Diagnosis and Treatment

Resources: Ch. 12–13 of Understanding Psychology

Choose one of the psychological disorders discussed in Ch. 12.

Write a 750- to 1,050-word paper in which you briefly describing the disorder and detail the current trends in diagnosis and treatment for the disorder you have chosen.

Format the essay consistent with APA guidelines.

Psychological
Disorders12

Enduring Issues in
Psychological Disorders
Perspectives on
Psychological Disorders
• Historical Views of

Psychological Disorders
• The Biological Model
• The Psychoanalytic Model
• The Cognitive–Behavioral

Model
• The Diathesis–Stress Model

and Systems Theory

• The Prevalence of
Psychological Disorders

• Mental Illness and the Law
• Classifying Abnormal

Behavior

Mood Disorders
• Depression
• Suicide
• Mania and Bipolar Disorder
• Causes of Mood Disorders

Anxiety Disorders
• Specific Phobias
• Panic Disorder
• Other Anxiety Disorders
• Causes of Anxiety Disorders
Psychosomatic and
Somatoform Disorders
Dissociative Disorders
Sexual and Gender-Identity
Disorders
Personality Disorders

Schizophrenic Disorders
• Types of Schizophrenic

Disorders
• Causes of Schizophrenia
Childhood Disorders
Gender and Cultural
Differences in Psychological
Disorders
• Gender Differences
• Cultural Differences

O V E R V I E W

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J
ack was a very successful chemical engineer known for the
meticulous accuracy of his work. But Jack also had a “little
quirk.” He constantly felt compelled to double-, triple-, and

even quadruple-check things to assure himself that they were
done properly. For instance, when leaving his apartment in the
morning, he occasionally got as far as the garage—but invariably
he would go back to make certain that the door was securely
locked and the stove, lights, and other appliances were all turned
off. Going on a vacation was particularly difficult for him because
his checking routine was so exhaustive and time-consuming. Yet
Jack insisted that he would never want to give up this chronic
checking. Doing so, he said, would make him “much too nervous.”

For Claudia, every day was more than just a bad-hair day.
She was always in utter despair over how “hideous” her hair
looked. She perceived some parts of it to be too long, and others
to be too short. In her eyes, one area would look much too
“poofy,” while another area would look far too flat. Claudia got
up early each morning just to work on her hair. For about 2 hours
she would wash it, dry it, brush it, comb it, curl it, straighten it,
and snip away infinitesimal amounts with an expensive pair of
hair-cutting scissors. But she was never satisfied with the

391

results. Not even trips to the most expensive salons could make
her feel content about her hair. She declared that virtually every
day was ruined because her hair looked so bad. Claudia said
that she desperately wanted to stop focusing on her hair, but for
some reason she just couldn’t.

Jonathan was a 22-year-old auto mechanic whom everyone
described as a loner. He seldom engaged in conversation and
seemed lost in his own private world. At work, the other
mechanics took to whistling sharply whenever they wanted to
get his attention. Jonathan also had a “strange look” on his face
that could make customers feel uncomfortable. But his oddest
behavior was his assertion that he sometimes had the distinct
feeling his dead mother was standing next to him, watching
what he did. Although Jonathan realized that his mother was not
really there, he nevertheless felt reassured by the illusion of her
presence. He took great care not to look or reach toward the
spot where he felt his mother was, because doing so inevitably
made the feeling go away.

Cases adapted from J. S. Nevis, S. A. Rathus, & B. Green (2005). Abnormal Psychol-

ogy in a Changing World (5th ed.) Upper Saddle River, NJ: Prentice Hall.

ENDURING ISSUES IN PSYCHOLOGICAL
DISORDERS
As we explore psychological disorders in this chapter, we will again encounter some of the
enduring issues that interest psychologists. A recurring topic is the relationship between
genetics, neurotransmitters, and behavior disorders (mind–body). We will also see that
many psychological disorders arise because a vulnerable person encounters a particularly
stressful environment (person–situation). As you read the chapter, think about how you
would answer the question “What is normal?” and how the answer to that question has
changed over time and differs even today across cultures (diversity–universality). Consider
also whether a young person with a psychological disorder is likely to suffer from it later in
life and, conversely, whether a well-adjusted young person is immune to psychological dis-
orders later in life (stability–change).

PERSPECTIVES ON PSYCHOLOGICAL
DISORDERS
How does a mental health professional define a psychological disorder?

When is a person’s behavior abnormal? This is not always easy to determine. There is no
doubt about the abnormality of a man who dresses in flowing robes and accosts pedestri-
ans on the street, claiming to be Jesus Christ, or a woman who dons an aluminum-foil hel-
met to prevent space aliens from “stealing” her thoughts. But other instances of abnormal
behavior aren’t always so clear. What about the three people we have just described? All of
them exhibit unusual behavior. But does their behavior deserve to be labeled “abnormal”?
Do any of them have a genuine psychological disorder?

