prevention, positive psychology, and psychological wellness,

we have increased the textbook’s attention to these important approaches (for example, pages 16,

70, and 492).

•EXPANDED COVERAGE• Multicultural Issues Consistent with the field’s continuing

appreciation of the impact of ethnicity, race, gender, gender identity, and other cultural factors

on psychological functioning, this edition further expands its coverage of the multicultural

perspective and includes additional multicultural material and research throughout the text (for

example, pages 66–67, 281–282, 427–428, and 453–454). Even a quick look through the pages

of this textbook will reveal that it truly reflects the diversity of our society and of the field of

abnormal psychology.

Continuing Strengths As we noted earlier, in this edition we have also retained the themes, material, and techniques

that have worked successfully for and been embraced enthusiastically by past readers.

Breadth and Balance The field’s many theories, studies, disorders, and treatments are presented

completely and accurately. All major models—psychological, biological, and sociocultural—

receive objective, balanced, up-to-date coverage, without bias toward any single approach.

Integration of Models Discussions throughout the text help students better understand where

and how the various models work together and how they differ.

Empathy The subject of abnormal psychology is people—very often people in great pain. We

have tried therefore to write always with empathy and to impart this awareness to students.

Pervasive Coverage of Treatment Discussions of treatment are presented throughout the book.

In addition to a complete overview of treatment in the opening chapters, each of the pathology

chapters includes a full discussion of relevant treatment approaches.

Rich Case Material As we mentioned earlier, the textbook features hundreds of culturally diverse

clinical examples to bring theoretical and clinical issues to life.

DSM-5 This edition continues to include discussions of DSM-5 throughout the book,

highlighting the classification system’s flaws as well as its utility. In addition to weaving DSM-5

categories, criteria, and information into the narrative of each chapter, we regularly provide a

reader-friendly pedagogical feature called Dx Checklist to help students fully grasp DSM-5 and

related diagnostic tools (for example, pages 89–93, 102, 120, 187, and 248).

Margin Glossary Hundreds of key words are defined in the margins of pages on which the words

appear. In addition, a traditional glossary is featured at the back of the book.

Focus on Critical Thinking The textbook provides various tools for thinking critically about

abnormal psychology. As we mentioned earlier, for example, “critical thought” questions appear

at carefully selected locations within the text discussion, asking readers to stop and think critically

about the material they have just read.

Striking Photos and Stimulating Illustrations Once again, the textbook features a wide range of

truly stunning photographs, diagrams, graphs, and anatomical figures that bring to life the

discussions of various concepts, disorders, and treatments. The carefully chosen photos range

from historical to today’s world to pop culture. They do more than just illustrate topics: they

touch and move readers and enhance understanding.

Adaptability Chapters are self-contained, so they can be assigned in any order that makes sense

to the professor.

Supplements We are delighted by the enthusiastic responses of both professors and students to the

supplements that have accompanied Fundamentals of Abnormal Psychology over the years. This

edition offers those supplements once again, revised and enhanced, and adds a number of

exciting new ones.

For Professors Worth Video Collection for Abnormal Psychology 2.0 Produced and edited by Ronald J. Comer,

Princeton University, and Gregory P. Comer, Princeton Academic Resources. Faculty Guide included.

This incomparable video package offers more than 125 clips on different kinds of clinical events,

psychopathologies, and treatments. More than 50 new videos have been added to this edition on

current topics such as the national opioid crisis, the impact of body shaming, mindfulness-based

interventions, transgender issues, borderline personality disorder, dialectical behavior therapy, cell

phone addiction, gaming addiction, acceptance and commitment therapy, binge-eating disorder,

training police for mental health interventions, mental health courts, and CTE and football.

These cutting-edge videos are available on LaunchPad and on the Video Collection for Abnormal

Psychology 2.0 flash drive. The package is accompanied by a guide that fully describes each video

clip, so that professors can make informed decisions about the use of the segments in lectures.

Instructor’s Resource Manual by Jeffrey B. Henriques, University of Wisconsin–Madison and Laurie

A. Frost. This comprehensive guide, revised by an experienced instructor and a clinician, ties

together the ancillary package for professors and teaching assistants. The manual includes

detailed chapter outlines, lists of principal learning objectives, ideas for lectures, discussion

launchers, classroom activities, extra credit projects, and DSM criteria for each of the disorders

discussed in the text. It also offers strategies for using the accompanying media, including the

video collection. Finally, it includes a comprehensive set of valuable materials that can be

obtained from outside sources—items such as relevant feature films, documentaries, teaching

references, and Internet sites related to abnormal psychology.

Lecture Slides These slides focus on key concepts and themes from the text and can be used as is

or customized to fit a professor’s needs.

iClicker Classroom Response System This is a versatile polling system developed by educators

for educators that makes class time more efficient and interactive. iClicker allows you to ask

questions and instantly record your students’ responses, take attendance, and gauge students’

understanding and opinions. A set of iClicker Questions for each chapter is available online and

in LaunchPad.

Image Slides and Tables These slides, featuring all chapter photos, illustrations, and tables, can

be used as is or customized to fit a professor’s needs.

Chapter Figures and Photos This collection gives professors access to all of the photographs,

illustrations, and alt text from Fundamentals of Abnormal Psychology, Ninth Edition.

Assessment Tools Computerized Test Bank powered by Diploma, includes a full assortment of test items. Each

chapter features over 200 questions to test students at several levels of Bloom’s taxonomy. All the

questions are tagged to the outcomes recommended in the 2013 APA Guidelines for the

Undergraduate Psychology Major, Bloom’s level, the book page, the chapter section, and the

learning objective from the Instructor’s Resource Manual. The Diploma Test Bank files also

provide tools for converting the Test Bank into a variety of useful formats as well as Blackboard-

and WebCT-formatted versions of the Test Bank for Fundamentals of Abnormal Psychology,

Ninth Edition.

For Students Case Studies In Abnormal Psychology, Second Edition, by Ethan E. Gorenstein, Behavioral

Medicine Program, New York–Presbyterian Columbia Hospital, and Ronald J. Comer, Princeton

University. This edition of our popular case study book provides 20 case histories, each going

beyond diagnoses to describe the individual’s history and symptoms, theories behind treatment, a

specific treatment plan, and the actual treatment conducted. The casebook also provides three

cases without diagnoses or treatment so that students can identify disorders and suggest

appropriate therapies. Wonderful case material for somatic symptom disorder, hoarding disorder,

and gender dysphoria has been added by Danae Hudson and Brooke Whisenhunt, professors at

Missouri State University.

with LearningCurve Quizzing—Multimedia to Support Teaching and

Learning Available at www.launchpadworks.com

A comprehensive Web resource for teaching and learning psychology, LaunchPad combines

Worth Publishers’ award-winning media with an innovative platform for easy navigation. For

students, it is the ultimate online study guide, with rich interactive tutorials, videos, an e-book,

and the LearningCurve adaptive quizzing system. For instructors, LaunchPad is a full-course

space where class documents can be posted, quizzes can be easily assigned and graded, and

students’ progress can be assessed and recorded. Whether you are looking for the most effective

study tools or a robust platform for an online course, LaunchPad is a powerful way to enhance

your class.

http://www.launchpadworks.com

LaunchPad to accompany Fundamentals of Abnormal Psychology, Ninth Edition, can be

previewed at www.launchpadworks.com. Fundamentals of Abnormal Psychology, Ninth Edition,

and LaunchPad can be ordered together with:

ISBN-10: 1-319-25126-9

ISBN-13: 978-1-319-25126-0

LaunchPad for Fundamentals of Abnormal Psychology, Ninth Edition, includes the following

resources:

The LearningCurve quizzing system was designed based on the latest findings from learning and memory research. It combines adaptive question selection, immediate and valuable feedback, and a game-like interface to engage students in a learning experience that is unique to each student. Each LearningCurve quiz is fully integrated with other resources in LaunchPad through the Personalized Study Plan, so students will be able to review the material with Worth’s extensive library of videos and activities. And state-of-the-art question-analysis reports allow instructors to track the progress of individual students as well as that of their class as a whole.

An interactive e-book allows students to highlight, bookmark, and make their own notes, just as they would with a printed textbook.

Clinical Choices Immersive Learning Activities by Taryn Myers, Virginia Wesleyan University. This edition polishes and streamlines Clinical Choices, the well-received interactive case studies available through LaunchPad, our online course-management system. Through an immersive mix of video, audio, and assessment, each of the 11 Clinical Choices case studies allows students to simulate the thought process of a clinician by identifying and evaluating a virtual “client’s” symptoms, gathering information about the client’s life situation and family history, determining a diagnosis, and formulating a treatment plan.

Abnormal Psychology Video Activities, by Ronald J. Comer, Princeton University; Jonathan S. Comer, Florida International University; and Taryn Myers, Virginia Wesleyan. These intriguing video cases run 3 to 7 minutes each and focus on people affected by disorders discussed in the text. Students first view a video case and then answer a series of thought- provoking questions.

Research Exercises in each chapter help stimulate critical thinking skills. Students are asked to consider real research, make connections among ideas, and analyze arguments and the evidence on which they are based.

Deep integration is available between LaunchPad products and Blackboard, Brightspace by Desire2Learn, Canvas, and Moodle. These deep integrations offer educators single sign-on and Gradebook sync, now with auto-refresh. Also, these best-in-class integrations offer deep linking to all Macmillan digital content at the chapter and asset level, giving professors ultimate flexibility and customization capability within their learning management system.

•NEW• Achieve Read & Practice with LearningCurve Quizzing—Achieve Read & Practice is

the marriage of Worth’s LearningCurve adaptive quizzing and our mobile, accessible e-book in

one easy-to-use and affordable product.

With Achieve Read & Practice, instructors can arrange and assign chapters and sections from

the e-book in any sequence they prefer, assign the readings to their class, and track student

performance.

Assignments come with LearningCurve quizzes offering individualized and adaptive question

sets, immediate feedback, and e-book references for correct and incorrect answers. If students

struggle with a particular topic, they are encouraged to reread the material and check their

understanding by answering a few short additional questions before being given the option to

quiz themselves again.

The Read & Practice Gradebook provides analytics for student performance individually and

for the whole class, by chapter, section, and topic, helping instructors prepare for class and one-

on-one discussions.

Fundamentals of Abnormal Psychology and Read & Practice can be ordered together with

ISBN-10: 1-319-25132-3

ISBN-13: 978-1-319-25132-1

The Loose-leaf Edition of Fundamentals of Abnormal Psychology and Read & Practice can be

ordered together with

ISBN-10: 1-319-25130-7

ISBN-13: 978-1-319-25130-7

Acknowledgments We are very grateful to the many people who have contributed to writing and producing this

book. We particularly thank Gregory Comer for his outstanding work on a range of text and

digital materials. In addition, we are indebted to Marlene Glissmann and Jean Erler for their fast,

furious, and fantastic work on the references.

We are indebted greatly to those outstanding academicians and clinicians who have provided

feedback on this new edition of Fundamentals of Abnormal Psychology, along with that of its

partner, Abnormal Psychology, and have commented with great insight and wisdom on its clarity,

accuracy, and completeness. Their collective knowledge has in large part shaped the current

edition: Seth A. Brown, University of Northern Iowa; Andrea Cartwright, Jefferson Community

& Technical College; Gisele Casanova, Purdue University Northwest; Lauren Dattilo, University

of South Carolina; Andrea Glenn, University of Alabama; Amanda Haliburton, Virginia

Polytechnic Institute and State University; Jacqueline Heath, Ohio State University; Robert

Hoople, Ivy Tech Community College of Indiana; Rick Ingram, The University of Kentucky;

Joni Jecklin, Heartland Community College; Kristin Juarez, Cochise College; Julia Kim-Cohen,

University of Illinois–Chicago; Terese Landry, Houston Community College; Vance Maloney,

Taylor University; Donna Marie McElroy, Atlantic Cape Community College; Jane-Marie

McKinney, Gordon State College; Alejandro Morales, California State Polytechnic University,

Pomona; Justin Peer, University of Michigan–Dearborn; Christopher Schulte, Coastal Carolina

Community College; Jerome Short, George Mason University; LaTishia Smith, Ivy Tech

Community College of Indiana; Caroline Stanley, Bridgewater State University; Helen Taylor,

Bellevue College; Sandra Terneus, Tennessee Tech University; Joseph Vielbig, Arizona Western

College; BJ Wallace, Albright College; Shannon Williams, Prince George’s Community College.

Earlier we also received valuable feedback from academicians and clinicians who reviewed

portions of the previous editions of Fundamentals of Abnormal Psychology and Abnormal

Psychology. Certainly their collective knowledge has also helped shape this new edition, and we

gratefully acknowledge their important contributions: Christopher Adams, Fitchburg State

University; Dave W. Alfano, Community College of Rhode Island; Jeffrey Armstrong,

Northampton Community College; Alisa Aston, University of North Florida; Kent G. Bailey,

Virginia Commonwealth University; Stephanie Baralecki, Chestnut Hill College; Sonja Barcus,

Rochester College; Wendy Bartkus, Albright College; Marna S. Barnett, Indiana University of

Pennsylvania; Jennifer Bennett, University of New Mexico; Jillian Bennett, University of

Massachusetts Boston; Otto A. Berliner, Alfred State College; Allan Berman, University of

Rhode Island; Douglas Bernstein, University of Toronto Mississauga; Sarah Bing, University of

Maryland Eastern Shore; Greg Bolich, Cleveland Community College; Stephen Brasel, Moody

Bible Institute; Conrad Brombach, Christian Brothers University; Barbara Brown, Georgia

Perimeter College; Christine Browning, Victory University; Gregory M. Buchanan, Beloit

College; Jeffrey A. Buchanan, Minnesota State University, Mankato; Laura Burlingame-Lee,

Colorado State University; Loretta Butehorn, Boston College; Glenn M. Callaghan, San José

State University; E. Allen Campbell, University of St. Francis; Julie Carboni, San Jose Christian

College and National University; David N. Carpenter, Southwest Texas University; Marc

Celentana, The College of New Jersey; Edward Chang, University of Michigan; Daniel Chazin,

Rutgers University; Sarah Cirese, College of Marin; June Madsen Clausen, University of San

Francisco; Victor B. Cline, University of Utah; E. M. Coles, Simon Fraser University; Michael

Connor, California State University, Long Beach; Frederick L. Coolidge, University of Colorado,

Colorado Springs; Patrick J. Courtney, Central Ohio Technical College; Charles Cummings,

Asheville Buncombe Technical Community College; Dennis Curtis, Metropolitan Community

College; Timothy K. Daugherty, Missouri State University; Megan Davies, NOVA, Woodbridge

Campus; Pernella Deams, Grambling State University; Lauren Doninger, Gateway Community

College; Pernella Deams, Grambling State University; Mary Dosier, University of Delaware; S.

Wayne Duncan, University of Washington, Seattle; Anne Duran, California State University,

Bakersfield; Morris N. Eagle, York University; Miriam Ehrenberg, John Jay College of Criminal

Justice; Jon Elhai, University of Toledo; Frederick Ernst, University of Texas, Pan American;

Daniella K. C. Errett, Pennsylvania Highlands Community College; Carlos A. Escoto, Eastern

Connecticut State University; William Everist, Pima Community College; Jennifer Fiebig,

Loyola University Chicago; David M. Fresco, Kent State University; Anne Fisher, University of

Southern Florida; William E. Flack Jr., Bucknell University; John Forsyth, State University of

New York, Albany; Alan Fridlund, University of California, Santa Barbara; Stan Friedman,

Southwest Texas State University; Dale Fryxell, Chaminade University; Lawrence L. Galant,

Gaston College; Kathryn E. Gallagher, Georgia State University; Rosemarie B. Gilbert, Brevard

Community College; Karla Gingerich, Colorado State University; Nicholas Greco, College of

Lake County; Jane Halonen, James Madison University; James Hansell, University of Michigan;

David Harder, Tufts University; Morton G. Harmatz, University of Massachusetts; Jinni A.

Harrigan, California State University, Fullerton; Jumi Hayaki, College of the Holy Cross; RaNae

Healy, GateWay Community College; Anthony Hermann, Kalamazoo College; Paul Hewitt,

University of British Columbia; Abby Hill, Trinity International University; Tony Hoffman,

University of California, Santa Cruz; Art Hohmuth, The College of New Jersey; Art Houser,

Fort Scott Community College; Danae Hudson, Missouri State University; William G. Iacono,

University of Minnesota; Jessica Goodwin Jolly, Gloucester County College; Ashleigh E. Jones,

University of Illinois at Urbana-Champaign; Ricki E. Kantrowitz, Westfield State University;

Barbara Kennedy, Brevard Community College; Lynn M. Kernen, Hunter College; Audrey Kim,

University of California, Santa Cruz; Guadalupe Vasquez King, Milwaukee Area Technical

College; Tricia Z. King, Georgia State University; Bernard Kleinman, University of Missouri,

Kansas City; Craig Knapp, College of St. Joseph; Futoshi Kobayashi, Northern State University;

Alan G. Krasnoff, University of Missouri, St. Louis; Sally Kuhlenschmidt, Western Kentucky

University; Robert D. Langston, University of Texas, Austin; Kimberlyn Leary, University of

Michigan; Harvey R. Lerner, Kaiser-Permanente Medical Group; Arnold D. LeUnes, Texas

A&M University; Michael P. Levin, Kenyon College; Barbara Lewis, University of West Florida;

Paul Lewis, Bethel College; Mary Margaret Livingston, Louisiana Technical University; Karsten

Look, Columbus State Community College; Joseph LoPiccolo, University of Missouri,

Columbia; L. E. Lowenstein, Southern England Psychological Services; Gregory Mallis,

University of Indianapolis; Jerald J. Marshall, University of Central Florida; Toby Marx, Union

County College; Janet R. Matthews, Loyola University; Robert J. McCaffrey, State University of

New York, Albany; Rosemary McCullough, Ave Maria University; F. Dudley McGlynn, Auburn

University; Tara McKee, Hamilton College; Lily D. McNair, University of Georgia; Mary W.

Meagher, Texas A&M University; Dorothy Mercer, Eastern Kentucky University; Michele

Metcalf, Coconino Community College; Joni L. Mihura, University of Toledo; Andrea Miller,

Georgia Southwestern State University; Antoinette Miller, Clayton State University; Regina

Miranda, Hunter College; John Mitchell, Lycoming College; Robin Mogul, Queens University;

Linda M. Montgomery, University of Texas, Permian Basin; Jeri Morris, Roosevelt University;

Karen Mottarella, University of Central Florida; Maria Moya, College of Southern Nevada;

Karla Klein Murdock, University of Massachusetts, Boston; Taryn Myers, Virginia Wesleyan

University; Sandy Naumann, Delaware Technical Community College; David Nelson, Sam

Houston State University; Hansjörg Neth, Rensselaer Polytechnic Institute; Paul Neunuebel,

Sam Houston State University; Ryan Newell, Oklahoma Christian University; Katherine M.

Nicolai, Rockhurst University; Susan A. Nolan, Seton Hall University; Fabian Novello, Purdue

University; Edward O’Brien, Marywood University; Ryan O’Loughlin, Nazareth College; Mary

Ann M. Pagaduan, American Osteopathic Association; Crystal Park, University of Connecticut;

Dominic J. Parrott, Georgia State University; Daniel Paulson, Carthage College; Paul A. Payne,

University of Cincinnati; Mary Pelton-Cooper, Northern Michigan University; David V.

Perkins, Ball State University; Julie C. Piercy, Central Virginia Community College; Lloyd R.

Pilkington, Midlands Technical College; Harold A. Pincus, chair, DSM-IV, University of

Pittsburgh, Western Psychiatric Institute and Clinic; Chris Piotrowski, University of West

Florida; Debbie Podwika, Kankakee Community College; Ginger Pope, South Piedmont

Community College; Norman Poppel, Middlesex County College; David E. Powley, University

of Mobile; Laura A. Rabin, Brooklyn College; Max W. Rardin, University of Wyoming,

Laramie; Lynn P. Rehm, University of Houston; Leslie A. Rescorla, Bryn Mawr College; R. W.

Rieber, John Jay College, CUNY; Lisa Riley, Southwest Wisconsin Technical College; Esther

Rothblum, University of Vermont; Vic Ryan, University of Colorado, Boulder; Randall Salekin,

Florida International University; Edie Sample, Metropolitan Community College; Jackie

Sample, Central Ohio Technical College; A. A. Sappington, University of Alabama,

Birmingham; Martha Sauter, McLennan Community College; Laura Scaletta, Niagara County

Community College; Ty Schepis, Texas State University; Elizabeth Seebach, Saint Mary’s

University of Minnesota; George W. Shardlow, City College of San Francisco; Shalini Sharma,

Manchester Community College; Roberta S. Sherman, Bloomington Center for Counseling and

Human Development; Wendy E. Shields, University of Montana; Sandra T. Sigmon, University

of Maine, Orono; Susan J. Simonian, College of Charleston; Janet A. Simons, Central Iowa

Psychological Services; Jay R. Skidmore, Utah State University; Rachel Sligar, James Madison

University; Katrina Smith, Polk Community College; Robert Sommer, University of California,

Davis; Jason S. Spiegelman, Community College of Baltimore County; John M. Spores, Purdue

University, South Central; Caroline Stanley, Wilmington College; Wayne Stein, Brevard

Community College; Arnit Steinberg, Tel Aviv University; David Steitz, Nazareth College; B. D.

Stillion, Clayton College & State University; Deborah Stipp, Ivy Tech Community College;

Joanne H. Stohs, California State University, Fullerton; Jaine Strauss, Macalester College;

Mitchell Sudolsky, University of Texas, Austin; John Suler, Rider University; Sandra Todaro,

Bossier Parish Community College; Terry Trepper, Purdue University Calumet; Thomas A.

Tutko, San José State University; Maggie VandeVelde, Grand Rapids Community College;

Arthur D. VanDeventer, Thomas Nelson Community College; Jennifer Vaughn, Metropolitan

Community College; Norris D. Vestre, Arizona State University; Jamie Walter, Roosevelt

University; Steve Wampler, Southwestern Community College; Eleanor M. Webber, Johnson

State College; Lance L. Weinmann, Canyon College; Doug Wessel, Black Hills State University;

Laura Westen, Emory University; Brook Whisenhunt, Missouri State University; Joseph L.

White, University of California, Irvine; Justin Williams, Georgia State University; Amy C.