The answer depends in part on the perspective you take. As Table 12–1 summarizes,
society, the individual, and the mental health professional all adopt different perspectives

L E A R N I N G O B J E C T I V E S
• Compare the three perspectives on

what constitutes abnormal behavior.
Explain what is meant by the statement
“Identifying behavior as abnormal is
also a matter of degree.” Distinguish
between the prevalence and incidence
of psychological disorders, and
between mental illness and insanity.

• Describe the key features of the
biological, psychoanalytic,
cognitive–behavioral, diathesis–stress,
and systems models of psychological
disorders.

• Explain what is meant by “DSM-IV-TR”
and describe the basis on which it
categorizes disorders.

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when distinguishing abnormal behavior from normal behavior. Society’s main standard of
abnormality is whether the behavior fails to conform to prevailing ideas about what is
socially expected of people. In contrast, when individuals assess the abnormality of their
own behavior, their main criterion is whether that behavior fosters a sense of unhappiness
and lack of well-being. Mental health professionals take still another perspective. They
assess abnormality chiefly by looking for maladaptive personality traits, psychological dis-
comfort regarding a particular behavior, and evidence that the behavior is preventing the
person from functioning well in life.

These three approaches to identifying abnormal behavior are not always in agree-
ment. For example, of the three people previously described, only Claudia considers her
own behavior to be a genuine problem that is undermining her happiness and sense of
well-being. In contrast to Claudia, Jack is not really bothered by his compulsive behavior
(in fact, he sees it as a way of relieving anxiety); and Jonathan is not only content with
being a loner, but he also experiences great comfort from the illusion of his dead
mother’s presence. But now suppose we shift our focus and adopt society’s perspective.
In this case, we must include Jonathan on our list of those whose behavior is abnormal.
His self-imposed isolation and talk of sensing his mother’s ghost violate social expecta-
tions of how people should think and act. Society would not consider Jonathan normal.
Neither would a mental health professional. In fact, from the perspective of a mental
health professional, all three of these cases show evidence of a psychological disorder.
The people involved may not always be distressed by their own behavior, but that behav-
ior is impairing their ability to function well in everyday settings or in social relation-
ships. The point is that there is no hard and fast rule as to what constitutes abnormal
behavior. Distinguishing between normal and abnormal behavior always depends on the
perspective taken.

Identifying behavior as abnormal is also a matter of degree. To understand why, imag-
ine that each of our three cases is slightly less extreme. Jack is still prone to double-checking,
but he doesn’t check over and over again. Claudia still spends much time on her hair, but she
doesn’t do so constantly and not with such chronic dissatisfaction. As for Jonathan, he only
occasionally withdraws from social contact; and he has had the sense of his dead mother’s
presence just twice over the last 3 years. In these less severe situations, a mental health pro-
fessional would not be so ready to diagnose a mental disorder. Clearly, great care must be
taken when separating mental health and mental illness into two qualitatively different cate-
gories. It is often more accurate to think of mental illness as simply being quantitatively dif-
ferent from normal behavior—that is, different in degree. The line between one and the
other is often somewhat arbitrary. Cases are always much easier to judge when they fall at
the extreme end of a dimension than when they fall near the “dividing line.”

Table 12–1 PERSPECTIVES ON PSYCHOLOGICAL DISORDERS

Standards/Values Measures

Society Orderly world in which people assume responsibility for their
assigned social roles (e.g., breadwinner, parent), conform to
prevailing mores, and meet situational requirements.

Observations of behavior, extent to which a person fulfills
society’s expectations and measures up to prevailing standards.

Individual Happiness, gratification of needs. Subjective perceptions of self-esteem, acceptance, and well-being.
Mental health
professional

Sound personality structure characterized by growth,
development, autonomy, environmental mastery, ability to
cope with stress, adaptation.

Clinical judgment, aided by behavioral observations and
psychological tests of such variables as self-concept; sense of
identity; balance of psychic forces; unified outlook on life;
resistance to stress; self-regulation; the ability to cope with
reality; the absence of mental and behavioral symptoms;
adequacy in interpersonal relationships.

Source: From “A Tripartite Model of Mental Health and Therapeutic Outcomes with Special Reference to Negative Effects on Psychotherapy” by H. H. Strupp and
S. W. Hadley, American Psychologist, 32 (1977), pp. 187–196. Copyright © 1977 by American Psychological Association.

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Psychological Disorders 393

Historical Views of
Psychological Disorders
How has the view of psychological
disorders changed over time?

The place and times also contribute to how we define
mental disorders. Thousands of years ago, mysterious
behaviors were often attributed to supernatural powers
and madness was a sign that spirits had possessed a per-
son. As late as the 18th century, the emotionally dis-
turbed person was thought to be a witch or to be
possessed by the devil. Exorcisms, ranging from the
mild to the hair raising, were performed, and many
people endured horrifying tortures. Some people were
even burned at the stake.

By the late Middle Ages, there was a move away
from viewing the mentally ill as witches and possessed
by demons, and they were increasingly confined to
public and private asylums. Even though these institu-
tions were founded with good intentions, most were little more than prisons. In the
worst cases, inmates were chained down and deprived of food, light, or air in order to
“cure” them.

Little was done to ensure humane standards in mental institutions until 1793, when
Philippe Pinel (1745–1826) became director of the Bicêtre Hospital in Paris. Under his
direction, patients were released from their chains and allowed to move about the hospital
grounds, rooms were made more comfortable and sanitary, and questionable and violent
medical treatments were abandoned (James Harris, 2003). Pinel’s reforms were soon fol-
lowed by similar efforts in England and, somewhat later, in the United States where
Dorothea Dix (1802–1887), a schoolteacher from Boston, led a nationwide campaign for
the humane treatment of mentally ill people. Under her influence, the few existing asylums
in the United States were gradually turned into hospitals.

The basic reason for the failed—and sometimes abusive—treatment of mentally dis-
turbed people throughout history has been the lack of understanding of the nature and
causes of psychological disorders. Although our knowledge is still inadequate, important
advances in understanding abnormal behavior can be traced to the late 19th and 20th cen-
turies, when three influential but conflicting models of abnormal behavior emerged: the
biological model, the psychoanalytic model, and the cognitive–behavioral model.

The Biological Model
How can biology influence the development of psychological disorders?

The biological model holds that psychological disorders are caused by physiological mal-
functions often stemming from hereditary factors. As we shall see, support for the biologi-
cal model has been growing rapidly as scientists make advances in the new interdisciplinary
field of neuroscience, which directly links biology and behavior (see Chapter 2, “The Biolog-
ical Basis of Behavior”).

For instance, new neuroimaging techniques have enabled researchers to pinpoint
regions of the brain involved in such disorders as schizophrenia (Kumra, 2008; Ragland,
2007) and antisocial personality (Birbaumer et al., 2005; Narayan et al., 2007). By unravel-
ing the complex chemical interactions that take place at the synapse, neurochemists have
spawned advances in neuropharmacology leading to the development of promising new
psychoactive drugs (see Chapter 13, “Therapies”). Many of these advances are also linked to
the field of behavior genetics, which is continually increasing our understanding of the role

In the 17th century, French physicians tried
various devices to cure their patients of
“fantasy and folly.”

biological model View that psychological
disorders have a biochemical or physiological
basis.

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of specific genes in the development of complex disorders such as schizophrenia (Horiuchi
et al., 2006; Tang et al., 2006; Ying-Chieh Wang et al., 2008) and autism (Kuehn, 2006; Losh,
Sullivan, Trembath, & Piven, 2008).

Although neuroscientific breakthroughs are indeed remarkable, to date no neu-
roimaging technique can clearly and definitively differentiate among various mental dis-
orders (Callicott, 2003; Sarason & Sarason, 1999). And despite the availability of an
increasing number of medications to alleviate the symptoms of some mental disorders,
most drugs can only control—rather than cure—abnormal behavior. There is also some
concern that advances in identifying the underlying neurological structures and mecha-
nisms associated with mental illnesses may interfere with the recognition of equally impor-
tant psychological causes of abnormal behavior (Dudai, 2004; Widiger & Sankis, 2000).
Despite this concern, the integration of neuroscientific research and traditional psycholog-
ical approaches to understanding behavior is taking place at an increasingly rapid pace, and
will undoubtedly reshape our view of mental illness in the future (Lacy & Hughes, 2006;
Westen, 2005).

The Psychoanalytic Model
What did Freud and his followers believe was the underlying cause
of psychological disorders?

Freud and his followers developed the psychoanalytic model during the late 19th and early
20th centuries. (See Chapter 10, “Personality.”) According to this model, behavior disorders
are symbolic expressions of unconscious conflicts, which can usually be traced to childhood.
The psychoanalytic model argues that in order to resolve their problems effectively, people
must become aware that the source of their problems lies in their childhood and infancy.

Although Freud and his followers profoundly influenced both the mental health disci-
plines and Western culture, only weak and scattered scientific evidence supports their psy-
choanalytic theories about the causes and effective treatment of mental disorders.

The Cognitive–Behavioral Model
According to the cognitive–behavioral model, what causes
abnormal behavior?