Willis, Veterans Administration Medical Center, Washington, DC; James M. Wood, University

of Texas, El Paso; Lisa Wood, University of Puget Sound; Lucinda E. Woodward, Indiana

University Southeast; Kim Wright, Trine University; David Yells, Utah Valley State College;

Jessica Yokely, University of Pittsburgh; Carlos Zalaquett, University of South Florida; and

Anthony M. Zoccolillo, Rutgers University.

We would also like to thank a group of talented professors who provided valuable feedback that

shaped the development of our exciting immersive learning activities, Clinical Choices: David

Berg, Community College of Philadelphia; Seth Brown, University of Northern Iowa; Julia

Buckner, Louisiana State University; Robin Campbell, Eastern Florida State University;

Christopher J. Dyszelski, Madison Area Technical College; Paul Deal, Missouri State University;

Urminda Firlan, Kalamazoo Valley Community College; Roy Fish, Zane State College; Julie

Hanauer, Suffolk County Community College; Stephanie Brooke Hindman, Greenville

Technical College; Sally Kuhlenschmidt, Western Kentucky University; Alejandro Morales,

California State Polytechnic University, Pomona; Erica Musser, Florida International University;

Garth Neufeld, Highline Community College; Kruti Patel, Ohio University; and Jeremy Pettit,

Florida International University.

A special thank you to the authors of the book’s supplements package for doing splendid jobs

with their respective supplements: Jeffrey B. Henriques, University of Wisconsin–Madison and

Laurie A. Frost (Instructor’s Resource Manual); Taryn Myers, Virginia Wesleyan University

(Clinical Choices); Joy Crawford, Green River Community College (Practice Quizzes). And thank

you to the contributors from previous editions: Ann Brandt-Williams, Glendale Community

College; Elaine Cassel, Marymount University and Lord Fairfax Community College; Danae L.

Hudson, Missouri State University; John Schulte, Cape Fear Community College and University

of North Carolina; and Brooke L. Whisenhunt, Missouri State University.

We also extend our deep appreciation to the core team of professionals at Worth Publishers and

W. H. Freeman and Company who have worked with us almost every day for the past year to

produce this edition: Un Hye Kim, assistant editor; Mimi Melek, senior development editor;

Martha Emry, senior content project manager; Paul Lacy, layout designer; and Jennifer Atkins,

photo editor and video researcher. It is accurate to say that these members of the core team were

our co-authors and co-teachers in this enterprise, and we are in their debt.

We also thank the following individuals, each of whom made significant contributions to the

writing and production of this textbook: Chuck Linsmeier, senior vice president, content

strategy; Matt Wright, executive program manager; Jennifer MacMillan, permissions manager;

Susan Wein, senior workflow project supervisor; Shani Fisher, program director, social sciences;

Tracey Kuehn, director of content management enhancement; Diana Blume, director of design;

Blake Logan, designer; John Callahan, cover designer; Natasha Wolfe, design services manager;

Matthew McAdams, art manager; Chuck Yuen, book and InfoCentral designer; Lucille Clerc,

cover and chapter-opener artist; Stefani Wallace, media editor; Noel Hohnstine, director of

media editorial & assessment, social sciences; Michael McCarty, permissions associate; Arthur

Johnson, text permissions researcher; Christine Buese, media permissions manager; Hillary

Newman, director of rights and permissions; Lisa Kinne, senior managing editor; Jean Erler,

copyeditor and references editor; William LaDue, proofreader; and Sherri Dietrich, indexer.

And, of course, not to be overlooked are the superb professionals at Worth Publishers who

continuously work with great passion, skill, and judgment to bring our books to the attention of

professors across the world: Kate Nurre, executive marketing manager; Clay Bolton, senior

marketing manager; Chelsea Simens, marketing assistant; Greg David, senior vice president,

Macmillan Learning sales; and the company’s wonderful sales representatives. Thank you so

much.

Two remaining notes. First, as you can imagine, we have found it more than a little exciting to

work together on this monumental project. But beyond our personal delight, we believe that our

co-authorship brings a valuable blend to the textbook. More than father and son, we are

psychology professors and clinicians at very different points in our lives and careers, with

different areas of expertise and accomplishment, and, at times, different sensibilities. Bridging

such differences in the writing of this book has enabled us to grow enormously—both

professionally and personally. We hope that our collaboration has, likewise, resulted in a special

textbook for our readers.

Finally, both in terms of our textbooks and more generally, we are very aware of just how

fortunate we are. We feel profoundly privileged to be able to work with so many interesting and

stimulating students during this important and exciting stage of their lives. Similarly, we are

grateful beyond words for our dear friends and for our extraordinary family, particularly our

magnificent wives Marlene and Jami (Marlene is also Jon’s mom); our wonderful son/brother,

Greg, and daughter-/sister-in-law, Emily; Jon’s loving parents-in-law, Jim and Mindy Furr; and

the lights of our lives, Delia (age 7) and Emmett (age 5).

Ronald J. Comer

Jonathan S. Comer

January, 2019

CHAPTER 1 Abnormal Psychology: Past and Present

TOPIC OVERVIEW

What Is Psychological Abnormality?

Deviance Distress Dysfunction Danger The Elusive Nature of Abnormality

What Is Treatment?

How Was Abnormality Viewed and Treated in the Past?

Ancient Views and Treatments Greek and Roman Views and Treatments Europe in the Middle Ages The Renaissance and the Rise of Asylums The Nineteenth Century The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives

Recent Decades and Current Trends

How Are People with Severe Disturbances Cared For? How Are People with Less Severe Disturbances Treated? A Growing Emphasis on Preventing Disorders and Promoting Mental Health Multicultural Psychology The Increasing Influence of Insurance Coverage What Are Today’s Leading Theories and Professions? Technology and Mental Health

What Do Clinical Researchers Do?

The Case Study The Correlational Method The Experimental Method Alternative Research Designs What Are the Limits of Clinical Investigations? Protecting Human Participants

Moving Forward

Johanne cries herself to sleep every night. She is certain that the future holds nothing but misery. Indeed, this is the only thing

she does feel certain about. “I’m going to suffer and suffer and suffer, and my daughters will suffer as well. We’re doomed. The

world is ugly. I hate every moment of my life.” She has great trouble sleeping. She is afraid to close her eyes. When she does, the

hopelessness of her life—and the ugly future that awaits her daughters—becomes all the clearer to her. When she drifts off to sleep,

her dreams are nightmares filled with terrible images—bodies, decay, death, destruction.

Some mornings Johanne even has trouble getting out of bed. The thought of facing another day overwhelms her. She wishes

that she and her daughters were dead. “Get it over with. We’d all be better off.” She feels paralyzed by her depression and anxiety,

overwhelmed by her sense of hopelessness, and filled with fears of becoming ill, too tired to move, too negative to try anymore. On

such mornings, she huddles her daughters close to her and remains all day in the cramped tent she shares with her daughters. She

feels she has been deserted by the world and left to rot. She is both furious at life and afraid of it at the same time.

During the past year Alberto has been hearing mysterious voices that tell him to quit his job, leave his family, and prepare for

the coming invasion. These voices have brought tremendous confusion and emotional turmoil to Alberto’s life. He believes that they

come from beings in distant parts of the universe who are somehow wired to him. Although it gives him a sense of purpose and

specialness to be the chosen target of their communications, the voices also make him tense and anxious. He does all he can to warn

others of the coming apocalypse. In accordance with instructions from the voices, he identifies online articles that seem to be filled

with foreboding signs, and he posts comments that plead with other readers to recognize the articles’ underlying messages. Similarly,

he posts long, rambling YouTube videos that describe the invasion to come. The online comments and feedback that he receives

typically ridicule and mock him. If he rejects the voices’ instructions and stops his online commentary and videos, then the voices

insult and threaten him and turn his days into a waking nightmare.

Alberto has put himself on a sparse diet as protection against the possibility that his enemies may be contaminating his food.

He has found a quiet apartment far from his old haunts, where he has laid in a good stock of arms and ammunition. After

witnessing the abrupt and troubling changes in his behavior and watching his ranting and rambling videos, his family and friends

have tried to reach out to Alberto, to understand his problems, and to dissuade him from the disturbing course he is taking. Every

day, however, he retreats further into his world of mysterious voices and imagined dangers.

Most of us would probably consider Johanne’s and Alberto’s emotions, thoughts, and behaviors

psychologically abnormal. They are the result of a state sometimes called psychopathology,

maladjustment, emotional disturbance, or mental illness (see PsychWatch). These terms have been

applied to the many problems that seem closely tied to the human brain or mind. Psychological

abnormality affects the famous and the unknown, the rich and the poor. Celebrities, writers,

politicians, and other public figures of the present and the past have struggled with it.

Psychological problems can bring great suffering, but they can also be the source of inspiration

and energy.

PSYCHWATCH

Verbal Debuts

We use words like “abnormal” and “mental disorder” so often that it is easy to forget that there was a

time not that long ago when these terms did not exist. When did these and similar words (including slang terms) make

their debut in print as expressions of psychological dysfunction? The Oxford English Dictionary offers the following dates.

Why do actors who portray characters with psychological

disorders tend to receive more awards for their

performances?

Because they are so common and so

personal, these problems capture the

interest of us all. Hundreds of novels,

plays, films, and television programs have

explored what many people see as the

dark side of human nature, and self-help books flood the market. Mental health experts are

popular guests on both television and radio, and some even have their own shows, Web sites, and

blogs.

The field devoted to the scientific study of the problems we find so fascinating is usually

called abnormal psychology. As in any science, workers in this field, called clinical scientists,

gather information systematically so that they can describe, predict, and explain the phenomena

they study. The knowledge that they acquire is then used by clinical practitioners, whose role is to

detect, assess, and treat abnormal patterns of functioning.

abnormal psychology The scientific study of abnormal behavior undertaken to describe, predict, explain, and change abnormal patterns of functioning.

Deviance and abnormality This woman, like others from certain tribes in Myanmar (Burma), has permanently tattooed

her entire face with an elaborate pattern of black lines, a tradition that began centuries ago to repel invaders and discourage

kidnappings. In Western society, total facial disfigurement of this kind would break norms and might be considered

abnormal.

What Is Psychological Abnormality? Although their general goals are similar to those of other scientific professionals, clinical scientists

and practitioners face problems that make their work especially difficult. One of the most

troubling is that psychological abnormality is very hard to define. Consider once again Johanne

and Alberto. Why are we so ready to call their responses abnormal?

While many definitions of abnormality have been proposed over the years, none has won total

acceptance (Bergner & Bunford, 2017, 2014). Still, most of the definitions have certain features

in common, often called “the four Ds”: deviance, distress, dysfunction, and danger. That is,

patterns of psychological abnormality are typically deviant (different, extreme, unusual, perhaps

even bizarre), distressing (unpleasant and upsetting to the person), dysfunctional (interfering with

the person’s ability to conduct daily activities in a constructive way), and possibly dangerous. This

definition offers a useful starting point from which to explore the phenomena of psychological

abnormality. As you will see, however, it has key limitations.

Changing times Prior to this century, a woman’s love for race car driving might have been considered strange, perhaps even

abnormal. Then recently retired Danica Patrick (right) became one of America’s finest race car drivers. The size difference

between her first-place trophy at the 2008 Indy Japan 300 auto race and that of second-place male driver Hélio Castroneves

symbolizes just how far women have come in this sport.

Deviance Abnormal psychological functioning is deviant, but deviant from what? Johanne’s and Alberto’s

behaviors, thoughts, and emotions are different from those that are considered normal in our

place and time. We do not expect people to cry themselves to sleep each night, hate the world,

wish themselves dead, or obey voices that no one else hears.

In short, abnormal behavior, thoughts, and emotions are those that differ markedly from a

society’s ideas about proper functioning. Each society establishes norms—stated and unstated

rules for proper conduct. Behavior that breaks legal norms is considered to be criminal. Behavior,

thoughts, and emotions that break norms of psychological functioning are called abnormal.

norms A society’s stated and unstated rules for proper conduct.

Judgments about what constitutes abnormality vary from society to society. A society’s norms

grow from its particular culture—its history, values, institutions, habits, skills, technology, and

arts. A society that values competition and assertiveness may accept aggressive behavior, whereas

one that emphasizes cooperation and gentleness may consider aggressive behavior unacceptable

and even abnormal. A society’s values may also change over time, causing its views of what is

psychologically abnormal to change as well. In Western society, for example, a woman seeking

the power of running a major corporation or indeed of leading the country would have been

considered inappropriate and even delusional a hundred years ago. Today the same behavior is

valued.

culture A people’s common history, values, institutions, habits, skills, technology, and arts.

Judgments of abnormality depend on specific circumstances as well as on cultural norms. What

if, for example, we were to learn that Johanne is a citizen of Haiti and that her desperate

unhappiness began in the days, weeks, and months following the massive earthquake that struck

her country, already the poorest country in the Western hemisphere, on January 12, 2010? The

quake, one of the worst natural disasters in history, killed 250,000 Haitians and left 1.5 million

homeless. Half of Haiti’s homes and buildings were immediately turned into rubble, and its

electricity and other forms of power disappeared. Tent cities replaced homes for most people

(Dube et al., 2018).

In the weeks and months that followed the earthquake, Johanne came to accept that she

wouldn’t get all of the help she needed and that she might never again see the friends and

neighbors who had once given her life so much meaning. As she and her daughters moved from

one temporary tent or hut to another throughout the country, always at risk of developing

serious diseases, she gradually gave up all hope that her life would ever return to normal. In this

light, Johanne’s reactions do not seem quite so inappropriate. If anything is abnormal here, it is

her situation. Many human experiences produce intense reactions—financial ruin, large-scale

catastrophes and disasters, rape, child abuse, war, terminal illness, chronic pain (Compean &

Hamner, 2019; Scott et al., 2018). Is there an “appropriate” way to react to such things? Should

we ever call reactions to such experiences abnormal?

Distress Even functioning that is considered unusual does not necessarily qualify as abnormal. According

to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they

can be labeled abnormal. Consider the Ice Breakers, a group of people in Michigan who go

swimming in lakes throughout the state every weekend from November through February. The

colder the weather, the better they like it. One man, a member of the group for 17 years, says he

loves the challenge of human against nature. A 37-year-old lawyer believes that the weekly shock

is good for her health. “It cleanses me,” she says. “It perks me up and gives me strength.”

Certainly these people are different from most of us, but is their behavior abnormal? Far from

experiencing distress, they feel energized and challenged. Their positive feelings must cause us to

hesitate before we decide that they are functioning abnormally.

Context is key A couple dressed as Supergirl and Superman stop and point upward as they cross a street in New York City.

Their appearance and behavior might suggest psychological dysfunction were it not for the fact that they are attendees at a

2016 Comic-Con, one of the many popular conventions held across the country to showcase comic books, graphic novels,

and the like.

Should we conclude, then, that feelings of distress must always be present before a person’s

functioning can be considered abnormal? Not necessarily. Some people who function abnormally

maintain a positive frame of mind. Consider once again Alberto, the young man who hears

mysterious voices. What if he enjoyed listening to the voices, felt honored to be chosen, loved

sending out warnings on the Internet, and looked forward to saving the world? Shouldn’t we still

regard his functioning as abnormal?

Dysfunction Abnormal behavior tends to be dysfunctional; that is, it interferes with daily functioning. It so

upsets, distracts, or confuses people that they cannot care for themselves properly, participate in

ordinary social interactions, or work productively. Alberto, for example, has quit his job, left his

family, and prepared to withdraw from the productive life he once led. Because our society holds

that it is important to carry out daily activities in an effective manner, Alberto’s behavior is likely

to be regarded as abnormal and undesirable. In contrast, the Ice Breakers, who continue to

#TheirWords “I can calculate the motion of heavenly bodies but not the

madness of people.”

Sir Isaac Newton

perform well in their jobs and enjoy fulfilling relationships, would probably be considered simply

unusual.

Danger Perhaps the ultimate psychological dysfunction is behavior that becomes dangerous to oneself or

others. Individuals whose behavior is consistently careless, hostile, or confused may be placing

themselves or those around them at risk. Alberto, for example, seems to be endangering both

himself, with his diet, and others, with his buildup of arms and ammunition.

Although danger is often cited as a feature of abnormal psychological functioning, research

suggests that it is actually the exception rather than the rule (Taylor, 2018; Bonnet et al., 2017).

Most people struggling with anxiety, depression, and even bizarre thinking pose no immediate

danger to themselves or to anyone else.

The Elusive Nature of Abnormality Efforts to define psychological abnormality typically raise as many questions as they answer.

Ultimately, a society selects general criteria for defining abnormality and then uses those criteria

to judge particular cases. One clinical theorist, Thomas Szasz (1920–2012), placed such emphasis

on society’s role that he found the whole concept of mental illness to be invalid, a myth of sorts

(Szasz, 2011, 1963, 1960). According to Szasz, the deviations that society calls abnormal are

simply “problems in living,” not signs of something wrong within the person.

Even if we assume that psychological

abnormality is a valid concept and that it

can indeed be defined, we may be unable

to apply our definition consistently. If a

behavior—excessive use of alcohol among

college students, say—is familiar enough,

the society may fail to recognize that it is deviant, distressful, dysfunctional, and dangerous.

Thousands of college students throughout the United States are so dependent on alcohol that it

interferes with their personal and academic lives, causes them great discomfort, jeopardizes their

health, and often endangers them and the people around them (Martin & Chaney, 2018; Testa

& Cleveland, 2017). Yet their problem often goes unnoticed and undiagnosed. Alcohol is so

much a part of the college subculture that it is easy to overlook drinking behavior that has

become abnormal.

What behaviors fit the criteria of deviant, distressful,

dysfunctional, or dangerous but would not be considered

abnormal by most people?

Conversely, a society may have trouble

separating an abnormality that requires

intervention from an eccentricity, an

unusual pattern with which others have

no right to interfere. From time to time we see or hear about people who behave in ways we

consider strange, such as a man who lives alone with two dozen cats and rarely talks to other

people. The behavior of such people is deviant, and it may well be distressful and dysfunctional,

yet many professionals think of it as eccentric rather than abnormal (see PsychWatch).

PSYCHWATCH

Marching to a Different Drummer: Eccentrics Writer James Joyce always carried a tiny pair of lady’s bloomers, which he waved in the air to show approval.

Benjamin Franklin took “air baths” for his health, sitting naked in front of an open window.

Alexander Graham Bell covered the windows of his house to keep out the rays of the full moon. He also tried to teach his dog how to talk.

Writer D. H. Lawrence enjoyed removing his clothes and climbing mulberry trees.

These famous persons have been called eccentrics. The dictionary defines an eccentric as a person who deviates from

common behavior patterns or displays odd or whimsical behavior. But how can we separate a psychologically healthy

person who has unusual habits from a person whose oddness is a symptom of psychopathology? Little research has been

done on eccentrics, but a few studies offer some insights (Weeks, 2015; Newman, 2013; Weeks & James, 1995).

Researcher David Weeks (2015) studied 1,000 eccentrics and estimated that as many as 1 in 5,000 persons may be

“classic, full-time eccentrics.” Weeks pinpointed 15 characteristics common to the eccentrics in his study: nonconformity,

creativity, strong curiosity, idealism, extreme interests and hobbies, lifelong awareness of being different, high intelligence,

outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinions or company, mischievous sense

of humor, nonmarriage, eldest or only child, and poor spelling skills.

Eccentric, but not abnormal Tran Van Hay holds his hair—more than 20 feet in length—around his body, as if it

were a cobra. When he died in 2010, he had not had a haircut for 50 years and had washed his hair only a few times.

The Vietnamese man otherwise lived and worked as a respected and productive herbalist who cared for many people

in need. He just liked his hair on the long side—longer than any other person on earth.

Weeks suggests that eccentrics do not typically suffer from mental disorders. Whereas the unusual behavior of persons

with mental disorders is thrust upon them and usually causes them suffering, eccentricity is chosen freely and provides

pleasure. In short, “Eccentrics know they’re different and glory in it” (Weeks & James, 1995, p. 14). Similarly, the thought

processes of eccentrics are not severely disrupted and do not leave these persons dysfunctional. In fact, Weeks found that

eccentrics in his study actually had fewer emotional problems than individuals in the general population. Perhaps being an

“original” is good for mental health.

In short, while we may agree to define psychological abnormalities as patterns of functioning

that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that

these criteria are often vague and subjective. In turn, few of the current categories of abnormality

that you will meet in this book are as clear-cut as they may seem, and most continue to be

debated by clinicians.

SUMMING UP

WHAT IS PSYCHOLOGICAL ABNORMALITY? Abnormal functioning is generally considered to be deviant, distressful, dysfunctional, and dangerous. Because

behavior must also be considered in the context in which it occurs, however, the concept of abnormality depends on

the norms and values of the society in question.

What Is Treatment? Once clinicians decide that a person is indeed suffering from some form of psychological

abnormality, they seek to treat it. Treatment, or therapy, is a procedure designed to change

abnormal behavior into more normal behavior; it, too, requires careful definition. For clinical

scientists, the problem is closely related to defining abnormality. Consider the case of Bill:

February: He cannot leave the house; Bill knows that for a fact. Home is the only place where he feels safe—safe from

humiliation, danger, even ruin. If he were to go to work, his coworkers would somehow reveal their contempt for him. A pointed

remark, a quizzical look—that’s all it would take for him to get the message. If he were to go shopping at the store, before long

everyone would be staring at him. Surely others would see his dark mood and thoughts; he wouldn’t be able to hide them. He dare

not even go for a walk alone in the woods—his heart would probably start racing again, bringing him to his knees and leaving

him breathless, incoherent, and unable to get home. No, he’s much better off staying in his room, trying to get through another

evening of this curse called life. Thank goodness for the Internet. Were it not for his reading of news sites and blog posts and online

forums, he would, he knows, be cut off from the world altogether.

July: Bill’s life revolves around his circle of friends: Bob and Jack, whom he knows from the office, where he was recently promoted

to director of customer relations, and Frank and Tim, his weekend tennis partners. The gang meets for dinner every week at

someone’s house, and they chat about life, politics, and their jobs. Particularly special in Bill’s life is Janice. They go to movies,

restaurants, and shows together. She thinks Bill’s just terrific, and Bill finds himself beaming whenever she’s around. Bill looks

forward to work each day and to his one-on-one dealings with customers. He is taking part in many activities and relationships

and more fully enjoying life.

treatment A systematic procedure designed to change abnormal behavior into more normal behavior. Also called therapy.