A third model of abnormal behavior grew out of 20th-century research on learning and
cognition. The cognitive–behavioral model suggests that psychological disorders, like all
behavior, result from learning. For example, a bright student who believes that he is acade-
mically inferior to his classmates and can’t perform well on a test may not put much effort
into studying. Naturally, he performs poorly, and his poor test score confirms his belief that
he is academically inferior.

The cognitive–behavioral model has led to innovations in the treatment of psycholog-
ical disorders, but the model has been criticized for its limited perspective, especially its
emphasis on environmental causes and treatments.

The Diathesis–Stress Model
and Systems Theory
Why do some people with a family history of a psychological disorder
develop the disorder, whereas other family members do not?

Each of the three major theories is useful in explaining the causes of certain types of disor-
ders. The most exciting recent developments, however, emphasize integration of the vari-
ous theoretical models to discover specific causes and specific treatments for different
mental disorders.

394 Chapter 12

psychoanalytic model View that
psychological disorders result from unconscious
internal conflicts.

cognitive–behavioral model View that
psychological disorders result from learning
maladaptive ways of thinking and behaving.

The cognitive–behavioral view of mental dis-
orders suggests that people can learn—and
unlearn—thinking patterns that affect their
lives unfavorably. For example, an athlete who
is convinced she will not win may not practice
as hard as she should and end up “defeating
herself.”

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Psychological Disorders 395

One promising integrative approach is seen in the diathesis–stress model
(McKeever & Huff, 2003; L. A. Schmidt, Polak, & Spooner, 2005). This model suggests
that a biological predisposition called a diathesis must combine with a stressful circum-
stance before the predisposition to a mental disorder is manifested (S. R. Jones & Ferny-
hough, 2007).

The systems approach, also known as the biopsychosocial model, examines how bio-
logical risks, psychological stresses, and social pressures and expectations combine to pro-
duce psychological disorders (Fava & Sonino, 2007; Weston, 2005). According to this
model, emotional problems are “lifestyle diseases” that, much like heart disease and many
other physical illnesses, result from a combination of risk factors and stresses. Just as heart
disease can result from a combination of genetic predisposition, personality styles, poor
health habits (such as smoking), and stress, psychological problems result from several risk
factors that influence one another. In this chapter, we follow the systems approach in exam-
ining the causes and treatments of abnormal behavior.

diathesis Biological predisposition.

systems approach View that biological,
psychological, and social risk factors combine
to produce psychological disorders. Also
known as the biopsychosocial model of
psychological disorders.

Mind–Body Causes of Mental Disorders
Throughout this chapter, as we discuss what is known about the causes of psychological
disorders, you will see that biological and psychological factors are intimately connected.
For example, there is strong evidence for a genetic component in some personality disor-
ders as well as in schizophrenia. However, not everyone who inherits these factors develops
a personality disorder or suffers from schizophrenia. Our current state of knowledge allows
us to pinpoint certain causative factors for certain conditions, but it does not allow us to
completely differentiate biological and psychological factors. ■

The Prevalence of Psychological Disorders
How common are mental disorders?

Psychologists and public-health experts are concerned with both the prevalence and
the incidence of mental health problems. Prevalence refers to the frequency with which
a given disorder occurs at a given time. If there were 100 cases of depression in a popu-
lation of 1,000, the prevalence of depression would be 10%. The incidence of a disorder
refers to the number of new cases that arise in a given period. If there were 10 new cases
of depression in a population of 1,000 in a single year, the incidence would be 1%
per year.

In 2005, the National Institute of Mental Health conducted a survey finding that
26.2% or approximately 57.7 million Americans were suffering from a mental disorder.
While only about 6% were regarded as having a serious mental illness, almost half the peo-
ple (45%) suffering from one mental disorder also met the criteria for 2 or more other
mental disorders (Kessler, Chiu, Demler, & Walters, 2005). Notably, mental disorders are
the leading cause of disability in the United States for people between the ages of 15 and 44
(The World Health Organization, 2004). Figure 12–1 shows the prevalence for some of the
more common mental disorders among adult Americans. As shown in Figure 12–1, anxi-
ety disorders are the most common mental disorder followed by mood disorders. (All of
these are described in detail later in this chapter.)

More recently diagnostic interviews with more than 60,000 people in 14 countries
around the world showed that over a 1-year period, the prevalence of moderate or serious
psychological disorders varied widely from 12% of the population in the Americas to 7% in
Europe, 6% in the Middle East and Africa, and just 4% in Asia (World Health Organization
[WHO] World Mental Health Survey Consortium, 2004).

diathesis–stress model View that people
biologically predisposed to a mental disorder
(those with a certain diathesis) will tend to exhibit
that disorder when particularly affected by stress.

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Mental Illness and the Law
Is there a difference between being “mentally ill”
and being “insane”?

Particularly horrifying crimes have often been attributed to mental disturbance, because
it seems to many people that anyone who could commit such crimes must be “crazy.”
But to the legal system, this presents a problem: If a person is truly “crazy,” are we justi-
fied in holding him or her responsible for criminal acts? The legal answer to this ques-
tion is a qualified yes. A mentally ill person is responsible for his or her crimes unless he
or she is determined to be insane. What’s the difference between being “mentally ill” and
being “insane”? Insanity is a legal term, not a psychological one. It is typically applied to
defendants who were so mentally disturbed when they committed their offense that
they either lacked substantial capacity to appreciate the criminality of their actions (to
know right from wrong) or to conform to the requirements of the law (to control their
behavior).

When a defendant is suspected of being mentally disturbed or legally insane,
another important question must be answered before that person is brought to trial: Is
the person able to understand the charges against him or her and to participate in a
defense in court? This issue is known as competency to stand trial. The person is exam-
ined by a court-appointed expert and, if found to be incompetent, is sent to a mental
institution, often for an indefinite period. If judged to be competent, the person is
required to stand trial.

396 Chapter 12

Figure 12–1
Prevalence of selected mental disorders in the United States.
A 2005 survey by the National Institute of Mental Health found that approximately 26.2%, or about
57.7 million Americans suffer from a mental disorder. The prevalence among adult Americans for a
few of the more common mental disorders is shown here.
Source: National Institute of Mental Health (2005).

Major Depressive Disorder

5 10 15 25

Number of American Adults (in millions)

30 35 40 45

Bipolar 2.

Post-Traumatic Stress Disorder 3.5%

Attention-Deficit Hyperactivity Disorder (ADHD) 4.1%

6.7%

Specific Phobias 8.7%

All Mood Disorders 9.5%

All Anxiety Disorders 18.1%

Schizophrenia 1.1%

Obsessive-Compulsive Disorder 1.0%

insanity Legal term applied to defendants who
do not know right from wrong or are unable to
control their behavior.

Watch PTSD 911 at
www.mypsychlab.com

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Psychological Disorders 397

Classifying Abnormal Behavior
Why is it useful to have a manual of psychological disorders?

For nearly 40 years, the American Psychiatric Association (APA) has issued a manual
describing and classifying the various kinds of psychological disorders. This publication,
the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been revised four
times. The DSM-IV-TR (American Psychiatric Association, 2000) provides a complete
list of mental disorders, with each category painstakingly defined in terms of significant
behavior patterns (see Table 12–2). The DSM has gained increasing acceptance because
its detailed criteria for diagnosing mental disorders have made diagnosis much more reli-
able. Today, it is the most widely used classification of psychological disorders. In the
remainder of this chapter, we will explore some of the key categories in greater detail.

Table 12–2 DIAGNOSTIC CATEGORIES OF DSM-IV-RT

Category Example

Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence

Mental retardation, learning disorders, autistic disorder, attention-deficit/hyperactivity
disorder.

Delirium, Dementia, and Amnestic and Other
Cognitive Disorders

Delirium, dementia of the Alzheimer’s type, amnestic disorder.

Mental Disorders Due to a General Medical
Condition

Psychotic disorder due to epilepsy.

Substance-Related Disorders Alcohol dependence, cocaine dependence, nicotine dependence.
Schizophrenia and Other Psychotic Disorders Schizophrenia, schizoaffective disorder, delusional disorder.
Mood Disorders Major depressive disorder, dysthymic disorder, bipolar disorder.
Anxiety Disorders Panic disorder with agoraphobia, social phobia, obsessive-compulsive disorder, post-

traumatic stress disorder, generalized anxiety disorder.
Somatoform Disorders Somatization disorder, conversion disorder, hypochondriasis.
Factitious Disorders Factitious disorder with predominantly physical signs and symptoms.
Dissociative Disorders Dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization

disorder.
Sexual and Gender-Identity Disorders Hypoactive sexual desire disorder, male erectile disorder, female orgasmic disorder,

vaginismus.
Eating Disorders Anorexia nervosa, bulimia nervosa.
Sleep Disorders Primary insomnia, narcolepsy, sleep terror disorder.
Impulse-Control Disorders Kleptomania, pyromania, pathological gambling.
Adjustment Disorders Adjustment disorder with depressed mood, adjustment disorder with conduct disturbance.
Personality Disorders Antisocial personality disorder, borderline personality disorder, narcissistic personality

disorder, dependent personality disorder.

Answers:1. supernatural.2. genetic.3. Insanity.4. (T).5. (F).6. (F).

CHECK YOUR UNDERSTANDING

1. It is likely that people in early societies believed that ________ forces caused abnormal behavior.
2. There is growing evidence that ________ factors are involved in mental disorders as diverse

as schizophrenia, depression, and anxiety.
3. ________ is a legal term that is not the same thing as mental illness.