Bill’s thoughts, feelings, and behavior interfered with all aspects of his life in February. Yet

most of his symptoms had disappeared by July. All sorts of factors may have contributed to Bill’s

improvement—advice from friends and family members, a new job or vacation, perhaps a big

change in his diet or exercise regimen. Any or all of these things may have been useful to Bill, but

they could not be considered treatment or therapy. Those terms are usually reserved for special,

systematic procedures for helping people overcome their psychological difficulties. According to a

pioneering clinical theorist, Jerome Frank, all forms of therapy have three essential features:

1. A sufferer who seeks relief from the healer.

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

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

(Frank, 1973, pp. 2–3)

Despite this seemingly straightforward definition, clinical treatment is surrounded by conflict

and, at times, confusion. Some clinicians view abnormality as an illness and so consider therapy a

procedure that helps cure the illness. Others see abnormality as a problem in living and therapists

as teachers of more functional behavior and thought. Clinicians even differ on what to call the

person who receives therapy: those who see abnormality as an illness speak of the “patient,” while

those who view it as a problem in living refer to the “client.” Because both terms are so common,

this book will use them interchangeably.

Despite their differences, most clinicians do agree that large numbers of people need therapy

of one kind or another. Later you will encounter evidence that therapy is indeed often helpful.

Therapy … not At age 11, Ciro Ortiz set up a “therapy” office each week on a New York City subway platform. Calling

himself the Emotional Advice Kid, he talked to people of all ages with various kinds of psychological issues, charging 2

dollars for a five-minute session. Ciro’s advice may have been therapeutic for many persons, but it was not therapy. The

discussions lacked, for example, a “trained healer” and a series of systematic contacts between healer and sufferer.

SUMMING UP

WHAT IS TREATMENT? Therapy is a systematic process for helping people overcome their psychological difficulties. It typically requires a

patient, a therapist, and a series of therapeutic contacts.

How Was Abnormality Viewed and Treated in the Past? In any given year, as many as 30 percent of the adults and 19 percent of the children and

adolescents in the United States display serious psychological disturbances and are in need of

clinical treatment (Williams et al., 2018; Kessler et al., 2015, 2012, 2009; Merikangas et al.,

2013). The rates in other countries are similarly high. It is tempting to conclude that something

about the modern world is responsible for these many emotional problems—perhaps rapid

technological change, resultant losses of employment, the threat of terrorism, or a decline in

religious, family, or other support systems (Elhai et al., 2017). But, as we shall see in the

following sections, every society, past and present, has witnessed psychological abnormality.

Ancient Views and Treatments Historians who have examined the unearthed bones, artwork, and other remnants of ancient

societies have concluded that these societies probably regarded abnormal behavior as the work of

evil spirits. People in prehistoric societies apparently believed that all events around and within

them resulted from the actions of magical, sometimes sinister, beings who controlled the world.

In particular, they viewed the human body and mind as a battleground between external forces of

good and evil. Abnormal behavior was typically interpreted as a victory by evil spirits, and the

cure for such behavior was to force the demons from a victim’s body.

Expelling evil spirits The two holes in this skull recovered from ancient times indicate that the person underwent

trephination, possibly for the purpose of releasing evil spirits and curing mental dysfunction.

This supernatural view of abnormality may have begun as far back as the Stone Age, a half-

million years ago. Some skulls from that period recovered in Europe and South America show

evidence of an operation called trephination, in which a stone instrument, or trephine, was used

to cut away a circular section of the skull (Verano, 2017; Wang, 2017). Some historians have

concluded that this early operation was performed as a treatment for severe abnormal behavior—

either hallucinations, in which people saw or heard things not actually present, or melancholia,

characterized by extreme sadness and immobility. The purpose of opening the skull was to release

the evil spirits that were supposedly causing the problem (Selling, 1940).

trephination An ancient operation in which a stone instrument was used to cut away a circular section of the skull to treat abnormal behavior.

Later societies also explained abnormal behavior by pointing to possession by demons.

Egyptian, Chinese, and Hebrew writings all account for psychological deviance this way, and the

Bible describes how an evil spirit from the Lord affected King Saul and how David feigned

madness to convince his enemies that he was visited by divine forces.

The treatment for abnormality in these

What demonological explanations or treatments, besides

exorcism, are still around today, and why do they persist?

early societies was often exorcism. The idea

was to coax the evil spirits to leave or to

make the person’s body an uncomfortable

place in which to live. A shaman, or

priest, might recite prayers, plead with the evil spirits, insult the spirits, perform magic, make

loud noises, or have the person drink bitter potions. If these techniques failed, the shaman

performed a more extreme form of exorcism, such as whipping or starving the person.

Greek and Roman Views and Treatments In the years from roughly 500 B.C. to 500 A.D., when the Greek and Roman civilizations

thrived, philosophers and physicians often offered different explanations and treatments for

abnormal behaviors. Hippocrates (460–377 B.C.), often called the father of modern medicine,

taught that illnesses had natural causes. He saw abnormal behavior as a disease arising from

internal physical problems. Specifically, he believed that some form of brain pathology was the

culprit and that it resulted—like all other forms of disease, in his view—from an imbalance of

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

(Smith & Smith, 2016). An excess of yellow bile, for example, caused mania, a state of frenzied

activity; an excess of black bile was the source of melancholia, a condition marked by unshakable

sadness.

humors According to the Greeks and Romans, bodily chemicals that influence mental and physical functioning.

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

pathology. He believed, for instance, that the excess of black bile underlying melancholia could

be reduced by a quiet life, a diet of vegetables, temperance, exercise, celibacy, and even bleeding.

Hippocrates’ focus on internal causes for abnormal behavior was shared by the great Greek

philosophers Plato (427–347 B.C.) and Aristotle (384–322 B.C.) and by influential Greek and

Roman physicians.

“Just tell me about the new continent. I don’t give a damn what you’ve discovered about yourself.”

Europe in the Middle Ages: Demonology Returns The enlightened views of Greek and Roman physicians and scholars were not enough to shake

ordinary people’s belief in demons. And with the decline of Rome, demonological views and

practices became popular once again. A growing distrust of science spread throughout Europe.

From 500 to 1350 A.D., the period known as the Middle Ages, the power of the clergy

increased greatly throughout Europe. In those days the church rejected scientific forms of

investigation, and it controlled all education. Religious beliefs, which were highly superstitious

and demonological, came to dominate all aspects of life. Deviant behavior, particularly

psychological abnormality, was seen as evidence of Satan’s influence.

The Middle Ages were a time of great stress and anxiety—of war, urban uprisings, and

plagues. People blamed the devil for these troubles and feared being possessed by him (Ruys,

2017; Sluhovsky, 2017, 2011). Abnormal behavior apparently increased greatly during this

period. In addition, there were outbreaks of mass madness, in which large numbers of people

apparently shared absurd false beliefs and imagined sights or sounds. In one such disorder,

tarantism (also known as Saint Vitus’ dance), groups of people would suddenly start to jump,

dance, and go into convulsions (Lanska, 2018; Corral-Corral & Corral-Corral, 2016). All were

convinced that they had been bitten and possessed by a wolf spider, now called a tarantula, and

they sought to cure their disorder by performing a dance called a tarantella. In another form of

mass madness, lycanthropy, people thought they were possessed by wolves or other animals. They

acted wolflike and imagined that fur was growing all over their bodies.

Bewitched or bewildered? A great fear of witchcraft swept Europe beginning in the 1300s and extending through the

“enlightened” Renaissance. Tens of thousands of people, mostly women, were thought to have made a pact with the devil.

Some appear to have had mental disorders, which caused them to act strangely (Zilboorg & Henry, 1941). This woman is

being “dunked” repeatedly until she confesses to witchery.

Not surprisingly, some of the earlier demonological treatments for psychological abnormality

reemerged during the Middle Ages. Once again the key to the cure was to rid the person’s body

of the devil that possessed it. Exorcisms were revived, and clergymen, who generally were in

charge of treatment during this period, would plead, chant, or pray to the devil or evil spirit

(Sluhovsky, 2017, 2011). If these techniques did not work, they had others to try, some

amounting to torture.

It was not until the Middle Ages drew to a close that demonology and its methods began to

lose favor. Towns throughout Europe grew into cities, and government officials gained more

power and took over nonreligious activities. Among their other responsibilities, they began to run

#DoctorShakespeare Writing during the Renaissance, Shakespeare speculated on the

nature and causes of abnormal behavior in 20 of his 38 plays

and in many of his sonnets.

hospitals and direct the care of people suffering from mental disorders. Medical views of

abnormality gained favor once again, and many people with psychological disturbances received

treatment in medical hospitals, such as the Trinity Hospital in England (Allderidge, 1979).

The Renaissance and the Rise of Asylums During the early part of the Renaissance, a period of flourishing cultural and scientific activity

from about 1400 to 1700, demonological views of abnormality continued to decline. German

physician Johann Weyer (1515–1588), the first physician to specialize in mental illness, believed

that the mind was as susceptible to sickness as the body was. He is now considered the founder of

the modern study of psychopathology.

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

England, such individuals might be kept at home while their families were aided financially by

the local parish. Across Europe, religious shrines were devoted to the humane and loving

treatment of people with mental disorders. Perhaps the best known of these shrines was at Gheel

in Belgium. Beginning in the fifteenth century, people came to Gheel from all over the world for

psychic healing. Local residents welcomed these pilgrims into their homes, and many stayed on

to form the world’s first “colony” of mental patients. Gheel was the forerunner of today’s

community mental health programs (Goldstein, 2016; Aring, 1975, 1974). Many patients still live

in foster homes there, interacting with other residents, until they recover.

Unfortunately, these improvements in

care began to fade by the mid-sixteenth

century. Government officials discovered

that private homes and community

residences could house only a small

percentage of those with severe mental disorders and that medical hospitals were too few and too

small. More and more, they converted hospitals and monasteries into asylums, institutions

whose primary purpose was to care for people with mental illness. These institutions were begun

with the intention that they would provide good care (Philo & Andrews, 2016; Kazano, 2012).

Once the asylums started to overflow, however, they became virtual prisons where patients were

held in filthy conditions and treated with unspeakable cruelty.

asylum A type of institution that first became popular in the sixteenth century to provide care for persons with mental disorders. Most asylums became virtual prisons.

#MythBuster Although it is popularly believed that a full moon is regularly

accompanied by significant increases in crime, strange and

abnormal behaviors, and admissions to mental hospitals,

decades of research have failed to support this notion.

(Chaput et al., 2016; Bakalar, 2013; McLay et al., 2006)

The “crib” Outrageous devices and techniques, such as the “crib,” were used in asylums, and some continued to be used

even during the reforms of the nineteenth century.

In 1547, for example, Bethlehem Hospital was given to the city of London by Henry VIII for

the sole purpose of confining the mentally ill. In this asylum, patients bound in chains cried out

for all to hear. The hospital even became a popular tourist attraction; people were eager to pay to

look at the howling and gibbering inmates. The hospital’s name, pronounced “Bedlam” by the

local people, has come to mean a chaotic uproar (Arie, 2016; Selling, 1940).

The Nineteenth Century: Reform and Moral Treatment

As 1800 approached, the treatment of

people with mental disorders began to

improve once again. Historians usually

point to La Bicêtre, an asylum in Paris for

male patients, as the first site of asylum

reform. In 1793, during the French

Revolution, Philippe Pinel (1745–1826)

was named the chief physician there. He argued that the patients were sick people whose illnesses

should be treated with sympathy and kindness rather than chains and beatings (Sushma &

Tavaragi, 2016; Pelletier & Davidson, 2015). He allowed them to move freely about the hospital

grounds; replaced the dark dungeons with sunny, airy rooms; and offered support and advice.

Pinel’s approach proved remarkably successful. Many patients who had been shut away for

decades improved greatly over a short period of time and were released. Pinel later brought

similar reforms to a mental hospital in Paris for female patients, La Salpetrière.

Meanwhile, an English Quaker named William Tuke (1732–1819) was bringing similar

reforms to northern England. In 1796 he founded the York Retreat, a rural estate where about

30 mental patients lived as guests in quiet country houses and were treated with a combination of

rest, talk, prayer, and manual work (Rollin & Reynolds, 2018; Kibria & Metcalfe, 2016).

The Spread of Moral Treatment The methods of Pinel and Tuke, called moral treatment because they emphasized moral

guidance and humane and respectful techniques, caught on throughout Europe and the United

States. Patients with psychological problems were increasingly perceived as potentially productive

human beings who deserved individual care, including discussions of their problems, useful

activities, work, companionship, and quiet.

moral treatment A nineteenth-century approach to treating people with mental dysfunction that emphasized moral guidance and humane and respectful treatment.

The person most responsible for the early spread of moral treatment in the United States was

Benjamin Rush (1745–1813), an eminent physician at Pennsylvania Hospital who is now

considered the father of American psychiatry. Limiting his practice to mental illness, Rush

developed humane approaches to treatment (Brown, 2018; Hopkins, 2014). For example, he

required that the hospital hire intelligent and sensitive attendants to work closely with patients,

reading and talking to them and taking them on regular walks. He also suggested that it would

be therapeutic for doctors to give small gifts to their patients now and then.

Rush’s work was influential, but it was a Boston school-teacher named Dorothea Dix (1802–

1887) who made humane care a public and political concern in the United States. From 1841 to

1881, Dix went from state legislature to state legislature and to Congress, speaking of the horrors

she had observed at asylums and calling for reform. Dix’s campaign led to new laws and greater

government funding to improve the treatment of people with mental disorders (Stamberg, 2017;

Kazano, 2012). Each state was made responsible for developing effective public mental hospitals,

or state hospitals, all of which were intended to offer moral treatment. Similar hospitals were

established throughout Europe.

state hospitals State-run public mental institutions in the United States.

Dance in a madhouse A popular feature of moral treatment was the “lunatic ball.” Hospital officials would bring patients

together to dance and enjoy themselves. One such ball is shown in this painting, Dance in a Madhouse, by George Bellows.

The Decline of Moral Treatment By the 1850s, a number of mental hospitals throughout Europe and America reported success

using moral approaches. By the end of that century, however, several factors led to a reversal of

the moral treatment movement (Bartlett, 2017; Shepherd, 2016). One factor was the speed with

which the movement had spread. As mental hospitals multiplied, severe money and staffing

shortages developed, recovery rates declined, and overcrowding in the hospitals became a major

problem. Another factor was the assumption behind moral treatment that all patients could be

cured if treated with humanity and dignity. For some, this was indeed sufficient. Others,

however, needed more effective treatments than any that had yet been developed. An additional

factor contributing to the decline of moral treatment was the emergence of a new wave of

prejudice against people with mental disorders. The public came to view them as strange and

dangerous. Moreover, many of the patients entering public mental hospitals in the United States

in the late nineteenth century were poor foreign immigrants, whom the public had little interest

in helping.

By the early years of the twentieth century, the moral treatment movement had ground to a

halt in both the United States and Europe. Public mental hospitals were providing only custodial

care and ineffective medical treatments, and they were becoming more overcrowded every year.

Long-term hospitalization became the rule once again.

The Early Twentieth Century: The Somatogenic and Psychogenic Perspectives As the moral movement was declining in the late 1800s, two opposing perspectives emerged and

began to compete for the attention of clinicians: the somatogenic perspective, the view that

abnormal psychological functioning has physical causes, and the psychogenic perspective, the

view that the chief causes of abnormal functioning are psychological. These perspectives came

into full bloom during the twentieth century.

somatogenic perspective The view that abnormal functioning has physical causes. psychogenic perspective The view that the chief causes of abnormal functioning are psychological.

The Somatogenic Perspective The somatogenic perspective has at least a 2,400-year history—remember Hippocrates’ view that

abnormal behavior resulted from brain disease and an imbalance of humors? Not until the late

nineteenth century, however, did this perspective make a triumphant return and begin to gain

wide acceptance.

Two factors were responsible for this rebirth. One was the work of a distinguished German

researcher, Emil Kraepelin (1856–1926). In 1883, Kraepelin published an influential textbook

arguing that physical factors, such as fatigue, are responsible for mental dysfunction. In addition,

as you will see in Chapter 4, he developed the first modern system for classifying abnormal

behaviors, listing their physical causes and discussing their expected course (Kendler &

Engstrom, 2018; Hoff, 2015).

The more things change … Two patients lie on a table in their cage-like ward at a modern-day mental hospital in Bekasi,

Indonesia, while other patients live with a similar lack of privacy, activity, and sanitation in the wire-walled units behind

them. Despite the passage of Indonesia’s Mental Health Law in 2014, many patients still wind up living under conditions

reminiscent of those that existed in some state hospitals throughout the United States well into the twentieth century.

New biological discoveries also triggered the rise of the somatogenic perspective. One of the

most important discoveries was that an organic disease, syphilis, led to general paresis, an

irreversible disorder with both mental symptoms such as delusions of grandeur and physical ones

like paralysis (Kragh, 2017). In 1897, the German neurologist Richard von Krafft-Ebing (1840–

1902) injected matter from syphilis sores into patients suffering from general paresis and found

that none of the patients developed symptoms of syphilis. Their immunity could have been

caused only by an earlier case of syphilis. Since all of his patients with general paresis were now

immune to syphilis, Krafft-Ebing theorized that syphilis had been the cause of their general

paresis. The work of Kraepelin and the new understanding of general paresis led many

researchers and practitioners to suspect that physical factors were responsible for many mental

disorders, perhaps all of them.

Despite the general optimism, biological approaches yielded mostly disappointing results

throughout the first half of the twentieth century. Although many medical treatments were

developed for patients in mental hospitals during that time, most of the techniques failed to

work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy (alternating hot and cold

baths), and lobotomy, a surgical cutting of certain nerve fibers in the brain. Even worse,

biological views and claims led, in some circles, to proposals for immoral solutions such as

eugenic sterilization, the elimination (through medical or other means) of the ability of

individuals to reproduce (see Table 1-1). Not until the 1950s, when a number of effective

medications were finally discovered, did the somatogenic perspective truly begin to pay off for

patients.

TABLE: 1-1 Eugenics and Mental Disorders Year Event

1896 Connecticut became the first state in the United States to prohibit persons with mental disorders from marrying.

1896−1933 Every state in the United States passed a law prohibiting marriage by persons with mental disorders.

1907 Indiana became the first state to pass a bill calling for people with mental disorders, as well as criminals and other “defectives,” to undergo sterilization.

1927 The U.S. Supreme Court ruled that eugenic sterilization was constitutional.

1907−1945 Approximately 45,000 Americans were sterilized under eugenic sterilization laws; 21,000 of them were patients in state mental hospitals.

1929−1932 Denmark, Norway, Sweden, Finland, and Iceland passed eugenic sterilization laws.

1933 Germany passed a eugenic sterilization law, under which 375,000 people were sterilized by 1940.

1940 Nazi Germany began to use “proper gases” to kill people with mental disorders; 70,000 or more people were killed in less than two years.

Information from: Lombardo, 2017; Stern, 2016; Fischer, 2012; Whitaker, 2002.

The Psychogenic Perspective The late 1800s also saw the emergence of the psychogenic perspective, the view that the chief

causes of abnormal functioning are often psychological. This view, too, had a long history, but it

did not gain much of a following until studies of hypnotism demonstrated its potential.

Hypnotism is a procedure in which a person is placed in a trancelike mental state during

which he or she becomes extremely suggestible. It was used to help treat psychological disorders

as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734–1815)

established a clinic in Paris. His patients suffered from hysterical disorders, mysterious bodily

ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room

filled with music; then he appeared, dressed in a colorful costume, and touched the troubled area

of each patient’s body with a special rod. A surprising number of patients seemed to be helped by

this treatment, called mesmerism (Deeley, 2017; Ellis, 2015). Their pain, numbness, or paralysis

disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients

and that this state was causing their symptoms to disappear. The treatment was so controversial,

however, that eventually Mesmer was banished from Paris.

It was not until years after Mesmer died that many researchers had the courage to investigate

his procedure, later called hypnotism (from hypnos, the Greek word for “sleep”), and its effects on

hysterical disorders. The experiments of two physicians practicing in the city of Nancy in France,

Hippolyte-Marie Bernheim (1840–1919) and Ambroise-Auguste Liébault (1823–1904), showed

that hysterical disorders could actually be induced in otherwise normal people while they were

under the influence of hypnosis. That is, the physicians could make normal people experience

deafness, paralysis, blindness, or numbness by means of hypnotic suggestion—and they could

remove these artificial symptoms by the same means. Thus they established that a mental process

—hypnotic suggestion—could both cause and cure even a physical dysfunction. Leading

scientists concluded that hysterical disorders were largely psychological in origin, and the

psychogenic perspective rose in popularity.

Hypnotism update Hypnotism, the procedure that opened the door for the psychogenic perspective, continues to influence

many areas of modern life, including psychotherapy, entertainment, and law enforcement. Here, a forensic clinician uses

hypnosis to help a witness recall the details of a crime. Recent research has clarified, however, that hypnotic procedures are

as capable of creating false memories as they are of uncovering real memories.

Among those who studied the effects of hypnotism on hysterical disorders was Josef Breuer

#OddName Doctors who treated people with mental disorders in the 18th

century were called “mad-doctors.”

(1842–1925) of Vienna. Breuer, a physician, discovered that his patients sometimes awoke free

of hysterical symptoms after speaking candidly under hypnosis about past upsetting events.

During the 1890s, Breuer was joined in his work by another Viennese physician, Sigmund Freud

(1856–1939). As you will see in Chapter 3, Freud’s work eventually led him to develop the

theory of psychoanalysis, which holds that many forms of abnormal and normal psychological

functioning are psychogenic. In particular, Freud believed that unconscious psychological

processes are at the root of such functioning.

psychoanalysis Either the theory or the treatment of abnormal mental functioning that emphasizes unconscious psychological forces as the cause of psychopathology.

Freud also developed the technique of

psychoanalysis, a form of discussion in

which clinicians help troubled people gain

insight into their unconscious

psychological processes. He believed that

such insight, even without hypnotic procedures, would help the patients overcome their

psychological problems. Freud and his followers offered psychoanalytic treatment to patients in

their offices for sessions of approximately an hour—a format now known as outpatient therapy.

By the early twentieth century, psychoanalytic theory and treatment were widely accepted

throughout the Western world.

SUMMING UP

HOW WAS ABNORMALITY VIEWED AND TREATED IN THE PAST?