Indicate whether the following statements are true (T) or false (F):

4. The line separating normal from abnormal behavior is somewhat arbitrary.
5. About two-thirds of Americans are suffering from one or more serious mental disorders

at any given time.
6. The cognitive view of mental disorders suggests that they arise from unconscious conflicts,

often rooted in childhood.

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MOOD DISORDERS
How do mood disorders differ from ordinary mood changes?

Most people have a wide emotional range; they can be happy or sad, animated or quiet,
cheerful or discouraged, or overjoyed or miserable, depending on the circumstances. In
some people with mood disorders, this range is greatly restricted. They seem stuck at one
or the other end of the emotional spectrum—either consistently excited and euphoric or
consistently sad—regardless of life circumstances. Others with mood disorders alternate
between the extremes of euphoria and sadness.

Depression
How does clinical depression differ from ordinary sadness?

The most common mood disorder is depression, a state in which a person feels over-
whelmed with sadness. Depressed people lose interest in the things they normally enjoy.
Intense feelings of worthlessness and guilt leave them unable to feel pleasure. They are tired
and apathetic, sometimes to the point of being unable to make the simplest decisions.
Many depressed people feel as if they have failed utterly in life, and they tend to blame
themselves for their problems. Seriously depressed people often have insomnia and lose
interest in food and sex. They may have trouble thinking or concentrating—even to the
extent of finding it difficult to read a newspaper. In fact, difficulty in concentrating and
subtle changes in short-term memory are sometimes the first signs of the onset of depres-
sion (Janice Williams et al., 2000). In extreme cases, depressed people may be plagued by
suicidal thoughts or may even attempt suicide (C. T. S. Kumar, Mohan, & Ranjith, 2006).
The earlier the age of onset of depressive symptoms, the greater the likelihood that suicide
may be attempted (A. H. Thompson, 2008).

Clinical depression is different from the “normal” kind of depression that all people
experience from time to time. Only when depression is long lasting and goes well beyond
the typical reaction to a stressful life event is it classified as a mood disorder (American Psy-
chological Association, 2000). (See “Applying Psychology: Recognizing Depression.”)

DSM-IV-TR distinguishes between two forms of depression: Major depressive disor-
der is an episode of intense sadness that may last for several months; in contrast,
dysthymia involves less intense sadness (and related symptoms), but persists with little

398 Chapter 12

depression A mood disorder characterized by
overwhelming feelings of sadness, lack of
interest in activities, and perhaps excessive guilt
or feelings of worthlessness.

APPLY YOUR UNDERSTANDING

1. You are talking to a friend whose behavior has you concerned. She says, “Look, I’m
happy, I feel good about myself, and I think things are going well.” Which viewpoint on
mental health is reflected in her statement?

a. society’s view
b. the individual’s view
c. the mental health professional’s view
d. Both (b) and (c) are true.

2. A friend asks you, “What causes people to have psychological disorders?” You respond,
“Most often, it turns out that some people are biologically prone to developing a
particular disorder. When they have some kind of stressful experience, the predisposition
shows up in their behavior.” What view of psychological disorders are you taking?

a. psychoanalytic model
b. cognitive model
c. behavioral model
d. diathesis–stress model

Answers:1. b.2. d.

L E A R N I N G O B J E C T I V E S
• Explain how mood disorders differ from

ordinary mood changes. List the key
symptoms that are used to diagnose
major depression, dysthymia, mania,
and bipolar disorder. Describe the
causes of mood disorders.

• Describe the factors that are related to
a person’s likelihood of committing
suicide. Contrast the three myths about
suicide with the actual facts about
suicide.

mood disorders Disturbances in mood or
prolonged emotional state.

major depressive disorder A depressive
disorder characterized by an episode of intense
sadness, depressed mood, or marked loss of
interest or pleasure in nearly all activities.

dysthymia A depressive disorder where the
symptoms are generally less severe than for
major depressive disorder, but are present most
days and persist for at least 2 years.

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Psychological Disorders 399

relief for a period of 2 years or more. Depression is two to three times more prevalent in
women than in men (Inaba et al., 2005; Kessler et al., 2003; Nolen-Hoeksema, 2006).

Children and adolescents can also suffer from depression. In very young children,
depression is sometimes difficult to diagnose because the symptoms are usually different
than those seen in adults. For instance, in infants or toddlers, depression may be manifest
as a “failure to thrive” or gain weight, or as a delay in speech or motor development. In
school-age children, depression may be manifested as antisocial behavior, excessive worry-
ing, sleep disturbances, or unwarranted fatigue (Kaslow, Clark, & Sirian, 2008).