The history of psychological disorders stretches back to ancient times. Prehistoric societies apparently viewed

abnormal behavior as the work of evil spirits. There is evidence that Stone Age cultures used trephination to treat

abnormal behavior. People of early societies also sought to drive out evil spirits by exorcism.

Physicians of the Greek and Roman empires offered more enlightened explanations of mental disorders.

Hippocrates believed that abnormal behavior was caused by an imbalance of the four bodily fluids, or humors.

In the Middle Ages, Europeans returned to demonological explanations of abnormal behavior. The clergy was

very influential and held that mental disorders were the work of the devil. As the Middle Ages drew to a close, such

explanations and treatments began to decline, and care of people with mental disorders continued to improve during

the early part of the Renaissance. Certain religious shrines became dedicated to the humane treatment of such

individuals. By the middle of the sixteenth century, however, persons with mental disorders were being warehoused

in asylums.

Care of those with mental disorders started to improve again in the nineteenth century. In Paris, Philippe Pinel

started the movement toward moral treatment. In the United States, Dorothea Dix spearheaded a movement to

ensure legal rights and protection for people with mental disorders and to establish state hospitals for their care.

However, the moral treatment movement disintegrated by the late nineteenth century, and mental hospitals again

became warehouses where inmates received minimal care.

The turn of the twentieth century saw the return of the somatogenic perspective and the rise of the psychogenic

perspective. Sigmund Freud’s psychogenic approach, psychoanalysis, eventually gained wide acceptance and

influenced future generations of clinicians.

Recent Decades and Current Trends It would hardly be accurate to say that we now live in a period of great enlightenment about or

dependable treatment of mental disorders. In fact, surveys have found that 43 percent of

respondents believe that people bring mental disorders on themselves, 31 percent consider such

disorders to be a sign of personal weakness, and 35 percent believe the disorders are caused by

sinful behavior (Roper, 2017; NMHA, 1999). Nevertheless, there have been major changes over

the past 60 years in the ways clinicians understand and treat abnormal functioning. There are

more theories and types of treatment, more research studies, more information, and—perhaps

because of those increases—more disagreements about abnormal functioning today than at any

time in the past.

From Juilliard to the streets Nathaniel Ayers, subject of the book and movie The Soloist, plays his violin on the streets of

Los Angeles while living as a homeless person in 2005. Once a promising musical student at the Juilliard School in New

York, Ayers developed schizophrenia and eventually found himself without treatment and without a home. Tens of

thousands of people with severe mental disorders are currently homeless.

How Are People with Severe Disturbances Cared For? In the 1950s, researchers discovered a number of new psychotropic medications—drugs that

primarily affect the brain and reduce many symptoms of mental dysfunction. They included the

first antipsychotic drugs, which correct extremely confused and distorted thinking; antidepressant

drugs, which lift the mood of depressed people; and antianxiety drugs, which reduce tension and

worry.

psychotropic medications Drugs that mainly affect the brain and reduce many symptoms of mental dysfunction.

When given these drugs, many patients who had spent years in mental hospitals began to

show signs of improvement. Hospital administrators, encouraged by these results and pressured

by a growing public outcry over the terrible conditions in public mental hospitals, began to

discharge patients almost immediately.

Since the discovery of these medications, mental health professionals in most of the developed

nations of the world have followed a policy of deinstitutionalization, releasing hundreds of

thousands of patients from public mental hospitals. On any given day in 1955, close to 600,000

people were confined in public mental institutions across the United States (see Figure 1-1).

Today the daily patient population in the same kinds of hospitals is around 42,000 (Amadeo,

2017; Smith & Milazzo-Sayre, 2014). In addition, some 58,000 people receive treatment in

private psychiatric hospitals, care that is paid for by the patients themselves and/or their insurance

companies. On average, the private facilities offer more pleasant surroundings and more favorable

staff−patient ratios than the public ones.

deinstitutionalization The practice, begun in the 1960s, of releasing hundreds of thousands of patients from public mental hospitals.

FIGURE 1-1

The Impact of Deinstitutionalization

The number of patients (around 42,000) now hospitalized in public mental hospitals in the United States is a small fraction

of the number hospitalized in 1955. (Information from: Amadeo, 2017; Smith & Milazzo-Sayre, 2014; Torrey, 2001; Lang,

1999.)

Without question, outpatient care has now become the primary mode of treatment for people

with severe psychological disturbances as well as for those with more moderate problems. When

severely disturbed people do need institutionalization these days, they are usually hospitalized for

a short period of time. Ideally, they are then provided with outpatient psychotherapy and

medication in community programs and residences (Stein et al., 2015).

Chapters 2 and 12 will look more closely at this current emphasis on community care for

people with severe psychological disturbances—a philosophy called the community mental health

approach. The approach has been helpful for many patients, but too few community programs

are available to address current needs in the United States (NIMH, 2017; Dixon & Schwarz,

2014). As a result, hundreds of thousands of persons with severe disturbances fail to make lasting

recoveries, and they shuttle back and forth between the mental hospital and the community.

After release from the hospital, they at best receive minimal care and often wind up living in

decrepit rooming houses or on the streets. Around 140,000 people with such disturbances are

homeless on any given day; another 440,000 are inmates of jails and prisons (Allison et al., 2017;

NAMI, 2016). Their abandonment is truly a national disgrace.

How Are People with Less Severe Disturbances Treated? The treatment picture for people with moderate psychological disturbances has been more

positive than that for people with severe disorders. Since the 1950s, outpatient care has

continued to be the preferred mode of treatment for them, and the number and types of facilities

that offer such care have expanded to meet the need.

Before the 1950s, almost all outpatient care took the form of private psychotherapy, in

which individuals meet with a self-employed therapist for counseling services. Since the 1950s,

most health insurance plans have expanded coverage to include private psychotherapy, so that it

is now also widely available to people of all incomes. Today, outpatient therapy is also offered in

a number of less expensive settings, such as community mental health centers, crisis intervention

centers, family service centers, and other social service agencies. Surveys suggest that around 60

percent of people with psychological disorders in the United States receive treatment in the

course of a year (APA, 2016).

private psychotherapy An arrangement in which a person directly pays a therapist for counseling services.

Outpatient treatments are also becoming available for more and more kinds of problems.

When Freud and his colleagues first began to practice, most of their patients suffered from

anxiety or depression. Almost half of today’s clients suffer from those same problems, but people

with other kinds of disorders are also receiving therapy. In addition, at least 20 percent of clients

enter therapy because of milder problems in living—problems with marital, family, job, peer,

school, or community relationships (Ten Have et al., 2013).

Yet another change in outpatient care since the 1950s has been the development of programs

devoted exclusively to specific psychological problems. We now have, for example, suicide

prevention centers, substance abuse programs, eating disorder programs, phobia clinics, and

sexual dysfunction programs. Clinicians in these programs have the kind of expertise that can be

acquired only by concentration in a single area.

Why do you think it has taken psychologists so long to start

studying positive behaviors?

A Growing Emphasis on Preventing Disorders and Promoting Mental Health Although the community mental health approach has often failed to address the needs of people

with severe disorders, it has given rise to an important principle of mental health care

—prevention (Mendelson & Eaton, 2018). Rather than wait for psychological disorders to

occur, many of today’s community programs try to correct the social conditions that underlie

psychological problems (poverty or violence in the community, for example) and to help

individuals who are at risk for developing emotional problems (for example, teenage mothers or

the children of people with severe psychological disorders). As you will see later, community

prevention programs are not always successful, but they have grown in number, offering great

promise as the ultimate form of intervention.

prevention Interventions aimed at deterring mental disorders before they can develop.

Positive psychology in action Often, positive psychology and multicultural psychology work together. Here, for example,

two young girls come together as one at the end of a “slave reconciliation” walk by 400 people in Maryland. The walk was

intended to promote racial understanding and to help Americans overcome the lasting psychological effects of slavery.

Prevention programs have been further

energized in the past few decades by the

field of psychology’s ever-growing interest

in positive psychology (Yaden,

Eichstaedt, & Medaglia, 2018; Seligman & Fowler, 2011). Positive psychology is the study and

promotion of positive feelings such as optimism and happiness, positive traits like hard work and

wisdom, and group-directed virtues, including altruism and tolerance (see InfoCentral).

positive psychology The study and enhancement of positive feelings, traits, and abilities.

While researchers study and learn more about positive psychology in the laboratory, clinical

practitioners with this orientation are teaching people coping skills that may help to protect them

from stress and adversity and encouraging them to become more involved in personally

meaningful activities and relationships—thus helping to prevent mental disorders (Sergeant &

Mongrain, 2014).

INFOCENTRAL

HAPPINESS

Positive psychology is the study of positive feelings, traits, and abilities. A better understanding

of constructive functioning enables clinicians to better promote psychological wellness.

Happiness is the positive psychology topic currently receiving the most attention. Many, but far

from all, people are happy. In fact, only one-third of adults declare themselves “very happy.”

Let’s take a look at some of today’s leading facts, figures, and notions about happiness.

Multicultural Psychology We are, without question, a society of multiple cultures, races, and languages. Members of racial

and ethnic minority groups in the United States collectively make up 39 percent of the

population, a percentage that is expected to grow to more than 50 percent by the year 2044

(KFF, 2016; U.S. Census Bureau, 2015). This change is due in part to shifts in immigration

trends and also to higher birth rates among minority groups in the United States (NVSR, 2016,

2010).

In response to this growing diversity, an area of study called multicultural psychology has

emerged. Multicultural psychologists seek to understand how culture, race, ethnicity, gender, and

similar factors affect behavior and thought and how people of different cultures, races, and

genders may differ psychologically (Alegría et al., 2018, 2016, 2013, 2010). As you will see

throughout this book, the field of multicultural psychology has begun to have a powerful effect

on our understanding and treatment of abnormal behavior.

multicultural psychology The field that examines the impact of culture, race, ethnicity, and gender on behaviors and thoughts, and focuses on how such factors may influence the origin, nature, and treatment of abnormal behavior.

Preventing an even worse outcome Children attend activities at this psychological support and education center in

Damascus, Syria, in 2016. The center was set up, on the advice of mental health, medical, and education advisers, to help

prevent or at least minimize the psychological and physical problems being experienced by millions of Syrian children

caught up in the ongoing horrors of the country’s civil war.

The Increasing Influence of Insurance Coverage So many people now seek mental health services that insurance programs have changed their

coverage for these patients in recent decades (Iglehart, 2016). The dominant form of insurance

#FilmPsych

“My philosophy is if you worry, you suffer twice.” (Fantastic Beasts and Where to Find Them, 2016)

now consists of managed care programs—programs in which the insurance company determines

such key issues as which therapists its clients may choose, the cost of sessions, and the number of

sessions for which a client may be reimbursed (Xiang et al., 2018; Bowers, Owen, & Heller,

2016).

managed care program Health care coverage in which the insurance company largely controls the nature, scope, and cost of medical or psychological services.

Managed care coverage for mental health treatment follows the same basic principles as

coverage for medical treatment, including a limited pool of practitioners from which patients can

choose, preapproval of treatment by the insurance company, strict standards for judging whether

problems and treatments qualify for reimbursement, and ongoing reviews. In the mental health

realm, both therapists and clients typically dislike managed care programs (Decker, 2016). They

fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments

whose results are not always lasting (for example, drug therapy), pose a special hardship for those

with severe mental disorders, and result in treatments determined by insurance companies rather

than by therapists (Bowers et al., 2016).

A key problem with insurance coverage—both managed care and other kinds of insurance

programs—is that reimbursements for mental disorders tend to be lower than those for physical

disorders. This places persons with psychological difficulties at a distinct disadvantage (McGuire,

2016). Thus, in 2008, the U.S. Congress passed a federal parity law that directed insurance

companies to provide equal coverage for mental and physical problems, and in 2014 the mental

health provisions of the Affordable Care Act (the ACA)—referred to colloquially as

“Obamacare”—went into effect and extended the reach of the earlier law. The ACA designated

mental health care as 1 of 10 types of “essential health benefits” that must be provided by all

insurers. The changes in federal leadership brought about by the election of 2016 have led to

some changes in the ACA and may eventually result in its repeal. Currently, it is not clear how

such changes will affect the decade-long efforts to achieve mental health insurance parity.

What Are Today’s Leading Theories and Professions? One of the most important developments

in the clinical field has been the growth of

numerous theoretical perspectives that

“I suffer from short-term memory loss.” (Finding Dory, 2016)

“Fear of death is illogical.” (Star Trek Beyond, 2016)

“She wore the gloves all the time, so I just thought, maybe she has a thing about dirt.” (Frozen, 2013)

“I just want to be perfect.” (Black Swan, 2010)

“Take baby steps.” (What About Bob?, 1991)

“I love the smell of napalm in the morning.” (Apocalypse Now, 1979)

“Snakes. Why’d it have to be snakes?” (Raiders of the Lost Ark, 1981)

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

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

now coexist in the field. Before the 1950s,

the psychoanalytic perspective, with its

emphasis on unconscious psychological

problems as the cause of abnormal

behavior, was dominant. Since then,

additional influential perspectives have

emerged, particularly the biological,

cognitive-behavioral, humanistic-existential,

sociocultural, and developmental

psychopathology schools of thought. At

present, no single viewpoint dominates

the clinical field as the psychoanalytic

perspective once did. In fact, the

perspectives often conflict and compete

with one another.

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

Before the 1950s, psychotherapy was offered only by psychiatrists, physicians who complete three

to four additional years of training after medical school (a residency) in the treatment of abnormal

mental functioning. After World War II, however, with millions of soldiers returning home to

countries throughout North America and Europe, the demand for mental health services

expanded so rapidly that other professional groups had to step in to fill the need.

Among those other groups are clinical psychologists—professionals who earn a doctorate in

clinical psychology by completing four to five years of graduate training in abnormal functioning

and its treatment as well as a one-year internship in a mental health setting. Psychotherapy and

related services are also provided by counseling psychologists, educational and school psychologists,

psychiatric nurses, marriage therapists, family therapists, and—the largest group—clinical social

workers (see Table 1-2). Each of these specialties has its own graduate training program.

Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the

various specialties often use similar techniques.

TABLE: 1-2 Profiles of Mental Health Professionals in the United States Degree Began to

Practice Current Number

Average Annual Salary

Percent Female

Psychiatrists MD, DO 1840s 49,000 $194,000 35%

Psychologists PhD, PsyD, Late 1940s 188,000 $73,000 67%

EdD

Social workers

MSW, DSW Early 1950s 649,000 $46,000 84%

Counselors Various Early 1950s 570,000 $45,000 71%

Information from: BLS, 2017, 2016; DPE, 2016; Salary.com, 2016; APA, 2015; Block, 2015; Pallardy, 2015.

A related development in the study and treatment of mental disorders since World War II has

been the growth of effective research. Clinical researchers have tried to determine which concepts

best explain and predict abnormal behavior, which treatments are most effective, and what kinds

of changes in clinical theory or practice may be required. Well-trained clinical researchers

conduct studies in universities, medical schools, laboratories, mental hospitals, mental health

centers, and other clinical settings throughout the world. Their work has produced important

discoveries and has changed many of our ideas about abnormal psychological functioning.

Technology and Mental Health The breathtaking rate of technological change that characterizes today’s world has begun to have

significant effects—both positive and negative—on the mental health field, and it will

undoubtedly affect the field even more in the coming years.

Our digital world provides new triggers for abnormal behavior (Turkle, 2017, 2015; Cottle,

2016). As you’ll see in Chapter 10, for example, many individuals who grapple with gambling

disorder have found the ready availability of Internet gambling to be all too inviting. Similarly,

the Internet, texting, and social media have become convenient tools for those who wish to stalk

or bully others, express sexual exhibitionism, or pursue pedophilic desires. Likewise, some

clinicians believe that violent video games may contribute to the development of antisocial

behavior. And, in the opinion of many clinicians, constant texting, tweeting, and Internet

browsing may become an addictive behavior or may help lead to shorter attention spans.

“Looks like another case of someone over forty trying to understand Snapchat.”

A number of clinicians also worry that social networking can contribute to psychological

dysfunction in certain cases. On the positive side, research indicates that, on average, social media

users are particularly likely to maintain close relationships, receive social support, be trusting, and

lead active lives (Hu et al., 2017; ACOG, 2016). But, on the negative side, there is research

suggesting that social networking sites may increase peer pressure and social anxiety in some

adolescents (Hanna et al., 2017; Houston, 2016). The sites may, for example, cause some people

to develop fears that others in their network will exclude them socially. Similarly, such sites may

facilitate shy or socially anxious people’s withdrawal from valuable face-to-face relationships.

In addition, the face of clinical treatment is constantly changing in our fast-moving digital

world. For example, telemental health, the use of various technologies to deliver mental health

services without the therapist being physically present, is growing by leaps and bounds

(Carpenter et al., 2018; Comer et al., 2017). As you’ll see in Chapter 2, telemental health takes

such forms as long-distance therapy between clients and therapists using videoconferencing,

therapy offered by computer programs, and Internet-based support groups. And literally

#GenderShift

28% Percentage of psychologists in 1978 who were female

74% Percentage of current psychology graduate students who are female

(NCES, 2016; APA, 2015, 2014; Cynkar, 2007)

thousands of smartphone apps are devoted to relaxing people, cheering them up, giving them

feel-good advice, helping them track their shifting moods and thoughts, or otherwise improving

their psychological states.

telemental health The use of digital technologies to deliver mental health services without the therapist being physically present.

Similarly, countless Web sites offer

mental health information.

Unfortunately, along with this wealth of

online information comes an enormous

amount of misinformation about

psychological problems and their

treatments, offered by persons and sites

that are far from knowledgeable. And there are numerous antitreatment Web sites that try to

guide people away from seeking help for their psychological problems. In later chapters, for

example, you will read about pro-anorexia and pro-suicide Web sites and their dangerous

influences. Clearly, the impact of technological change presents difficult challenges for clinicians

and researchers alike.

SUMMING UP

RECENT DECADES AND CURRENT TRENDS In the 1950s, researchers discovered a number of new psychotropic medications. Their success contributed to a policy

of deinstitutionalization, under which hundreds of thousands of patients were released from public mental hospitals.

In addition, outpatient treatment has become the primary approach for most people with mental disorders, both mild

and severe; prevention programs are growing in number and influence; the field of multicultural psychology has

begun to influence how clinicians view and treat abnormality; and insurance coverage is having a significant impact

on the way treatment is conducted.

It is also the case that a variety of perspectives and professionals have come to operate in the field of abnormal

psychology, and many well-trained clinical researchers now investigate the field’s theories and treatments. And finally,

the remarkable technological advances of recent times have also affected the mental health field.

What Do Clinical Researchers Do? Research is the key to accuracy in all fields of study; it is particularly important in abnormal

psychology because a wrong belief in this field can lead to great suffering. At the same time,

clinical researchers, also called clinical scientists, face certain challenges that make their work very

difficult. They must, for example, figure out how to measure such elusive concepts as private

thoughts, mood changes, and human potential. They must consider the different cultural

backgrounds, races, and genders of the people they choose to study. And they must always ensure

that the rights of their research participants, both human and animal, are not violated. Let us

examine the leading methods used by today’s researchers.

Clinical researchers try to discover broad laws, or principles, of abnormal psychological

functioning. They search for a general, or nomothetic, understanding of the nature, causes, and

treatments of abnormality. To gain such broad insights, clinical researchers, like scientists in

other fields, use the scientific method—that is, they collect and evaluate information through

careful observations. These observations in turn enable them to pinpoint and explain

relationships between variables.

scientific method The process of systematically gathering and evaluating information, through careful observations, to understand a phenomenon.

Simply stated, a variable is any characteristic or event that can vary, whether from time to

time, from place to place, or from person to person. Age, sex, and race are human variables. So

are eye color, occupation, and social status. Clinical researchers are interested in variables such as

childhood upsets, present life experiences, moods, social functioning, and responses to treatment.

They try to determine whether two or more such variables change together and whether a change

in one variable causes a change in another. Will the death of a parent cause a child to become

depressed? If so, will a given treatment reduce that depression?

Such questions cannot be answered by logic alone because scientists, like all human beings,

frequently make errors in thinking. Thus, clinical researchers must depend mainly on three

methods of investigation: the case study, which typically is focused on one individual, and the

correlational method and experimental method, approaches that are usually used to gather

information about many individuals. Each is best suited to certain kinds of circumstances and

questions. Together, these methods enable scientists to form and test hypotheses, or hunches,

that certain variables are related in certain ways—and to draw broad conclusions as to why. More

properly, a hypothesis is a tentative explanation offered to provide a basis for an investigation.

hypothesis

A hunch or prediction that certain variables are related in certain ways.

The Case Study A case study is a detailed description of a person’s life and psychological problems. It describes

the person’s history, present circumstances, and symptoms. It may also include speculation about

why the problems developed, and it may describe the person’s treatment (Tight, 2017). As you

will see in Chapter 5, one of the field’s best-known case studies, called The Three Faces of Eve,

describes a woman with three alternating personalities, each having a distinct set of memories,

preferences, and personal habits (Thigpen & Cleckley, 1957).

case study A detailed account of a person’s life and psychological problems.

The Genains One of the most celebrated case studies in abnormal psychology is a study of identical quadruplets dubbed the

“Genain” sisters by researchers (after the Greek term for “dire birth”). All of the sisters developed schizophrenia in their

twenties.

Most clinicians take notes and keep records in the course of treating their patients, and some

further organize such notes into a formal case study to be shared with other professionals. The

clues offered by a case study may help a clinician better understand or treat the person under

discussion. In addition, case studies may play nomothetic roles that go far beyond the individual

clinical case.

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How Are Case Studies Helpful? Case studies are useful to researchers in many ways (Gerring, 2017; Tight, 2017). They can, for

example, be a source of new ideas about behavior and “open the way for discoveries” (Bolgar,

1965). Sigmund Freud’s theory of psychoanalysis was based mainly on the patients he saw in

private practice. In addition, a case study may offer tentative support for a theory. Freud used case

studies in this way as well, regarding them as evidence for the accuracy of his ideas. Conversely,

case studies may serve to challenge a theory’s assumptions.

“I’m a social scientist, Michael. That means I can’t explain electricity or anything like that, but if you ever want to know about

people I’m your man.”

Case studies may also show the value of new therapeutic techniques. And finally, case studies

may offer opportunities to study unusual problems that do not occur often enough to permit a

large number of observations. Investigators of disorders such as dissociative identity disorder, the

multiple personality pattern on display in The Three Faces of Eve, once relied entirely on case

studies for information.

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Why do case studies and other anecdotal offerings influence

people so much, often more than systematic research does?

What Are the Limitations of Case Studies?

Case studies also have limitations

(Gerring, 2017; Tight, 2017). First, they

are reported by biased observers, that is, by

therapists who have a personal stake in

seeing their treatments succeed. These therapists must choose what to include in a case study,

and their choices may at times be self-serving. Second, case studies rely on subjective evidence. Is a

client’s problem really caused by the events that the therapist or client says are responsible? After

all, those are only a fraction of the events that may be contributing to the situation. Finally, case

studies provide little basis for generalization. Even if we agree that Little Hans developed a dread

of horses because he was terrified of castration and feared his father, how can we be confident

that other people’s phobias are rooted in the same kinds of causes? Events or treatments that

seem important in one case may be of no help at all in efforts to understand or treat others.

The limitations of the case study are largely addressed by two other methods of investigation:

the correlational method and the experimental method. These methods do not offer the rich detail

that makes case studies so interesting, but they do help investigators draw broad conclusions

about abnormality in the population at large. Thus most clinical investigators prefer these

methods over the case study.

Three features of the correlational and experimental methods enable clinical investigators to

gain general, or nomothetic, insights: (1) The researchers typically observe many individuals. (2)

The researchers apply procedures uniformly and can thus repeat, or replicate, their investigations.

(3) The researchers use statistical tests to analyze the results of their studies and determine whether

broad conclusions are justified.

The Correlational Method Correlation is the degree to which events or characteristics vary with each other. The

correlational method is a research procedure used to determine this “co-relationship” between

variables (Salkind, 2017). This method can be used, for example, to answer the question, “Is

there a correlation between the amount of stress in people’s lives and the degree of depression

they experience?” That is, as people keep experiencing stressful events, are they increasingly likely

to become depressed?

correlation The degree to which events or characteristics vary along with each other.

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correlational method A research procedure used to determine how much events or characteristics vary along with each other.

To test this question, researchers have collected life stress scores (for example, the number of

threatening events experienced during a certain period of time) and depression scores (for

example, scores on a depression survey) from individuals and have correlated these scores. The

people who are chosen for a study are its subjects, or participants, the term preferred by today’s

investigators. Typically, investigators have found that life stress and depression variables do

indeed increase or decrease together (Yang et al., 2017; Hammen, 2016). That is, the greater

someone’s life stress score, the higher his or her score on the depression scale. When variables

change the same way, their correlation is said to have a positive direction and is referred to as a

positive correlation. Alternatively, correlations can have a negative rather than a positive direction.

In a negative correlation, the value of one variable increases as the value of the other variable

decreases. Researchers have found, for example, a negative correlation between depression and

activity level. The greater one’s depression, the lower the number of one’s activities.

Stress and depression At a 2016 prayer service in Flint, Michigan, a woman holds a sign that conveys the desperate

predicament faced by her and thousands of other victims in the wake of the city’s water contamination crisis. Studies find

that the stress produced by this and similar community catastrophes has been accompanied by depression and other

psychological symptoms in many residents (Goodnough & Atkinson, 2016).

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#WEIRDParticipants Nearly 70 percent of psychology studies use college students as

participants. These participants are often described by the

acronym WEIRD, because they are overwhelmingly from

societies that are Western, Educated, Industrialized, Rich, and

Democratic (Robson, 2017; Henrich et al., 2010).

There is yet a third possible outcome for a correlational study. The variables under study may

be unrelated, meaning that there is no consistent relationship between them. As the measures of

one variable increase, those of the other variable sometimes increase and sometimes decrease.

Studies have found that depression and intelligence are unrelated, for example.

In addition to knowing the direction of a correlation, researchers need to know its magnitude,

or strength. That is, how closely do the two variables correspond? Does one always vary along

with the other, or is their relationship less exact? When two variables are found to vary together

very closely in person after person, the correlation is said to be high, or strong.

The direction and magnitude of a correlation are often calculated numerically and expressed

by a statistical term called the correlation coefficient. The correlation coefficient can vary from

+1.00, which indicates a perfect positive correlation between two variables, down to −1.00,

which represents a perfect negative correlation. The sign of the coefficient (+ or −) signifies the

direction of the correlation; the number represents its magnitude. The closer the correlation is to

.00, the weaker, or lower in magnitude, it is. Thus correlations of +.75 and −.75 are of equal

magnitude and equally strong, whereas a correlation of +.25 is weaker than either.

Everyone’s behavior is changeable, and

many human responses can be measured

only approximately. Most correlations

found in psychological research, therefore,

fall short of perfect positive or negative

correlation. For example, studies of life

stress and depression have found

correlations as high as +.53 (Krishnan, 2017; Miller et al., 1976). Although hardly perfect, a

correlation of this magnitude is considered large in psychological research.

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Twins, correlation, and inheritance These healthy twin sisters are participating in a twin cultural festival at Honglingjin

Park in Beijing, China. Correlational studies of many pairs of twins have suggested a link between genetic factors and

certain psychological disorders. Identical twins (who have identical genes) display a higher correlation for some disorders

than do fraternal twins (whose genetic makeup is not identical).

When Can Correlations Be Trusted? Scientists must decide whether the correlation they find in a given sample of participants

accurately reflects a real correlation in the general population. Could the observed correlation

have occurred by mere chance? They can test their conclusions with a statistical analysis of their

data, using principles of probability (Salkind, 2017). In essence, they ask how likely it is that the

study’s particular findings have occurred by chance. If the statistical analysis indicates that chance

is unlikely to account for the correlation they found, researchers may conclude that their findings

reflect a real correlation in the general population.

What Are the Merits of the Correlational Method? The correlational method has certain advantages over the case study (see Table 1-3). Because

researchers measure their variables, observe many participants, and apply statistical analyses, they

are in a better position to generalize their correlations to people beyond the ones they have

studied. Furthermore, researchers can easily repeat correlational studies using new samples of

participants to check the results of earlier studies.

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Can you think of other correlations in life that are

interpreted mistakenly as causal?

TABLE: 1-3 Relative Strengths and Weaknesses of Research Methods Provides Individual Information

Provides General Information

Provides Causal Information

Statistical Analysis Possible

Replicable

Case study Yes No No No No

Correlational method

No Yes No Yes Yes

Experimental method

No Yes Yes Yes Yes

Although correlations allow researchers

to describe the relationship between two

variables, they do not explain the

relationship. When we look at the positive

correlation found in many life stress studies, we may be tempted to conclude that increases in

recent life stress cause people to feel more depressed. In fact, however, the two variables may be

correlated for any one of three reasons: (1) Life stress may cause depression. (2) Depression may

cause people to experience more life stress (for example, a depressive approach to life may cause

people to perform poorly at work or may interfere with social relationships). (3) Depression and

life stress may each be caused by a third variable, such as financial problems (Yazdi et al., 2018;

Gutman & Nemeroff, 2011).

Although correlations say nothing about causation, they can still be of great use to clinicians.

Clinicians know, for example, that suicide attempts increase as people become more depressed.

Thus, when they work with severely depressed clients, they stay on the lookout for signs of

suicidal thinking. Perhaps depression directly causes suicidal behavior, or perhaps a third variable,

such as a sense of hopelessness, causes both depression and suicidal thoughts. Whatever the cause,

just knowing that there is a correlation may enable clinicians to take certain measures (such as

hospitalization) to help save lives.

Of course, in other instances, clinicians do need to know whether one variable causes another.

Do parents’ marital conflicts cause their children to be more anxious? Does job dissatisfaction

lead to feelings of depression? Will a given treatment help people to cope more effectively in life?

Questions about causality call for the experimental method.

The Experimental Method An experiment is a research procedure in which a variable is manipulated and the manipulation’s

effect on another variable is observed (Leavy, 2017). The manipulated variable is called the

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independent variable and the variable being observed is called the dependent variable.

experiment A research procedure in which a variable is manipulated and the effect of the manipulation on another variable is observed. independent variable The variable in an experiment that is manipulated to determine whether it has an effect on another variable. dependent variable The variable in an experiment that is expected to change as the independent variable is manipulated.

To examine the experimental method more fully, let’s consider a question that is often asked

by clinicians (Priday et al., 2017): “Does a particular therapy relieve the symptoms of a particular

disorder?” Because this question is about a causal relationship, it can be answered only by an

experiment. That is, experimenters must give the therapy in question to people who are suffering

from a disorder and then observe whether they improve. Here the therapy is the independent

variable, and psychological improvement is the dependent variable.

As with correlational studies, investigators who conduct experiments must do a statistical

analysis on their data and find out how likely it is that the observed improvement is due to

chance (Salkind, 2017). Again, if that likelihood is very low, the improvement is considered to be

statistically significant, and the experimenter may conclude with some confidence that it is due to

the independent variable.

If the true cause of changes in the dependent variable cannot be separated from other possible

causes, then an experiment gives very little information. Thus, experimenters must try to

eliminate all confounds from their studies—variables other than the independent variable that

may also be affecting the dependent variable. When there are confounds in an experiment, they,

rather than the independent variable, may be causing the observed change.

confound In an experiment, a variable other than the independent variable that is also acting on the dependent variable.

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Is animal companionship an effective intervention? A ring-tailed lemur sits on the shoulder of an individual at Serengeti

Park near Hodenhagen, Germany. It’s part of a monthly program called “Psychiatric Animal Days” based on the premise

that animals—even lemurs—have a calming effect on people. More than 400 kinds of intervention are currently used for

psychological problems. An experimental design is needed to determine whether this or any other form of treatment causes

clients to improve.

For example, situational variables, such as the location of the therapy office (say, a quiet

country setting, as opposed to a busy city street) or soothing background music in the office, may

have a therapeutic effect on participants in a therapy study. Or perhaps the participants are

unusually motivated or have high expectations that the therapy will work, factors that thus

account for their improvement. To guard against confounds, researchers should include three

important features in their experiments—a control group, random assignment, and a masked design

(Comer & Bry, 2018).

The Control Group A control group is a group of research participants who are not exposed to the independent

variable under investigation but whose experience is similar to that of the experimental group,

the participants who are exposed to the independent variable. By comparing the two groups, an

experimenter can better determine the effect of the independent variable.

control group In an experiment, a group of participants who are not exposed to the independent variable.

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Why might sugar pills or other kinds of placebo treatments

help some people feel better?

To study the effectiveness of a particular therapy, for example, experimenters typically divide

participants into two groups. The experimental group may come into an office and receive the

therapy for an hour, while the control group may simply come into the office for an hour. If the

experimenters find later that the people in the experimental group improve more than the people

in the control group, they may conclude that the therapy was effective, above and beyond the

effects of time, the office setting, and any other confounds. To guard against confounds,

experimenters try to provide all participants, both control and experimental, with experiences

that are identical in every way—except for the independent variable.

experimental group In an experiment, the participants who are exposed to the independent variable under investigation.

Random Assignment Researchers must also watch out for differences in the makeup of the experimental and control

groups since those differences may also confound a study’s results. In a therapy study, for

example, the experimenter may unintentionally put wealthier participants in the experimental

group and poorer ones in the control group. This difference, rather than their therapy, may be

the cause of the greater improvement later found among the experimental participants. To

reduce the effects of preexisting differences, experimenters typically use random assignment.

This is the general term for any selection procedure that ensures that every participant in the

experiment is as likely to be placed in one group as the other (Comer & Bry, 2018). Researchers

might, for example, assign people to groups by flipping a coin or picking names out of a hat.

random assignment A selection procedure that ensures that participants are randomly placed either in the control group or in the experimental group.

Masked Design A final confound problem is bias. Participants may bias an experiment’s results by trying to please

or help the experimenter. In a therapy experiment, for example, if those participants who receive

the treatment know the purpose of the study and which group they are in, they might actually

work harder to feel better or fulfill the experimenter’s expectations. If so, subject, or participant,

bias rather than therapy could be causing their improvement.

To avoid this bias, experimenters can

prevent participants from finding out

which group they are in. This

experimental strategy is called a masked

design (previously termed a blind design) because the individuals are kept unaware of their

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assigned group. In a therapy study, for example, control participants could be given a placebo

(Latin for “I shall please”), something that looks or tastes like real therapy but has none of its key

ingredients. This “imitation” therapy is called placebo therapy. If the experimental (true therapy)

participants improve more than the control (placebo therapy) participants, experimenters have

more confidence that the true therapy has caused their improvement.

masked design An experiment in which participants do not know whether they are in the experimental or the control condition. Previously called a blind design.

An experiment may also be confounded by experimenter bias—that is, experimenters may have

expectations that they unintentionally transmit to the participants in their studies. In a drug

therapy study, for example, the experimenter might smile and act confident while providing real

medications to the experimental participants but frown and appear hesitant while offering

placebo drugs to the control participants. This kind of bias is sometimes referred to as the

Rosenthal effect, after the psychologist who first identified it (Rosenthal, 1966). Experimenters can

eliminate their own bias by arranging to be unaware themselves. In a drug therapy study, for

example, an aide could make sure that the real medication and the placebo drug look identical.

The experimenter could then administer treatment without knowing which participants were

receiving true medications and which were receiving false medications. While either the

participants or the experimenter may be kept unaware in an experiment, it is best that both be

unaware—a research strategy called a double-masked design. In fact, most medication experiments

now use double-masked designs to test promising drugs (Kim et al., 2017).

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#EthicallyChallenged Symptom-Exacerbation Studies In some studies, patients are

Flawed studies, gigantic impact Outside a court hearing in Beijing on conversion, or reparative, therapy, an LGBTQ activist

protests by pretending to inject a patient with a giant syringe. Conversion therapy, a now widely discredited psychological

treatment to help gay persons change their sexual orientation, was positively received in a number of clinical circles after its

development in the late 1990s. However, in 2012, Robert Spitzer, one of the world’s most respected psychiatric researchers,

offered a public apology to the gay community, saying that his and other influential research studies that had seemed to

support the effectiveness of conversion therapy were fatally flawed and morally wrong.

Alternative Research Designs Clinical scientists must often settle for research designs that are less than ideal. These alternative

designs are often called quasi-experimental designs, or mixed designs—designs that fail to

include key elements of a “pure” experiment or intermix elements of both experimental and

correlational studies (Leavy, 2017; Salkind, 2017). Such variations include the matched design,

natural experiment, analogue experiment, single-subject experiment, longitudinal study, and

epidemiological study.

quasi-experimental design A research design that fails to include key elements of a “pure” experiment and/or intermixes elements of both experimental and correlational studies. Also called a mixed design.

In matched designs, investigators do

not randomly assign participants to

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given drugs to intensify their symptoms so that researchers may

learn more about the biology of their disorder.

Medication-Withdrawal Studies In some studies, researchers

prematurely stop medications for patients who have been

symptom-free for a while, hoping to learn more about when

patients can be taken off particular medications.

control and experimental groups, but

instead make use of groups that already

exist in the world at large. Consider, for

example, research into the effects of child

abuse. Because it would be unethical for

investigators of this issue to actually abuse

a randomly chosen group of children,

they must instead compare children who already have a history of abuse with children who do

not. To make this comparison as valid as possible, the researchers match the experimental

participants (abused children) with control participants (non-abused children) who are similar in

age, sex, race, number of children in the family, type of neighborhood, or other characteristics

(Jacobsen, 2016). When the data from studies using this kind of design show that abused

children are typically sadder and have lower self-esteem than matched control participants who

have not been abused, the investigators can conclude with some confidence that abuse is causing

the differences (Greger et al., 2016; Jaschek et al., 2016).

matched design A research design that matches the experimental participants with control participants who are similar on key characteristics.

In natural experiments, nature itself manipulates the independent variable, while the

experimenter observes the effects. Natural experiments must be used for studying the

psychological effects of unusual and unpredictable events, such as floods, earthquakes, plane

crashes, and fires. Because the participants in these studies are selected by an accident of fate

rather than by the investigators’ design, natural experiments are in fact quasi-experiments.

natural experiment An experiment in which nature, rather than an experimenter, manipulates an independent variable.

On December 26, 2004, an earthquake occurred beneath the Indian Ocean off the coast of

Sumatra, Indonesia. The earthquake triggered a series of massive tsunamis that flooded the

ocean’s coastal communities, killed more than 225,000 people, injured over half a million, and

left millions of survivors homeless, particularly in Indonesia, Sri Lanka, India, and Thailand.

Within months of this disaster, researchers conducted natural experiments in which they

collected data from hundreds of survivors and from control groups of people who lived in areas

not directly affected by the tsunamis. The disaster survivors scored significantly higher on anxiety

and depression measures (dependent variables) than the controls did. The survivors also

experienced more sleep problems, feelings of detachment, arousal, difficulties concentrating,

startle responses, and guilt feelings than the controls did (Adeback et al., 2018; Hussain et al.,

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2016). Over the past several years, other natural experiments have focused on survivors of the

2010 Haitian earthquake, Japan’s massive earthquake in 2011, and the Northeast’s Superstorm

Sandy in 2012, as well as the devastating hurricanes in Houston, Florida, and Puerto Rico in

2017 and the raging wildfires that swept through parts of California in 2017 and 2018. These

studies have also revealed lingering psychological symptoms among survivors of those disasters

(Li et al., 2018; Usami et al., 2016).

Researchers often run analogue experiments. Here they induce laboratory participants to

behave in ways that seem to resemble real-life abnormal behavior and then conduct experiments

on the participants in the hope of shedding light on the real-life abnormality. For example, as

you’ll see in Chapter 6, investigator Martin Seligman, in a classic body of work, has produced

depression-like symptoms in laboratory participants—both animals and humans—by repeatedly

exposing them to negative events (shocks, loud noises, task failures) over which they have no

control. In these “learned helplessness” analogue studies, the participants seem to give up, lose

their initiative, and become sad—suggesting to some clinicians that human depression itself may

indeed be caused by loss of control over the events in one’s life.

analogue experiment A research method in which the experimenter produces abnormal-like behavior in laboratory participants and then conducts experiments on the participants.

Similar enough? Celebrity chimpanzee Cheetah, age 59, does some painting along with her friend and trainer. Chimps and

human beings share more than 90 percent of their genetic material, but their brains and bodies are very different, as are their

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perceptions and experiences. Thus, abnormal-like behavior produced in animal analogue experiments may differ from the

human abnormality under study.

Scientists often use a single-subject experimental design when they do not have the luxury of

experimenting on many participants (Comer & Bry, 2018; Lane et al., 2017). They may, for

example, be investigating a disorder so rare that few participants are available. In designs of this

kind, a single participant is observed both before and after the manipulation of an independent

variable.

single-subject experimental design A research method in which a single participant is observed and measured both before and after the manipulation of an independent variable.

For example, using a particular single-subject design, called an ABAB, or reversal, design, one

researcher sought to determine whether the systematic use of rewards would reduce a teenage

boy’s habit of disrupting his special education class with loud talk (Deitz, 1977). He rewarded

the boy, who suffered from intellectual disability (previously called mental retardation), with

extra teacher time whenever he went 55 minutes without interrupting the class more than three

times. In condition A, the student was observed prior to receiving any reward, and he was found

to disrupt the class frequently with loud talk. In condition B, the boy was given a series of teacher

reward sessions (introduction of the independent variable); as expected, his loud talk decreased

dramatically. Next, the rewards from the teacher were stopped (condition A again), and the

student’s loud talk increased once again. Apparently, the independent variable had indeed been

the cause of the improvement. To be still more confident about this conclusion, the researcher

had the teacher apply reward sessions yet again (condition B again). Once again the student’s

behavior improved.

Yet another alternative research design is the longitudinal study, in which investigators

observe the same individuals on many occasions over a long period of time (Bryman, 2016). In

several such studies, investigators have observed the progress over the years of normally

functioning children whose mothers or fathers suffered from schizophrenia (Hameed & Lewis,

2016; Rasic et al., 2014). The researchers have found, among other things, that the children of

the parents with the most severe cases of schizophrenia were particularly likely to develop a

psychological disorder and to commit crimes at later points in their development.

longitudinal study A study that observes the same participants on many occasions over a long period of time.

As with some of the other quasi-experiments, researchers cannot directly manipulate the

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independent variable or randomly assign participants to conditions in a longitudinal study, and

so they cannot definitively pinpoint causes. However, because longitudinal studies report the

order of events, they do provide compelling clues about which events are more likely to be causes

and which are more likely to be consequences.

Life is a longitudinal study Photos of this same individual at different points in his life underscore the logic behind

longitudinal studies. Just as this person’s eyes, nose, and overall smile at the age of 5 seem to predict similar facial features at

the ages of 35 and 55, so too might an individual’s early temperament, sociability, or other psychological features sometimes

predict adult characteristics. In some longitudinal studies, clinical researchers have found that a number of children who

seem to be at particular risk for psychological disorders do indeed develop such disorders at later stages of their lives.

Finally, researchers may conduct epidemiological studies to reveal how often a problem, such

as a particular psychological disorder, occurs in a particular population. More specifically, they

determine the incidence and prevalence of the problem (Jacobsen, 2016). Incidence is the number

of new cases that emerge in a population during a given period of time. Prevalence is the total

number of cases in the population during a given period; prevalence includes both existing and

new cases.

epidemiological study A study that measures the incidence and prevalence of a problem, such as a disorder, in a given population.

Over the past 45 years, clinical researchers throughout the United States have worked on one

of the largest epidemiological studies of mental disorders ever conducted, called the

Epidemiologic Catchment Area Study (Cottler et al., 2016; Ramsey et al., 2013). They have

interviewed more than 20,000 people in five cities to determine the prevalence of many

psychological disorders in the United States and the treatment programs used. Two other large-

scale epidemiological studies in the United States, the National Comorbidity Survey and the

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National Comorbidity Survey Replication, have questioned almost 15,000 individuals (Kelly &

Mezuk, 2017; Kessler et al., 2014, 2012). Findings from these broad-population studies have

been further compared with epidemiological studies of specific populations, such as Hispanic

Americans and Asian Americans, or with epidemiological studies conducted in other countries, to

see how rates of mental disorders and treatment programs vary from population to population

and from country to country (Nobles et al., 2016).

Such epidemiological comparisons have helped researchers identify groups at risk for

particular disorders. Women, it turns out, have a higher rate of anxiety disorders and depression

than men, while men have a higher rate of alcoholism than women. Elderly people have a higher

rate of suicide than young people. Hispanic Americans experience posttraumatic stress disorder

more than other racial and ethnic groups in the United States. And persons in Western countries

have higher rates of eating disorders than those in non-Western ones.