One of the most severe hazards of depression, as well as some of the other disorders
described in this chapter, is that people may become so miserable that they no longer
wish to live.

Recognizing Depression

F
rom time to time, almost everyone
gets “the blues.” Failing a major exam,
breaking up with a partner, even leav-

ing home and friends to attend college can
all produce a temporary state of sadness.
More significant life events can have an
even greater impact: The loss of one’s job
or the loss of a loved one can produce a
sense of hopelessness about the future that
feels very much like a slide into depres-
sion. But in all of these instances, either
the mood disorder is a normal reaction to
a real problem or it passes quickly.

At what point do these normal responses
evolve into clinical depression? The DSM-
IV-RT provides the framework for making
this distinction. First, clinical depression is
characterized by depressed mood or by
the loss of interest and pleasure in usual
activities, or both. Clinicians also look for
significant impairment or distress in social,
occupational, or other important areas of
functioning. People suffering from depres-
sion not only feel sad or empty, but also
have significant problems carrying on a
normal lifestyle. Clinicians also look for
other explanations. Could symptoms be
due to substance abuse or medication side
effects? Could they be the result of a med-
ical condition such as hypothyroidism (the
inability of the thyroid gland to produce an
adequate amount of its hormones)? Could
the symptoms be better interpreted as an
intense but otherwise normal reaction to
life events?

If the symptoms do not seem to be
explained by the preceding causes, clini-
cians make a diagnosis of major depressive
disorder according to the DSM-IV-TR,
which specifies that at least five of the fol-
lowing symptoms—including at least one
of the first two—are present:

1. Depressed mood: Does the person feel
sad or empty for most of the day,
most every day, or do others observe
these symptoms?

2. Loss of interest in pleasure: Has the
person lost interest in performing
normal activities, such as working or
going to social events? Does the per-
son seem to be “just going through
the motions” of daily life without
deriving any pleasure from them?

3. Significant weight loss or gain: Has the
person gained or lost more than 5% of
body weight in a month? Has the per-
son lost interest in eating or com-
plained that food has lost its taste?

4. Sleep disturbances: Is the person hav-
ing trouble sleeping? Conversely, is
the person sleeping too much?

5. Disturbances in motor activities: Do
others notice a change in the person’s
activity level? Does the person just “sit
around” or, conversely, behave in an
agitated or unusually restless manner?

6. Fatigue: Does the person complain of
being constantly tired and having no
energy?

7. Feelings of worthlessness or excessive
guilt: Does the person express feelings
such as “You’d be better off without
me” or “I’m evil and I ruin everything
for everybody I love”?

8. Inability to concentrate: Does the per-
son complain of memory problems
(“I just can’t remember anything
anymore”) or the inability to focus
attention on simple tasks, such as
reading a newspaper?

9. Recurrent thoughts of death: Does the
person talk about committing suicide
or express the wish that he or she
were dead?

If you or someone you know well
seems to have these symptoms, that per-
son should consult a doctor or mental
health professional. When these symp-
toms are present and are not due to other
medical conditions, a diagnosis of major
depression is typically the result, and
appropriate treatment can be prescribed.
As you will learn in Chapter 13, “Thera-
pies,” appropriate diagnosis is the first step
in the effective treatment of psychological
disorders.

Source: Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision.
Washington, DC, American Psychiatric Associ-
ation, 2000.

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Suicide
What factors are related to a person’s likelihood
of committing suicide?

Each year in the United States, approximately one suicide occurs every 17 minutes, making
it the 11th leading cause of death (Centers for Disease Control, 2006; Holloway, Brown, &
Beck, 2008). In addition, half a million Americans receive hospital treatment each year for
attempted suicide. Indeed, suicides outnumber homicides by five to three in the United
States. The suicide rate is much higher among Whites than among minorities (Centers for
Disease Control, 2006). Compared to other countries, the suicide rate in the United States
is below average (the highest rates are found in eastern European countries) (Curtin, 2004).
More women than men attempt suicide, but more men succeed, partly because men tend to
choose violent and lethal means, such as guns.

Although the largest number of suicides occurs among older White males, since the
1960s suicide attempt rates have been rising among adolescents and young adults
(Figure 12–2). In fact, adolescents account for 12% of all suicide attempts in the United
States, and in many other countries suicide ranks as either the first, second, or third leading
cause of death in that age group (Centers for Disease Control and Prevention, 1999;
Zalsman & Mann, 2005). We cannot as yet explain the increase, though the stresses of leav-
ing home, meeting the demands of college or a career, and surviving loneliness or broken
romantic attachments seem to be particularly great at this stage of life. Although external
problems such as unemployment and financial strain may also contribute to personal
problems, suicidal behavior is most common among adolescents with psychological prob-
lems. Several myths concerning suicide can be quite dangerous:

Myth: Someone who talks about committing suicide will never do it.
Fact: Most people who kill themselves have talked about it. Such comments should

always be taken seriously.