What Are the Limits of Clinical Investigations? We began this section by noting that clinical scientists look for general laws that will help them

understand, treat, and prevent psychological disorders. As we have seen, however, circumstances

can interfere with their progress.

Each method of investigation that we have observed addresses some of the problems involved

in studying human behavior, but no one approach overcomes them all. Thus it is best to view

each research method as part of a team of approaches that together may shed light on abnormal

human functioning. When more than one method has been used to investigate a disorder, it is

important to ask whether all the results seem to point in the same direction. If they do, clinical

scientists are probably making progress toward understanding and treating that disorder.

Conversely, if the various methods seem to produce conflicting results, the scientists must admit

that knowledge in that particular area is still limited.

Protecting Human Participants Human research participants have needs and rights that must be respected (see MindTech). In

fact, researchers’ primary obligation is to avoid harming the human participants in their studies

—physically or psychologically.

The vast majority of researchers are conscientious about fulfilling this obligation. They try to

conduct studies that test their hypotheses and further scientific knowledge in a safe and respectful

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Might outside restrictions on research interfere with

way (Leavy, 2017; Salkind, 2017). But there have been some notable exceptions to this over the

years, particularly three infamous studies conducted in the mid-twentieth century. Partly because

of such exceptions, the government and the institutions in which research is conducted now take

careful measures to ensure that the safety and rights of human research participants are properly

protected.

A national disgrace In a 1997 White House ceremony, President Bill Clinton offers an official apology to 94-year-old

Herman Shaw and other African American men whose syphilis went untreated by government doctors and researchers in

the Tuskegee Syphilis Study, a research undertaking conducted from 1932 to 1972, prior to the emergence of Institutional

Review Boards. In this infamous study, 399 participants were not informed that they had the disease, and they continued to

go untreated even after it was discovered that penicillin is an effective intervention for syphilis.

Who, beyond researchers themselves,

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necessary investigations and thus limit potential gains for

human beings? might directly watch over the rights and

safety of human participants? For the past

several decades, that responsibility has

been given to Institutional Review Boards, or IRBs. Each research facility has an IRB—a

committee of five or more members who review and monitor every study conducted at that

institution, starting when the studies are first proposed (Parker, 2016). The institution may be a

university, medical school, psychiatric or medical hospital, private research facility, mental health

center, or the like. If research is conducted there, the institution must have an IRB, and that IRB

has the responsibility and power to require changes in a proposed study as a condition of

approval. If acceptable changes are not made by the researcher, then the IRB can disapprove the

study altogether. Similarly, if over the course of the study, the safety or rights of the participants

are placed in jeopardy, the IRB must intervene and can even stop the study if necessary. These

powers are granted to IRBs (or similar ethics committees) by nations around the world. In the

United States, for example, IRBs are empowered by two agencies of the federal government—the

Office for Human Research Protections and the Food and Drug Administration.

Institutional Review Board (IRB) An ethics committee in a research facility that is empowered to protect the rights and safety of human research participants.

It turns out that protecting the rights and safety of human research participants is a complex

undertaking. Thus, IRBs often are forced to conduct a kind of risk-benefit analysis in their

reviews. They may, for example, approve a study that poses minimal or slight risks to participants

if that “acceptable” level of risk is offset by the study’s potential benefits to society. In general,

IRBs try to ensure that each study grants the following rights to its participants:

The participants enlist voluntarily.

Before enlisting, the participants are adequately informed about what the study entails (“informed consent”).

The participants can end their participation in the study at any time.

The benefits of the study outweigh its costs/risks.

The participants are protected from physical and psychological harm.

The participants have access to information about the study.

The participants’ privacy is protected by principles such as confidentiality or anonymity.

MINDTECH

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Can an argument be made that ethical standards for studies

The Use and Misuse of Social Media

Over the past several years, more and more researchers have been turning to social networks for their studies. One

study, for example, demonstrates the power and potential of using social media data (Kosinski et al., 2016, 2013). In this

investigation, 58,000 Facebook subscribers allowed the researchers access to their list of “likes,” and the subscribers further

filled out online personality tests. The study found that information about a participant’s likes could predict with some

accuracy his or her personality traits, level of happiness, use of addictive substances, and level of intelligence, among other

variables.

What a great resource, right? Not so fast. The study above did indeed ask subscribers whether they were willing to

participate. However, in a number of other such studies, social media users do not know that their posted data is being

examined and tested. Here, the researchers assert that because posted information is already publicly available, users need

not be informed that their data is under examination—a view that has produced enormous debate.

An area that has raised additional ethical concerns involves the direct and secret manipulation of social media users by

researchers—an approach illustrated in a study conducted by a team of researchers from both Facebook and academia

(Kramer et al., 2014). The investigators wanted to determine whether the content of news feeds on Facebook influences the

moods of its users. Without the users knowing it, the researchers reduced the number of positive news feed posts seen by

around 350,000 users and reduced the number of negative posts seen by another 350,000 users over a one-week period. As

a result, the moods of the former users became slightly (but significantly) more negative than those of the latter users, as

measured by the number of negative and positive words posted by the users themselves in their Facebook status updates

over the course of that same week.

This study immediately triggered a flood of criticism (Golder et al., 2017; Flick, 2016). One concern was that the users

in the study were unaware of and did not give consent for their participation. Critics holding this view were unimpressed

with the claim that signing on to Facebook’s lengthy and small-print user agreement represents a sufficient form of

informed consent for this or similar social media studies. Another concern was that, by inducing more negative moods, the

researchers in this study might have been feeding into the clinical depressions of some negative news feed users.

A core problem for all social media studies is

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using the Internet and social media should be different from

those applied to other kinds of research?

that most social media sites do not really have

policies prohibiting researchers from studying

subscribers or subscriber profiles without clear

permission. While the technology-driven questions

of what’s public and what’s private are under debate, it is probably best that posters follow a new version of that most

sacred rule of consumerism—“poster beware.”

Unfortunately, even with IRBs on the job, these rights can be in jeopardy. Consider, for

example, the right of informed consent. To help ensure that participants understand what they

are getting into when they enlist for a study, IRBs typically require that the individuals read and

sign an “informed consent form” that spells out everything they need to know. But how clear are

such forms? Not very, according to some investigations (Perrault & Nazione, 2016; Mathew &

McGrath, 2002).

It turns out that most such forms—the very forms deemed acceptable by IRBs—are too long

and/or are written at an advanced college level, making them incomprehensible to a large

percentage of participants. In fact, fewer than half of all participants may fully understand the

informed consent forms they are signing. Still other investigations indicate that only around 10

percent of human participants carefully read the informed consent forms before signing them,

and only 30 percent ask questions of the researchers during the informed consent phase of the

studies (CISCRP, 2013).

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Making a point The rights of animal subjects must also be considered. Here, with his body painted as a monkey, an activist

from the organization PETA (People for the Ethical Treatment of Animals) sits in a cage to protest the use of animals in

research at a medical science institute in India.

In short, the IRB system is flawed, much like the research undertakings it oversees. One

reason for this is that ethical principles are subtle notions that do not always translate into simple

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guidelines. Another reason is that ethical decisions—whether by IRB members or by researchers

—are subject to differences in perspective, interpretation, decision-making style, and the like.

Despite such problems, most observers agree that the creation and work of IRBs have helped

improve the rights and safety of human research participants over the years.

SUMMING UP

WHAT DO CLINICAL RESEARCHERS DO? Researchers use the scientific method to uncover nomothetic principles of abnormal psychological functioning. They

attempt to identify and examine relationships between variables and depend primarily on three methods of

investigation: the case study, the correlational method, and the experimental method.

A case study is a detailed account of a person’s life and psychological problems. Correlational studies are used to

systematically observe the degree to which events or characteristics vary together. This method allows researchers to

draw broad conclusions about abnormality in the population at large. In experiments, researchers manipulate

suspected causes to see whether expected effects will result. This method enables researchers to determine the causes

of various conditions or events.

Clinical scientists must often settle for alternative research designs that are less than ideal, called quasi-

experimental designs, or mixed designs. These include the matched design, natural experiment, analogue experiment,

single-subject experiment, longitudinal study, and epidemiological study.

Each research facility has an Institutional Review Board (IRB) that has the power and responsibility to protect

the rights and safety of human participants in all studies conducted at that facility. Members of the IRB review each

study during the planning stages and can require changes in the proposed study before granting approval for the

undertaking. Among the important participant rights that the IRB protects is the right of informed consent, an

acceptable risk/benefit balance, and privacy (confidentiality or anonymity).

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#TheirWords “I became insane, with long intervals of horrible sanity.”

Edgar Allan Poe

Moving Forward Since ancient times, people have tried to explain, treat, and study abnormal behavior. By

examining the responses of past societies to such behaviors, we can better understand the roots of

our present views and treatments. In addition, a look backward helps us appreciate just how far

we have come.

At the same time, we must recognize the many problems in abnormal psychology today. The

field has yet to agree on one definition of abnormality. It is currently made up of conflicting

schools of thought and treatment whose members are often unimpressed by the claims and

accomplishments of the others. Clinical practice is carried out by a variety of professionals trained

in different ways. And current research methods each have flaws that limit our knowledge and

use of clinical information.

As you travel through the topics in this

book, keep in mind the field’s current

strengths and weaknesses, the progress

that has been made, and the journey that

lies ahead. Perhaps the most important

lesson to be learned from our look at the history of this field is that our current understanding of

abnormal behavior represents a work in progress—with some of the most important insights,

investigations, and changes yet to come.

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Chapter 1 Review

Key Terms

abnormal psychology

deviance

norms

culture

distress

dysfunction

danger

treatment

trephination

humors

asylum

moral treatment

state hospitals

somatogenic perspective

psychogenic perspective

psychoanalysis

psychotropic medications

deinstitutionalization

private psychotherapy

prevention

positive psychology

multicultural psychology

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managed care program

telemental health

scientific method

hypothesis

case study

correlation

correlational method

experiment

independent variable

dependent variable

confound

control group

experimental group

random assignment

masked design

placebo therapy

quasi-experimental design

matched design

natural experiment

analogue experiment

single-subject experimental design

longitudinal study

epidemiological study

prevalence

Institutional Review Board (IRB)

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informed consent

Quick Quiz

1. What features are common to abnormal psychological functioning? pp. 2–4

2. Name two forms of past treatments that reflect a demonological view of abnormal behavior. pp. 7–9

3. Give examples of the somatogenic view of psychological abnormality from Hippocrates, the Renaissance, the nineteenth century, and the twentieth century. pp. 8–12

4. Describe the role of hypnotism and hysterical disorders in the development of the psychogenic view. pp. 12–13

5. How did Sigmund Freud come to develop the theory and technique of psychoanalysis? p. 13

6. Describe the major changes that have occurred since the 1950s in the understanding and treatment of psychological abnormality. pp. 14–20

7. What are the advantages and disadvantages of the case study, correlational method, and experimental method? pp. 21–30

8. What techniques do researchers include in experiments to guard against the influence of confounds? pp. 25–27

9. Describe six alternative research designs often used by investigators. pp. 27–29

10. What are Institutional Review Boards, and what are their responsibilities and goals? pp. 30–32

Visit LaunchPad

to access the e-Book, Clinical Choices, videos, activities, and

LearningCurve, as well as study aids including flashcards,

FAQs, and research exercises.

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CHAPTER 2 Models of Abnormality

TOPIC OVERVIEW

The Biological Model

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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 Cognitive-Behavioral Model

The Behavioral Dimension The Cognitive Dimension The Cognitive-Behavioral Interplay Assessing the Cognitive-Behavioral Model

The Humanistic-Existential Model

Rogers’ 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

Integrating the Models: The Developmental Psychopathology Perspective

Philip 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 [contacted] 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

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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 “sadistically.” 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 [permission], 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” … 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 [a disagreeable] 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.”

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 justification 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 [he] 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 … young man with pale skin who maintained 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,

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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. 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.

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

Until relatively 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 depression, rage, jealousy, and hatred. Similarly,

their treatments for him—from prayers to whippings—would have sought to drive foreign spirits

from his body.

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

public at large. Here an eighth-grade student holds and examines a brain ever so carefully during a visit to the psychology

department at Indiana University.

Today several models are used to explain and treat abnormal functioning. This variety has

resulted both from shifts in values and beliefs over the past half-century and from 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 three models that focus on more

psychological and personal aspects of human functioning: The psychodynamic model looks at

people’s unconscious internal processes and conflicts; the cognitive-behavioral model emphasizes

behavior, the ways in which it is learned, and 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 sociocultural model, which looks to social and cultural forces as the keys to human

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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 principles, the models are sometimes in conflict. Those

who exclusively follow one perspective often scoff at the “naïve” 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.

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The Biological Model Philip Berman is a biological being. His thoughts and feelings are the results of biochemical 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 surprisingly, 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 illness brought

about by malfunctioning parts of the organism. Typically, they point to problems in brain

anatomy, brain chemistry, and/or brain circuitry as the cause of such behavior.

Brain Anatomy and Abnormal Behavior The brain is made up of approximately 86 billion nerve cells, called neurons, and thousands of

billions of support cells, called glia (from the Greek word for “glue”) (Jernigan & Stiles, 2017).

Within the brain large groups of neurons form distinct regions, or brain structures. Toward the

top of the brain, for example, is a cluster of structures, collectively referred to as the cerebrum,

which includes the cortex, corpus callosum, basal ganglia, hippocampus, and amygdala (see Figure

2-1). The neurons in each of these brain structures help control important functions. The basal

ganglia, for example, plays a crucial role in planning and producing movement, and the

amygdala plays a key role in emotional memory. Clinical researchers have sometimes linked

particular psychological disorders to problems in specific structures of the brain. One such

disorder is Huntington’s disease, a disorder marked by involuntary body movements, violent

emotional outbursts, memory loss, suicidal thinking, and absurd beliefs. This disease has been

linked in part to a loss of cells in the basal ganglia and cortex.

neuron A nerve cell.

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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 cerebral cortex, corpus callosum, basal ganglia, hippocampus, and amygdala.

Brain Chemistry and Abnormal Behavior Biological researchers have also learned that psychological disorders can be related to problems in

the transmission 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 transmitted through the nerve ending at the end of the axon to the

dendrites of other neurons (see Figure 2-2). Each neuron has multiple dendrites and a single

axon. But that axon can be very long indeed, often extending all the way from one structure of

the brain to another.

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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

neurotransmitters are released and carry the message across the synaptic space to the dendrites of a receiving neuron.

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 give a message to 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. As you can see, neurotransmitters play a key role in moving

information through the brain.

synapse The tiny space between the nerve ending of one neuron and the dendrite of another. neurotransmitter A chemical that, released by one neuron, crosses the synaptic space to be received at receptors on the dendrites of neighboring neurons. receptor A site on a neuron that receives a neurotransmitter.

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Researchers have identified dozens of neurotransmitters in the brain, and they have learned

that each neuron uses only certain kinds. Studies indicate that abnormal activity by certain

neurotransmitters is sometimes tied to mental disorders. Depression, for example, has been

linked in part to low activity of the neurotransmitters serotonin and norepinephrine. Perhaps low

serotonin activity is at play in 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, 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 hormone cortisol to help the body deal with the

stress. Abnormal secretions of this chemical have been tied to anxiety and depression.

hormones The chemicals released by endocrine glands into the bloodstream.

Brain Circuitry and Abnormal Behavior Over the past decade, researchers have increasingly focused on brain circuits as the key to

psychological disorders rather than on dysfunction within a single brain structure or by a single

brain chemical. A brain circuit is a network of particular brain structures that work together,

triggering each other into action to produce a distinct behavioral, cognitive, or emotional

reaction. How do the structures of a given circuit work together? The answer, as you might

anticipate by now, is through their neurons. The long axons of the neurons from one structure

bundle together and extend across the brain to communicate with the neurons of another

structure, setting up a fiber pathway between the structures. The structures and

neurotransmitters that make up a given brain circuit are, as you read above, important

individually, but research indicates that it is usually most informative to look at the operation of

the entire circuit, including its interconnecting fiber pathways, to fully understand human

functioning. Proper interconnectivity (communication) among the structures of a circuit tends to

result in healthy psychological functioning, whereas flawed interconnectivity may lead to

abnormal functioning.

brain circuit A network of particular brain structures that work together, triggering each other into action to produce a distinct kind of behavioral, cognitive, or emotional reaction.

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#TheirWords

“Help! I’m being held prisoner by my heredity and

environment.”

Dennis Allen

One of the brain’s most important circuits is the “fear circuit.” As you will see in Chapter 4,

this circuit consists of a number of specific structures (including the amygdala and prefrontal

cortex) whose interconnecting fiber pathways enable the structures to trigger each other into

action and to produce our everyday fear reactions. Studies suggest that this circuit functions

improperly (that is, displays flawed interconnectivity) in people suffering from anxiety disorders

(Williams, 2017). Perhaps dysfunction by Philip Berman’s fear circuit is contributing to his

repeated concerns that things will go badly and that other people will have low opinions and

negative motives toward him, concerns that keep triggering his depression and anger.

Sources of Biological Abnormalities Why might the brain structures, neurotransmitters, or brain circuits of some people function

differently from the norm? As you will see throughout the textbook, a wide range of factors can

play a role—from prenatal events to brain injuries, viral infections, environmental experiences,

and stress. Two factors that have received particular attention in the biological model are genetics

and evolution.

GENETICS AND ABNORMAL BEHAVIOR

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 numerous genes—

segments that control the characteristics

and traits a person inherits. Altogether, each cell contains around 20,000 genes (Dunham, 2018).

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 possessing artistic or musical skill. Studies suggest that inheritance also

can play a part in certain mental disorders.

genes Chromosome segments that control the characteristics and traits we inherit.

In most instances, several or more genes combine to help produce our actions and reactions,

both functional and dysfunctional. The precise contributions of various genes or gene

combinations to mental disorders have become clearer in recent years, thanks in part to the

completion of the Human Genome Project in 2000, a major undertaking in which scientists used

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the tools of molecular biology to map, or sequence, all of the genes in the human body.

EVOLUTION AND ABNORMAL BEHAVIOR Genes that contribute to mental disorders are typically viewed as unfortunate occurrences—

almost mistakes of inheritance. The responsible 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 his or her 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 (Ram, Liberman, & Feldman, 2018; Fábrega, 2010).

More than coincidence? Identical twins Mike and Bob Bryan, shown here returning a shot during a semifinal tennis match

at the 2016 China Open, have had storied careers. Ranked as the world’s top doubles tennis players, they have won multiple

Olympic medals representing the United States. Studies of twins suggest that some aspects of behavior and personality are

influenced by genetic factors. Many identical twins, like the Bryans, have similar tastes, behave similarly, and make similar

life choices. Some even develop similar abnormal behaviors.

In general, evolutionary theorists argue that human reactions and the genes responsible for

them have survived over the course of time because they have helped individuals 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

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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 pass on their fear genes. Of course, in today’s world, pressures are more

numerous and often more subtle than they were in the past, condemning many individuals with

such genes to a near-endless stream of fear and arousal. That is, the very genes that helped their

ancestors to survive and reproduce might now leave these individuals particularly prone to fear

reactions, anxiety disorders, or related psychological patterns.

The evolutionary perspective is controversial in the clinical field and has been rejected by

many theorists. Imprecise and at times impossible to research, scientists often find such

explanations unacceptable.

Biological Treatments Biological practitioners look for certain kinds of clues when they treat people who are behaving

abnormally. Does the person’s family have a history of that behavior, and hence a possible

genetic predisposition to it? (Philip Berman’s case history mentions that his mother was once

hospitalized for depression.) Is the behavior produced by events that could have had a

physiological effect? (Philip was having a drink when he flew into a jealous rage at the

restaurant.) Once the clinicians have pinpointed physical sources of dysfunction, they are in a

better position to choose a biological course of treatment. The three leading kinds of biological

treatments used today are drug therapy, brain stimulation, and psychosurgery. Drug therapy is by

far the most common of these approaches.

In the 1950s, researchers discovered several effective psychotropic medications, drugs that

mainly affect emotions and thought processes. These drugs have greatly changed the outlook for

a number of mental disorders and today are used widely, either alone or with other forms of

therapy (see Trending). However, the psychotropic drug revolution has also produced some

major problems. Many people believe, for example, that the drugs are overused. Moreover, while

drugs are effective in many cases, they do not help everyone.

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

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What might the popularity of psychotropic drugs suggest

about coping styles and problem-solving skills in our

society?

Four major psychotropic drug groups

are used in therapy. Antianxiety drugs, also

called minor tranquilizers or anxiolytics,

help reduce tension and anxiety.

Antidepressant drugs help improve the

functioning of people with depression and certain other disorders. Antibipolar drugs, also called

mood stabilizers, help steady the moods of those with a bipolar disorder, a condition marked by

mood swings from mania to depression. And antipsychotic drugs help reduce the confusion,

hallucinations, and delusions that often accompany psychosis, a loss of contact with reality found

in schizophrenia and other disorders.

Psychotropic drugs, like all medications, reach the marketplace only after systematic research

and review. It takes an average of 12 years and hundreds of millions of dollars for a

pharmaceutical company in the United States to bring a newly identified chemical compound to

market. Along the way, the drug is vigorously tested in study after study—first on animals and

then on humans—to determine its efficacy, safety, dosage, and side effects, until finally it receives

approval by the U.S. Food and Drug Administration. Only 3 percent of newly discovered

chemical compounds make it to animal testing, only 2 percent of animal-tested compounds

reach human testing, and only 21 percent of human-tested drugs are eventually approved (FDA,

2018, 2016, 2014).

TRENDING

TV Drug Ads Come Under Attack

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

browses the Internet is familiar with phrases such as these. They are at the heart of direct-to-consumer (DTC) drug

advertising—advertisements in which pharmaceutical companies appeal directly to consumers, coaxing them to ask their

physicians to prescribe particular drugs for them. The United States and New Zealand are the only developed countries in

the world that allow such advertising. Around 80 percent of American adults have seen these ads, and at least 30 percent

ask their doctors about the specific medications they see advertised (ProCon, 2016; Hausman, 2008). Half of today’s

leading DTC-advertised medications are psychotropic drugs such as antibipolar and antipsychotic drugs (Bulik, 2017; Sukel,

2016).

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

restrictions for drug advertising on television, ruling that DTC ads must simply recommend that consumers speak with a

doctor about the drug, mention the drug’s important risks, and indicate where consumers can get further information

about it—often a Web site or phone number (Chesnes & Jin, 2016; FDA, 2016, 2015). Such ads have received relatively

little criticism over the past two decades, but this climate of tolerance is now changing. A number of consumer groups and

even the American Medical Association (AMA) are now calling for a ban on such advertising, saying that the ads often

contribute to economic hardships, patient misinformation, and less-than-optimal treatment (Kuzucan, Doshi, & Zito,

2017; AMA, 2015).

First, the economic concerns. Altogether, pharmaceutical companies spend $5.2 billion a year on American television

and some online advertising, an amount that keeps growing (Lazarus, 2017; Campbell, 2016). This leads to higher drug

prices, at a time when prescription drug costs and insurance premiums are already skyrocketing, increasing by close to 5

percent each year. Moreover, the DTC ads typically promote newer and more expensive drugs, inflating the demand for

such drugs even when older, generic, and cheaper drugs might be equally or more appropriate (Campbell, 2016; AMA,

2015).

DTC ads also may adversely affect patient awareness and clinical treatment (Aikin et al., 2017). Three-quarters of

surveyed doctors believe that most of the ads overemphasize a drug’s benefits while leaving out key negative information

(ProCon, 2016). Similarly, 80 percent of doctors believe DTC ads help patients better understand the benefits of a drug,

but only 40 percent of them believe that patients understand the possible risks of a drug after seeing the ad (Kiernicki &

Helme, 2017; FDA, 2016, 2015). Small wonder that many patients believe their mental or physical health will be put in

jeopardy if they do not take advertised drugs (Campbell, 2016).

Despite these problems, doctors often feel pressured to prescribe DTC-advertised drugs, even in cases in which the

drugs are not appropriate for patients (Brown, 2017; FDA, 2015). Over half of patient requests for such drugs are granted

by doctors. This has apparently contributed to an overuse of psychotropic and other drugs.

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

FDA, for example, believes that the ads may indeed serve a public service, protecting consumers—although imperfectly—

by directly educating them about drugs that are available in the marketplace (FDA, 2016, 2015). Many doctors also believe

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

better discussions with their patients about treatment options as a result of DTC advertising. Finally, not to be overlooked

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#FDAApproval

1954 Thorazine (antipsychotic drug)

1955 Ritalin (ADHD drug)

1958 MAO inhibitors (antidepressant drugs)

1960 Librium (antianxiety drug)

1961 Elavil (antidepressant drug)

1963 Valium (antianxiety drug)

1970 Lithium (mood stabilizer/antibipolar drug)

1987 Prozac (antidepressant drug)

1998 Viagra (erectile disorder drug)

are the profits that DTC advertising helps generate for pharmaceutical companies. The average number of prescriptions

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

DTC ads (ProCon, 2016).

As the name implies, a second form of biological treatment, brain stimulation, refers to

interventions that directly or indirectly stimulate certain areas of the brain. The oldest (and most

controversial) such approach, used primarily on severely depressed people, is electroconvulsive

therapy (ECT). Two electrodes are attached to a patient’s forehead, and an electrical current of

65 to 140 volts is passed briefly through the brain. The current causes a brain seizure that lasts up

to a few minutes. After seven to nine ECT sessions, spaced two or three days apart, many patients

feel considerably less depressed. This treatment is used on tens of thousands of persons annually,

particularly those whose depression fails to respond to other treatments (Hermida et al., 2018).

brain stimulation Interventions that directly or indirectly stimulate the brain in order to bring about psychological improvement. electroconvulsive therapy (ECT) A biological treatment in which a brain seizure is triggered when an electric current passes through electrodes attached to the patient’s forehead.

As you will see in Chapter 6, several

other brain stimulation techniques have

increasingly been used over the past

decade, particularly in cases of depression.

In one, transcranial magnetic stimulation

(TMS), an electromagnetic coil is placed

on or above a person’s head, sending a

current into certain areas of his or her

brain. In another such technique, vagus

nerve stimulation (VNS), a pulse generator

is implanted in a person’s neck, helping to

stimulate his or her vagus nerve, a long

nerve that extends from the brain down

through the neck and on to the abdomen.

The stimulated vagus nerve then delivers electrical signals to the brain. In a third technique,

called deep brain stimulation, electrodes are implanted in specific areas of a person’s brain and

connected to a battery (“pacemaker”) in his or her chest. The pacemaker proceeds to power the

electrodes, sending a steady stream of low-voltage electricity to the targeted brain areas. As with

ECT, research suggests that each of these newer brain stimulation techniques is able to improve

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#TheirWords “Mental illness is so much more complicated than any pill that

any mortal could invent.”

Elizabeth Wurtzel, Prozac Nation

the psychological functioning of many people whose depressive or related disorders have been

unresponsive to other forms of treatment (Bari et al., 2018; Luber et al., 2017).

A third kind of biological treatment is psychosurgery, brain surgery for mental disorders. It

has roots as far back as trephining, the prehistoric practice of chipping a hole in the skull of a

person who behaved strangely. Modern procedures are derived from a notorious technique

developed in the late 1930s by a Portuguese neuropsychiatrist, António Egas Moniz. In that

procedure, known as a lobotomy, a surgeon would cut the connections between the brain’s frontal

lobes and the lower regions of the brain. Today’s psychosurgery procedures are much more

precise than the lobotomies of the past (Bari et al., 2018). Even so, they are typically used only

after certain severe disorders have continued for years without responding to any other treatment.

It is worth noting that deep brain stimulation, one of the interventions described above, is also a

psychosurgery procedure inasmuch as it involves making small incisions in a person’s skull in

order to implant electrodes in a targeted brain area.

psychosurgery Brain surgery for mental disorders.

Assessing the Biological Model Today the biological model enjoys considerable respect. Biological research constantly produces

valuable new information, and biological treatments often bring great relief when other

approaches have failed. At the same time, this model has its shortcomings. Some of its

proponents seem to expect that all human behavior can be explained in biological terms and

treated with biological methods. This view can limit rather than enhance our understanding of

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.

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SUMMING UP

THE BIOLOGICAL MODEL Biological theorists look at biological factors to explain abnormal behavior, pointing in particular to problematic

brain structures, chemicals, and circuits. Such abnormalities are sometimes the result of genetic inheritance or normal

evolution. Biological therapists use chemical and physical methods to help people overcome their psychological

problems. The leading methods are drug therapy, brain stimulation, and psychosurgery.

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The Psychodynamic Model The psychodynamic model is the oldest and most famous of the modern psychological models.

Psychodynamic theorists believe that a person’s behavior, whether normal or abnormal, is

determined largely by underlying psychological forces of which 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.

Psychodynamic theorists would view Philip Berman as a person in conflict. They would want

to explore his past experiences because, in their view, psychological conflicts are tied to early

relationships and to traumatic experiences that occurred during childhood. Psychodynamic

theories rest on the deterministic assumption that no symptom or behavior is “accidental”: all

behavior is determined by past experiences. Thus Philip’s hatred for his mother, his memories of

her as cruel and overbearing, the apparent weakness of his father, and the birth of a younger

brother when Philip was 10 may all be important to the understanding of his current problems.

Freud takes a closer look at Freud Sigmund Freud, founder of psychoanalytic theory and therapy, contemplates a

sculptured bust of himself in 1931 at his village home in Potzlein, near Vienna. As Freud and the bust go eyeball to eyeball,

one can only imagine what conclusions each is drawing about the other.

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

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theory of psychoanalysis to explain both normal and abnormal psychological functioning as well as

a corresponding method of treatment, a conversational approach also called psychoanalysis.

During the early 1900s, Freud and several of his colleagues in the Vienna Psychoanalytic Society

—including Carl Gustav Jung (1875–1961)—became the most influential clinical theorists in

the Western world.

How Did Freud Explain Normal and Abnormal Functioning? Freud believed that three central forces shape the personality—instinctual needs, rational

thinking, and moral standards. All of these forces, he believed, operate at the unconscious level,

unavailable to immediate awareness; he further believed these forces to be dynamic, or

interactive. Freud called the forces the id, the ego, and the superego.

The Id Freud used the term id to denote instinctual needs, drives, and impulses. The id operates in

accordance with the pleasure principle; that is, it always seeks gratification. Freud also believed

that all id instincts tend to be sexual, noting that from the very earliest stages of life a child’s

pleasure is obtained from nursing, defecating, masturbating, or engaging in other activities that

he considered to have sexual ties. He further suggested that a person’s libido, or sexual energy,

fuels the id.

id According to Freud, the psychological force that produces instinctual needs, drives, and impulses.

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 unconsciously seeks gratification,

but it does so in accordance with the reality principle, the knowledge we acquire through

experience that it can be unacceptable to express our id impulses outright. The ego, employing

reason, guides us to know when we can and cannot express those impulses.

ego According to Freud, the psychological force that employs reason and operates in accordance with the reality principle.

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,

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repression, prevents unacceptable impulses from ever reaching consciousness. There are many

other ego defense mechanisms, and each of us tends to favor some over others (see Table 2-1).

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

TABLE: 2-1 The Defense Never Rests Defense Mechanism

Operation Example

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

An executive’s desire to run amok and attack 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 his or her 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 a perfect parking spot is taken by a person who cuts in front of your car, you release your pent-up anger by starting an argument with your roommate later.

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 in which no one is expected to behave maturely or responsibly.

A boy who cannot cope with the anger he feels toward his rejecting mother regresses to infantile behavior, soiling his clothes and no longer taking care of his basic needs.

The Superego The superego is the personality force that operates by the morality principle, a sense of what is

right and what is wrong. As we learn from our parents that many of our id impulses are

unacceptable, we unconsciously adopt our parents’ values. Judging ourselves by their standards,

we feel good when we uphold their values; conversely, when we go against them, we feel guilty.

In short, we develop a conscience.

superego According to Freud, the psychological force that represents a person’s values and ideals.

According to Freud, these three parts of the personality—the id, the ego, and the superego—

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are often in some degree of conflict. A healthy personality is one in which an effective working

relationship, an acceptable compromise, has formed among the three forces. If the id, ego, and

superego are in excessive conflict, the person’s behavior may show signs of dysfunction.

Freudians would therefore view Philip Berman as someone whose personality forces have a

poor working relationship. His ego and superego are unable to control his id impulses, which

lead him repeatedly to act in impulsive and often dangerous ways—suicide gestures, jealous rages,

job resignations, outbursts of temper, frequent arguments.

“I’m doing a lot better now that I’m back in denial.”

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.

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fixation According to Freud, a condition in which the id, ego, or superego do not mature properly and are frozen at an early stage of 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 comforts them will

disappear. Children whose mothers consistently fail to gratify their oral needs may become

fixated at the oral stage and display an “oral character” throughout their lives, one marked by

extreme dependence or extreme mistrust. Such persons are particularly prone to develop

depression. As you will see in later chapters, Freud linked fixations at the other stages of

development—anal (18 months to 3 years of age), phallic (3 to 5 years), latency (5 to 12 years),

and genital (12 years to adulthood)—to yet other kinds of psychological dysfunction.

“Luke … I am your father.” This lightsaber fight between Luke Skywalker and Darth Vader highlights the most famous,

and contentious, father–son relationship in movie history. According to Sigmund Freud, however, all fathers and sons have

significant tensions and conflicts that they must work through, even in the absence of the special pressures faced by Luke

and his father in the Star Wars series.

How Do Other Psychodynamic Explanations Differ from Freud’s?

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#FreudFacts

Freud’s fee for one session of therapy was $20.

For almost 40 years, Freud treated patients 10 hours per day, 5 or 6 days per week.

Freud was nominated for the Nobel Prize in 12 different years, but never won.

(Grohol, 2015; Hess, 2009; Gay, 2006, 1999)

Personal and professional differences between Freud and his colleagues led to a split in the

Vienna Psychoanalytic Society early in the twentieth century. Carl Jung and others developed

new theories. Although the new theories departed from Freud’s ideas in important ways, each

held on to Freud’s belief that human functioning is shaped by dynamic (interacting)

psychological forces. Thus all such theories, including Freud’s, are referred to as psychodynamic.

Two of today’s most influential psychodynamic theories are self theory and object relations

theory. Self theorists emphasize the role of the self—the unified personality. They believe that the

basic human motive is to strengthen the wholeness of the self (Corey, 2017; Kohut, 2001, 1977).

Object relations theorists, on the other hand, propose that people are motivated mainly by a need

to have relationships with others and that severe problems in the relationships between children

and their caregivers may lead to abnormal development (Kernberg, 2018, 2005, 1997; Rankin,

2017).

Psychodynamic Therapies Psychodynamic therapies range from

Freudian psychoanalysis to modern

therapies based on self theory or object

relations theory. Psychodynamic

therapists seek to uncover past traumas

and the inner conflicts that have resulted

from them (Safran, Kriss, & Foley, 2019).

They try to help clients resolve, or settle,

those conflicts and to resume personal

development.

According to most psychodynamic therapists, therapists must subtly guide therapy discussions

so that the patients discover their underlying problems for themselves. To aid in the process, the

therapists rely on such techniques as free association, therapist interpretation, catharsis, and working

through.

Free Association In psychodynamic therapies, the patient is responsible for starting and leading each discussion.

The therapist tells the patient to describe any thought, feeling, or image that comes to mind,

even if it seems unimportant. This practice is known as free association. The therapist expects

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that the patient’s associations will eventually uncover unconscious events. In the following

excerpts from a famous psychodynamic case, notice how free association helps a woman to

discover threatening impulses and conflicts within herself:

Patient: So I started walking, and walking, and decided to go behind the museum and walk through [New York’s] Central Park. … I saw a park bench next to a clump of bushes and sat down. There was a rustle behind me and I got frightened. I thought of men concealing themselves in the bushes. I thought of the sex perverts I read about in Central Park. I wondered if there was someone behind me exposing himself. The idea is repulsive, but exciting too. I think of father now and feel excited. … . There is something about this pushing in my mind. I don’t know what it is, like on the border of my memory. (Pause)

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

Patient: (The patient breathes rapidly and seems to be under great tension.) As a little girl, I slept with my father. I get a funny feeling. I get a funny feeling over my skin, tingly-like. It’s a strange feeling, like a blindness, like not seeing something. My mind blurs and spreads over anything I look at. I’ve had this feeling off and on since I walked in the park.

(Wolberg, 2005, 1967, p. 662)

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

Therapist Interpretation Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative

conclusions, and sharing interpretations when they think the patient is ready to hear them.

Interpretations of three phenomena are particularly important—resistance, transference, and

dreams.

Patients are showing resistance, an unconscious refusal to participate fully in therapy, when

they suddenly cannot free associate or when they change a subject to avoid a painful discussion.

They demonstrate transference when they act and feel toward the therapist as they did or do

toward important persons in their lives, especially their parents, siblings, and spouses. Consider

again the woman who walked in Central Park. As she continues talking, the therapist helps her to

explore her transference:

Patient: I get so excited by what is happening here. I feel I’m being held back by needing to be nice. … The worst thing would be that you wouldn’t like me. You wouldn’t speak to me friendly. . . you’d feel you

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Why do you think most people try to interpret and make

sense of their own dreams? Are such interpretations of value?

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

Therapist: Where do you think these attitudes come from?

Patient: When I was nine years old, 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 … I went against her will and suffered an accident that changed my life, a fractured back. Her attitude was, “I told you so.”

(Wolberg, 2005, 1967, p. 662)

resistance An unconscious refusal to participate fully in therapy. transference According to psychodynamic theorists, the redirection toward the psychotherapist of feelings associated with important figures in a patient’s life, now or in the past.

Finally, many psychodynamic

therapists try to help patients interpret

their dreams (Altszyler et al., 2017) (see

Table 2-2). 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.

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

TABLE: 2-2 Percent of Research Participants Who Have Had Common Dreams Men Women

Being chased or pursued, not injured 78% 83%

Sexual experiences 85 73

Falling 73 74

Schools, teachers, studying 57 71

Arriving too late, e.g., for a train 55 62

Trying to do something repeatedly 55 53

Flying or soaring through the air 58 44

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Failing an examination 37 48

Being physically attacked 40 44

Being frozen with fright 32 44

Information from: Cherry, 2018; Robert & Zadra, 2014; Kantrowitz & Springen, 2004.

Catharsis Insight must be an emotional as well as an intellectual process. Psychodynamic therapists believe

that patients must experience catharsis, a reliving of past repressed feelings, if they are to settle

internal conflicts and overcome their problems.

catharsis The reliving of past repressed feelings in order to settle internal conflicts and overcome 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.

working through The psychoanalytic process of facing conflicts, reinterpreting feelings, and overcoming one’s problems.

Current Trends in Psychodynamic Therapy The past 40 years have witnessed significant changes in the way many psychodynamic therapists

conduct sessions. An increased demand for focused, time-limited psychotherapies has resulted in

efforts to make psychodynamic therapy more efficient and affordable. Two current

psychodynamic approaches that illustrate this trend are short-term psychodynamic therapies and

relational psychoanalytic therapy.

SHORT-TERM PSYCHODYNAMIC THERAPIES In several short versions of psychodynamic therapy, patients choose a single problem—a dynamic

focus—to work on, such as difficulty getting along with other people (Levenson, 2017). The

therapist and patient focus on this problem throughout the treatment and work only on the

psychodynamic issues that relate to it (such as unresolved oral needs). Only a limited number of

studies have tested the effectiveness of these short-term psychodynamic therapies, but their

findings do suggest that the approaches are sometimes quite helpful to patients (Town et al.,

2017).

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What are some of the ways that Freud’s theories have

affected literature, film and television, philosophy, child

rearing, and education in Western society?

RELATIONAL PSYCHOANALYTIC THERAPY Whereas Freud believed that psychodynamic therapists should take on the role of a neutral,

distant expert during a treatment session, a contemporary school of psychodynamic therapy

referred to as relational psychoanalytic therapy argues that therapists are key figures in the lives of

patients—figures whose reactions and beliefs should be included in the therapy process (Corey,

2017). 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.

“Look! I’m having enough trouble right now without your bringing up the past.”

Assessing the Psychodynamic Model Freud and his followers have helped

change the way abnormal functioning is

understood. Largely because of their

work, a wide range of theorists today look

for answers outside of biological processes.

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Psychodynamic theorists have also helped us to understand that abnormal functioning may be

rooted in the same processes as normal functioning. Psychological conflict is a common

experience; it leads to abnormal functioning only if the conflict becomes excessive.

Freud and his many followers have also had a monumental impact on treatment. They were

the first to apply theory systematically to treatment. They were also the first to demonstrate the

potential of psychological, as opposed to biological, treatment, and their ideas have served as

starting points for many other psychological treatments.

At the same time, the psychodynamic model has its shortcomings. Its concepts are hard to

research (Safran et al., 2019). Because processes such as id drives, ego defenses, and fixation are

abstract and supposedly operate at an unconscious level, there is no way of knowing for certain if

they are occurring. Not surprisingly, then, psychodynamic explanations and treatments have

received relatively limited research support over the years, and psychodynamic theorists rely

largely on evidence from individual case studies. Nevertheless, recent research evidence suggests

that long-term psychodynamic therapy may be helpful for many persons with long-term complex

disorders (Berman, 2017; Werbart et al., 2017), and 18 percent of today’s clinical psychologists

identify themselves as psychodynamic therapists (Prochaska & Norcross, 2018).

SUMMING UP

THE PSYCHODYNAMIC MODEL Psychodynamic theorists believe that an individual’s behavior, whether normal or abnormal, is determined by

underlying psychological forces. They consider psychological conflicts to be rooted in early parent–child relationships

and traumatic experiences. The psychodynamic model was formulated 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 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 psychological phenomena such as

resistance, transference, and dreams. The leading contemporary psychodynamic approaches include short-term

psychodynamic therapies and relational psychoanalytic therapy.

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The Cognitive-Behavioral Model The cognitive-behavioral model of abnormality focuses on the behaviors people display and the

thoughts they have. The model is also interested in the interplay between behaviors and thoughts

—how behavior affects thinking and how thinking affects behavior. In addition, the model is

concerned with the impact the behavior–cognition interplay often has on feelings and emotions.

Whereas the psychodynamic model had its beginnings in the clinical work of physicians, the

cognitive-behavioral model began in laboratories where psychology researchers had been studying

behaviors, the responses an organism makes to its environment, since the late 1800s. Such

researchers believed that behaviors can be external (going to work, say) or internal (having a

feeling), and they ran experiments on conditioning, simple forms of learning, in order to better

understand how behaviors are acquired. In these experiments, researchers would manipulate

stimuli and rewards, then observe how such manipulations affect the behaviors of animal and

human subjects.

conditioning A simple form of learning.

During the 1950s, a number of clinicians, frustrated with what they viewed as the vagueness

and slowness of the psychodynamic model, began to explain and treat psychological abnormality

by applying principles derived from those laboratory conditioning studies. Consistent with the

laboratory studies, the clinicians viewed severe human anxiety, depression, and the like as

maladaptive behaviors, and they focused their work on how such behaviors might be learned and

changed.

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See and do Modeling may account for some forms of abnormal behavior. A well-known study by Albert Bandura and his

colleagues (1963) demonstrated that children learned to abuse a doll by observing an adult hit it. Children who had not

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

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A decade or so later, yet other clinicians came to believe that a focus on behaviors alone, while

moving in the right direction, was too simplistic, that behavioral conditioning principles failed to

account fully for the complexity of human functioning and dysfunction. They recognized that

human beings also engage in cognitive processes, such as anticipating or interpreting—ways of

thinking that until then had been largely ignored in the behavior-focused explanations and

therapies. These clinicians developed cognitive-behavioral theories of abnormality that took both

behaviors and cognitive processes into account, and cognitive-behavioral therapies that sought to

change both counterproductive behaviors and dysfunctional ways of thinking (Kodal et al., 2018;

Craske, 2017).

Some of today’s theorists and therapists still focus exclusively on the behavioral aspects of

abnormal functioning, while others focus only on cognitive processes. However, most clinicians

with such orientations include both behavioral and cognitive principles in their work. To best

appreciate the cognitive-behavioral model, let us look first at its behavioral dimension and then

its cognitive dimension.

The Behavioral Dimension Many learned behaviors help people to cope with daily challenges and to lead happy, productive

lives. However, abnormal behaviors also can be learned. Philip Berman, for example, might be

viewed as a man who has received improper training: he has learned behaviors that offend others

and get him into various kinds of trouble.

Theorists have identified several forms of conditioning, and each may produce abnormal

behavior as well as normal behavior. In classical conditioning, for example, people learn to

respond to one stimulus the same way they respond to another as a result of the two stimuli

repeatedly occurring together close in time. If, say, a physician wears a white lab coat whenever

she gives painful allergy shots to a little boy, the child may learn to fear not only injection

needles, but also white lab coats. Many phobias are acquired by classical conditioning, as you will

see in Chapter 4. In modeling, another form of conditioning, individuals learn responses simply

by observing other individuals and then repeating their behaviors. Phobias can also be acquired

by modeling. If a little girl observes her father become frightened whenever a dog crosses his

path, she herself may develop a phobic fear of dogs.

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

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In a third form of conditioning, operant conditioning, individuals learn to behave in certain

ways as a result of experiencing consequences of one kind or another—reinforcements (for

example, rewards) or punishments—whenever they perform the behavior (Skinner, 1958, 1957).

Research suggests that a number of abnormal behaviors may be acquired by operant conditioning

(Held-Poschardt et al, 2018; Calarco, 2016). Some children, for example, learn to display

extremely aggressive behaviors when their parents or peers consistently surrender to their threats

or demands or shower them with extra attention when they act out. In addition, a number of

people learn to abuse alcohol because initially such behaviors bring feelings of calm, comfort, or

pleasure.

operant conditioning A process of learning in which individuals come to behave in certain ways as a result of experiencing consequences of one kind or another whenever they perform the behavior.

Conditioning for entertainment and profit Animals can be taught a wide assortment of tricks by using the principles of

conditioning—but at what cost? Here an Asian elephant performs one called “the living statue” as she acknowledges the

crowd at a circus in Virginia. In recent years the public has become alarmed at the training procedures used on circus

animals, leading some circuses to remove elephants from their shows. This in turn has led to declining ticket sales and

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

In treatment, behavior-focused therapists seek to replace a person’s problematic behaviors

with more appropriate ones, applying the principles of operant conditioning, classical

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conditioning, or modeling (Antony, 2019; Foa et al., 2018). When treating extremely aggressive

children, for example, the therapists may guide parents to change the reinforcers they have been

unintentionally providing for their children’s behaviors. The parents may be taught to

systematically reinforce polite and appropriate behaviors by their children by providing the

children with displays of extra attention or special privileges. In addition, the parents may be

taught to systematically punish highly aggressive behaviors by withdrawing attention and

withholding privileges in the aftermath of such behaviors (Cornacchio et al., 2017; Elkins et al.,

2017).

The Cognitive Dimension Philip Berman, like the rest of us, has cognitive abilities—special intellectual capacities to think,

remember, and anticipate. These abilities can help him accomplish a great deal in life. Yet they

can also work against him. As he thinks about his experiences, Philip may misinterpret them in

ways that lead to poor decisions, maladaptive responses, and painful emotions.

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

best explain and treat abnormal functioning, not only by looking at behaviors, but also by

focusing on cognitions. Ellis and Beck claimed that clinicians must ask questions about the

assumptions and attitudes that color a client’s perceptions, the thoughts running through that

person’s mind, and the conclusions to which the assumptions and thoughts are leading.

According to these and other cognition-focused theorists, abnormal functioning can result

from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes

that are disturbing and inaccurate (Beck & Weishaar, 2019; Ellis & Ellis, 2019). Philip Berman,

for example, often seems to assume that his past history has locked him into his present situation.

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

He approaches all new experiences and relationships with expectations of failure and disaster.

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

focused theorists. Beck has found that depressed people consistently think in illogical ways and

keep arriving at self-defeating conclusions (Beck & Weishaar, 2019). They may, for example,

overgeneralize—draw broad negative conclusions on the basis of single insignificant events. One

depressed student couldn’t remember the date of Columbus’ third voyage to America while she

was in history class. Overgeneralizing, she spent the rest of the day in despair over her wide-

ranging ignorance.

In treatment, cognition-focused

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#TheirWords “We cannot solve our problems with the same thinking we

used when we created them.”

Albert Einstein

therapists use several strategies to help

people with psychological disorders adopt

new, more functional ways of thinking. In

an influential approach developed by

Beck, the therapists guide depressed

clients to identify and challenge any

negative thoughts, biased interpretations, and errors in logic that dominate their thinking and

contribute to their disorder. The therapists also guide the clients to try out new ways of thinking

in their daily lives. As you will see in Chapter 6, depressed people treated with Beck’s approach

improve much more than those who receive no treatment (Beck & Weishaar, 2019).

In the excerpt that follows, a Beck-like therapist guides a depressed 26-year-old graduate

student to see the link between her interpretations and her feelings and to begin questioning the

accuracy of those interpretations:

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?

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#SocialDistress For most people, silence becomes awkward after about four

seconds (Pear, 2013).

Patient: That I can never be happy …

Therapist: So it is the meaning of failing a test that makes you very unhappy. In fact, believing 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)

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

behavioral and cognitive elements in their explanations and treatments for psychological

disorders. Let’s look, for example, at the cognitive-behavioral approach to social anxiety disorder,

a problem that you will be reading more about in Chapter 4.

People with social anxiety disorder

have severe anxiety about social situations

in which they may face scrutiny by other

people. They worry that they will

function poorly in front of others and will

wind up feeling humiliated. Thus they may avoid speaking in public, reject social opportunities,

and limit their lives in numerous ways.

social anxiety disorder A psychological disorder in which people fear social situations.

Cognitive-behavioral theorists contend that people with this disorder hold a group of social

beliefs and expectations that consistently work against them (Hofmann, 2018; Thurston et al.,

2017; Heimberg et al., 2010). These include:

Holding unrealistically high social standards and so believing that they must perform perfectly in social situations.

Viewing themselves as unattractive social beings.

Viewing themselves as socially unskilled and inadequate.

Believing they are always in danger of behaving incompetently in social situations.

Believing that inept behaviors in social situations will inevitably lead to terrible consequences.

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Overrun by such beliefs and expectations, people with social anxiety disorder find that their

anxiety levels increase as soon as they enter into a social situation. In turn, say cognitive-

behavioral theorists, the individuals learn to regularly perform “avoidance” and “safety” behaviors

(Mesri et al., 2017; Moscovitch et al., 2013). Avoidance behaviors include, for example, talking

only to people they already know well at gatherings or parties, or avoiding social gatherings

altogether. Safety behaviors include wearing makeup to cover up blushing. Such behaviors are

reinforced by eliminating or reducing the individuals’ feelings of anxiety and the number of

unpleasant events they encounter.

To undo this cycle of problematic beliefs and behaviors, cognitive-behavioral therapists

combine several techniques, including exposure therapy, a behavior-focused intervention in

which fearful people are repeatedly exposed to the objects or situations they dread (Thurston et

al., 2017). In cases of social anxiety disorder, the therapists encourage clients to immerse

themselves in various dreaded social situations and to remain there until their fears subside.

Usually the exposure is gradual. Then, back in therapy, the clinicians and clients reexamine and

challenge the individuals’ maladaptive beliefs and expectations in light of the recent social

encounters.

exposure therapy A behavior-focused intervention in which fearful people are repeatedly exposed to the objects or situations they dread.

In the following discussion, a cognitive-behavioral therapist works with a socially anxious

client who fears he will be rejected if he speaks up at gatherings. The therapy discussion is taking

place after the man has done a homework assignment in which he was asked to identify his

negative social expectations and force himself to say anything he had on his mind in social

situations, no matter how stupid it might seem to him:

After two weeks of this assignment, the patient came into his next session of therapy and reported: “I did what you told me to

do. … [Every] time, just as you said, I found myself retreating from people, I said to myself: ‘Now, even though you can’t see it,

there must be some sentences. What are they?’ And I finally found them. And there were many of them! And they all seemed to say

the same thing.”

“What thing?”

“That I, uh, was going to be rejected. … [If] I related to them I was going to be rejected. And wouldn’t that be perfectly awful

if I was to be rejected.” …

“And did you do the second part of the homework assignment?”

“The forcing myself to speak up and express myself?”

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#TheirWords “The greatest discovery of my generation is that human beings

can alter their lives by altering their attitudes of mind.”

William James (1842–1910)

“Yes, that part.”

“That was worse. That was really hard. Much harder than I thought it would be. But I did it.”

“And?”

“Oh, not bad at all. I spoke up several times; more than I’ve ever done before. Some people were very surprised.”. . .

“And how did you feel after expressing yourself like that?”

“Remarkable! … I felt, uh, just remarkable—good, that is … . But it was so hard. I almost didn’t make it. And a couple of

other times during the week I had to force myself again. But I did. And I was glad!”

(Ellis, 1962, pp. 202–203)

In cognitive-behavioral approaches of this kind, clients come to adopt more accurate social

beliefs, engage in more social situations, and experience less fear during, and in anticipation of,

social encounters. Avoidance and safety behaviors drop away while social approach behaviors are

reinforced by opening the door to the joy and enrichment of social encounters. Studies show that

such approaches do indeed help many individuals to overcome social anxiety disorder (Gregory

& Peters, 2017; Heimberg & Magee, 2014).

Assessing the Cognitive-Behavioral Model The cognitive-behavioral model has

become a powerful force in the clinical

field. Various cognitive and behavioral

theories have been proposed over the

years, and many treatment techniques

have been developed. As you can see in

Figure 2-3, nearly half of today’s clinical psychologists report that their approach is cognitive

and/or behavioral (Prochaska & Norcross, 2018).

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FIGURE 2-3

Theoretical Orientations of Today’s Clinical Psychologists

In surveys, 22 percent of clinical psychologists labeled their approach as “eclectic,” 46 percent considered their model

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

Norcross, 2018.)

One reason for the appeal of the cognitive-behavioral model is that it can be tested in the

laboratory, whereas psychodynamic theories generally cannot. Many of the model’s basic

concepts—stimulus, response, reward, attitude, and interpretation—can be observed or, at least,

measured. Moreover, investigators have found that people with psychological disorders often

display the kinds of reactions, assumptions, and errors in thinking that cognitive-behavioral

theorists would predict (Kube et al., 2018).

Yet another reason for the popularity of this model is the impressive research performance of

cognitive-behavioral therapies. Both in the laboratory and real life, they have proved very helpful

to many people with anxiety disorders, depression, sexual dysfunction, intellectual disability, and

yet other problems (Reavell et al., 2018; Dobson & Dobson, 2017).

At the same time, the cognitive-behavioral model has drawbacks. First, although maladaptive

behaviors and disturbed cognitive processes are found in many forms of abnormality, their

precise role has yet to be determined. The problematic behaviors and cognitions seen in

psychologically troubled people could well be a result rather than a cause of their difficulties.

Second, although cognitive-behavioral therapies are clearly of help to many people, they do not

help everyone. Research indicates, in fact, that it is not always possible for clients to rid

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#WanderingThoughts Your mind wanders almost one-half of the time on average

(Killingsworth, 2013; Killingsworth & Gilbert, 2010).

themselves fully of their negative thoughts and biased interpretations (Sharf, 2015).

In response to such limitations, a new group of therapies, sometimes called the new wave of

cognitive-behavioral therapies, has emerged in recent years. These new approaches, including the

increasingly used acceptance and commitment therapy (ACT), help clients to accept many of their

problematic thoughts rather than judge them, act on them, or try fruitlessly to change them

(Gonzalez-Fernandez et al., 2018; Hayes, 2016). 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.

“Don’t take that tone of thought with me.”

As you will see in Chapter 4, ACT and similar therapies often employ mindfulness-based

techniques to help clients achieve such acceptance. These techniques borrow heavily from a form

of meditation called mindfulness meditation, which teaches individuals to pay attention to the

thoughts and feelings that are flowing through their minds during meditation and to accept such

thoughts in a nonjudgmental way (see InfoCentral). Research suggests that ACT and other

mindfulness-based approaches are often quite helpful in the treatment of anxiety and depression,

among other problems (Walsh, 2019; Gonzalez-Fernandez et al., 2018).

A final drawback of the cognitive-

behavioral model is that it is narrow in

certain ways. Although behavior and

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cognition obviously are key dimensions in

life, they are still only two aspects of human functioning. Shouldn’t explanations of human

functioning also consider broader issues, such as how people approach life, what value they

extract from it, and how they deal with the question of life’s meaning? This is the position of the

humanistic-existential model.

INFOCENTRAL

MINDFULNESS

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

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

Mindfulness training programs use mindfulness meditation techniques to help treat people

suffering from pain, anxiety disorders, and depressive disorders, as well as a variety of other

psychological disorders.

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SUMMING UP

THE COGNITIVE-BEHAVIORAL MODEL Proponents of the cognitive-behavioral model focus on maladaptive behaviors and cognitions to explain and treat

psychological disorders. Most such proponents include both the behavioral and cognitive dimensions in their work.

On the behavioral side, the proponents hold that three types of conditioning—classical conditioning, modeling,

and operant conditioning—account for behavior, whether normal or dysfunctional, and they treat people who display

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problematic behaviors by replacing such behaviors with more appropriate ones, using techniques based on the

principles of conditioning. On the cognitive side, the model’s proponents point to cognitive problems, like

maladaptive assumptions and illogical thinking processes, to explain abnormal functioning; and they treat

dysfunctional people by helping them recognize, challenge, and change their problematic ways of thinking.

In addition to the traditional cognitive-behavioral approaches, a new wave of cognitive-behavioral therapies, such

as acceptance and commitment therapy (ACT), try to teach clients to be mindful of and accept many of their

problematic thoughts.

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The Humanistic-Existential Model Philip Berman is more than the sum of his psychological conflicts, learned behaviors, or

cognitions. Being human, he also has the ability to pursue philosophical goals such as self-

awareness, strong values, a sense of meaning in life, and freedom of choice. According to

humanistic and existential theorists, Philip’s problems can be understood only in the light of

such complex goals. Humanistic and existential theorists are often grouped together—in an

approach known as the humanistic-existential model—because of their common focus on these

broader dimensions of human existence. At the same time, there are important differences

between them.

Humanists, the more optimistic of the two groups, believe that human beings are born with a

natural tendency to be friendly, cooperative, and constructive. People, these theorists propose, are

driven to self-actualize—that is, to fulfill their potential for goodness and growth. They can do

so, however, only if they honestly recognize and accept their weaknesses as well as their strengths

and establish satisfying personal values to live by. Humanists further suggest that self-

actualization leads naturally to a concern for the welfare of others and to behavior that is loving,

courageous, spontaneous, and independent (Maslow, 1970).

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

Existentialists agree that human beings must have an accurate awareness of themselves and live

meaningful—they say “authentic”—lives in order to be psychologically well adjusted. These

theorists do not believe, however, that people are naturally inclined to live positively. They

believe that from birth we have total freedom, either to face up to our existence and give meaning

to our lives or to shrink from that responsibility. Those who choose to “hide” from responsibility

and choice will view themselves as helpless and may live empty, inauthentic, and dysfunctional

lives as a result.

The humanistic and existential views of abnormality both date back to the 1940s. At that

time Carl Rogers (1902–1987), often considered the pioneer of the humanistic perspective,

developed client-centered therapy, a warm and supportive approach that contrasted sharply with

the psychodynamic techniques of the day. He also proposed a theory of personality that paid

little attention to irrational instincts and conflicts.

client-centered therapy The humanistic therapy developed by Carl Rogers in which clinicians try to help clients by conveying acceptance, accurate empathy, and genuineness.

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The existential view of personality and abnormality appeared during this same period. Many

of its principles came from the ideas of nineteenth-century European existential philosophers

who held that human beings are constantly defining and so giving meaning to their existence

through their actions (Schneider & Krug, 2017; Cooper, 2016).

The humanistic and existential theories, and their uplifting implications, were extremely

popular during the 1960s and 1970s, years of considerable soul-searching and social upheaval in

Western society. They have since lost some of their popularity, but they continue to influence the

ideas and work of many clinicians. In particular, humanistic principles are apparent throughout

positive psychology (the study and enhancement of positive feelings, traits, abilities, and selfless

virtues), an area of psychology that, as you read in Chapter 1, has gained much momentum in

recent years (see page 16).

Rogers’ Humanistic Theory and Therapy According to Carl Rogers, the road to dysfunction begins in infancy (Raskin, Rogers, & Witty,

2019; Rogers, 1987, 1951). We all have a basic need to receive positive regard from the important

people in our lives (primarily our parents). Those who receive unconditional (nonjudgmental)

positive regard early in life are likely to develop unconditional self-regard. That is, they come to

recognize their worth as persons, even while recognizing that they are not perfect. Such people

are in a good position to actualize their positive potential.

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Actualizing the self Humanists suggest that self-actualized people show concern for others, among other positive qualities.

Many work as volunteers. For example, as part of the Free Hugs Project, a worldwide campaign, volunteers offer hugs to

passersby who look like they could use a quick dose of comfort.

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 striving to fulfill

his positive human potential, he drifts from job to job and relationship to relationship. In every

interaction he is defending himself, trying to interpret events in ways he can live with, usually

blaming his problems on other people. Nevertheless, his basic negative self-image continually

reveals itself. Rogers would probably link this problem to the critical ways Philip was treated by

his mother throughout his childhood.

Clinicians who practice Rogers’ client-centered therapy try to create a supportive climate in

which clients feel able to look at themselves honestly and acceptingly (Raskin et al., 2019). The

therapist must display three important qualities throughout the therapy—unconditional positive

regard (full and warm acceptance for the client), accurate empathy (skillful listening and restating),

and genuineness (sincere communication). In the following classic case, the therapist uses 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.

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

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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 (Prochaska & Norcross, 2018,

2013). 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’ therapy has had a positive influence on clinical practice (Raskin et al., 2019). It

was one of the first major alternatives to psychodynamic therapy, and it helped open up the

clinical field to new approaches. Rogers also helped pave the way for psychologists to practice

psychotherapy, which had previously been considered the exclusive territory of psychiatrists. And

his commitment to clinical research helped promote the systematic study of treatment.

Approximately 2 percent of today’s clinical psychologists, 1 percent of social workers, and 3

percent of counseling psychologists report that they employ the client-centered approach

(Prochaska & Norcross, 2018).

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

clinician named Frederick (Fritz) Perls (1893–1970). Gestalt therapists, like client-centered

therapists, guide their clients toward self-recognition and self-acceptance (Yontef & Jacobs,

2019). But unlike client-centered therapists, they try to achieve this goal by challenging and even

frustrating the clients, demanding that they stay in the here and now during therapy discussions,

and pushing them to embrace their real emotions.

gestalt therapy The humanistic therapy 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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For example, gestalt therapists often use the technique of role playing, instructing clients to act

out various roles. A person may be told to be another person, an object, an alternative self, or

even a part of the body. The gestalt version of role playing can become intense, as individuals are

encouraged to express emotions fully. Many cry out, scream, kick, or pound. Through this

experience they may come to “own” (accept) feelings that previously made them uncomfortable.

Beating the blues Gestalt therapists often guide clients to express their needs and feelings in their full intensity by banging

on pillows, crying out, kicking, or pounding things. Building on these techniques, a new approach, drum therapy, teaches

clients, such as this woman, how to beat drums in order to help release traumatic memories, change beliefs, and feel more

liberated.

Approximately 1 percent of clinical psychologists and other kinds of clinicians describe

themselves as gestalt therapists (Prochaska & Norcross, 2018). Because they believe that

subjective experiences and self-awareness cannot be measured objectively, proponents of gestalt

therapy have not often performed controlled research on this approach (Yontef & Jacobs, 2019).

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. In the early 1900s, for example, Freud argued that religious

beliefs were defense mechanisms, “born from man’s need to make his helplessness tolerable”

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What various explanations might account for the correlation

between spirituality and mental health?

(1961, p. 23). This negative view of religion now seems to be ending, however. During the past

decade, many articles and books linking spiritual issues to clinical treatment have been published,

and the ethical codes of psychologists, psychiatrists, and counselors have each concluded that

religion is a type of diversity that mental health professionals must respect (APA, 2017, 2010).

Researchers have learned that

spirituality does, in fact, often correlate

with psychological health. In particular,

studies have examined the mental health

of people who are devout and who view God as warm, caring, helpful, and dependable.

Repeatedly, these individuals are found to be less lonely, pessimistic, depressed, or anxious than

people without any religious beliefs or those who view God as cold and unresponsive (Kucharska,

2017; Steffen, Masters, & Baldwin, 2017). Such people also seem to cope better with major life

stressors—from illness to war—and to attempt suicide less often. In addition, they are less likely

to abuse drugs.

Do such correlations indicate that spirituality helps produce greater mental health? Not

necessarily. As you’ll recall from Chapter 1, correlations do not indicate causation. It may be, for

example, that a sense of optimism leads to more spirituality, and that, independently, optimism

contributes to greater mental health. Whatever the proper interpretation, many therapists now

make a point of including spiritual issues when they treat religious clients, and some further

encourage clients to use their spiritual resources to help them cope with current stressors

(Barnett, 2018; McClintock, Lau, & Miller, 2016). Similarly, a number of religious institutions

offer counseling services to their members.

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Spirituality and science A few years ago, Tibetan spiritual leader the Dalai Lama (right) met with professor of psychiatry

Zindel Segal (left) and other mental health researchers at a conference examining possible ties between science, mental

health, and spirituality.

Existential Theories and Therapy Like humanists, existentialists believe that psychological dysfunction is caused by self-deception;

existentialists, however, are talking about a kind of self-deception in which people hide from life’s

responsibilities and fail to recognize that it is up to them to give meaning to their lives. According

to existentialists, many people become overwhelmed by the pressures of present-day society and

so look to others for explanations, guidance, and authority. They overlook their personal freedom

of choice and avoid responsibility for their lives and decisions (Yalom & Josselson, 2019;

Cooper, 2016). 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 teachers,

acquaintances, and employers as being oppressive. He fails to appreciate his choices in life and his

own capacity for finding meaning and direction. Quitting becomes a habit with him—he leaves

job after job, ends every romantic relationship, and flees difficult situations.

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

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their problems. Therapists try to help clients recognize their freedom so that they may choose a

different course and live with greater meaning (Yalom & Josselson, 2019; Schneider & Krug,

2017). The precise techniques used in existential therapy vary from clinician to clinician. At the

same time, most existential therapists place great emphasis on the relationship between therapist

and client and try to create an atmosphere of honesty, hard work, and shared learning and

growth.

Fundamentals of Abnormal Psychology ninth edition

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