Myth: Someone who has tried suicide and
failed is not serious about it.

Fact: Any suicide attempt means that the
person is deeply troubled and needs
help immediately. A suicidal person will
try again, picking a more deadly
method the second or third time
around.

Myth: Only people who are life’s losers—
those who have failed in their careers
and in their personal lives—commit
suicide.

Fact: Many people who kill themselves have
prestigious jobs, conventional families,
and a good income. Physicians, for
example, have a suicide rate several
times higher than that for the general
population; in this case, the tendency to
suicide may be related to their work
stresses.

People considering suicide are overwhelmed
with hopelessness. They feel that things cannot get
better and see no way out of their difficulties. This
perception is depression in the extreme, and it is
not easy to talk someone out of this state of mind.
Telling a suicidal person that things aren’t really so

400 Chapter 12

Figure 12–2
Gender and race differences in the
suicide rate across the life span.
The suicide rate for White males, who commit
the largest number of suicides at all ages,
shows a sharp rise beyond the age of 65. In
contrast, the suicide rate for African American
females, which is the lowest for any group,
remains relatively stable throughout the life
span.
Source: From Suicide and Life-Threatening Behavior
by E. K. Moscicki. Copyright © 1995 by Guilford Publi-
cations, Inc. Reprinted by permission of Copyright
Clearance Center on behalf of the publisher.

5–
9

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20
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4
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–2
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–3

4
35

–3
9

–4

4
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–4
9

–5

4
55

–5
9

–6

4
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–6
9

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4
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9

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–8

4
85

Age groups

N
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80
White Males
African American Males
White Females
African American Females

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Psychological Disorders 401

bad does no good; in fact, the person may only view this as further evidence that no one
understands his or her suffering. But most suicidal people do want help, however much
they may despair of obtaining it. If a friend or family member seems at all suicidal, getting
professional help is urgent. A community mental health center is a good starting place, as
are the national suicide hotlines.

Mania and Bipolar Disorder
What is mania, and how is it involved in bipolar disorder?

Another mood disorder, which is less common than depression, is mania, a state in which
the person becomes euphoric or “high,” extremely active, excessively talkative, and easily
distracted. People suffering from mania may become grandiose—that is, their self-esteem
is greatly inflated. They typically have unlimited hopes and schemes, but little interest in
realistically carrying them out. People in a manic state sometimes become aggressive and
hostile toward others as their self-confidence grows more and more exaggerated. At the
extreme, people going through a manic episode may become wild, incomprehensible, or
violent until they collapse from exhaustion.

The mood disorder in which both mania and depression are present is known as
bipolar disorder. In people with bipolar disorder, periods of mania and depression
alternate (each lasting from a few days to a few months), sometimes with periods of
normal mood in between. Occasionally, bipolar disorder occurs in a mild form, with
moods of unrealistically high spirits followed by moderate depression. Research sug-
gests that bipolar disorder is much less common than depression and, unlike depres-
sion, occurs equally in men and women. Bipolar disorder also seems to have a stronger
biological component than depression: It is more strongly linked to heredity and is most
often treated with drugs (Hayden & Nurnberger, 2006; Konradi et al., 2004; Serretti &
Mandelli, 2008).

Causes of Mood Disorders
What causes some people to experience extreme mood changes?

Mood disorders result from a combination of risk factors although researchers do not yet
know exactly how these elements interact to cause a mood disorder (Moffitt, Caspi, &
Rutter, 2006).

Biological Factors Genetic factors can play an important role in the development of
depression (Haghighi et al., 2008; Zubenko et al., 2003) and bipolar disorder (Badner,
2003; Serretti & Mandelli, 2008). Strong evidence comes from studies of twins. (See
Chapter 2, “The Biological Basis of Behavior.”) If one identical twin is clinically depressed,
the other twin (with identical genes) is likely to become clinically depressed also. Among
fraternal twins (who share only about half their genes), if one twin is clinically depressed,
the risk for the second twin is much lower (McGuffin, Katz, Watkins, & Rutherford, 1996).
In addition, genetic researchers have recently identified a specific variation on the 22 chro-
mosome that appears to increase an individual’s susceptibility to bipolar disorder by influ-
encing the balance of certain neurotransmitters in the brain (Hashimoto et al., 2005;
Kuratomi et al., 2008).

A new and particularly intriguing line of research aimed at understanding the cause of
mood disorders stems from the diathesis–stress model. Recent research shows that a
diathesis (biological predisposition) leaves some people particularly vulnerable to certain
stress hormones. Adverse or traumatic experiences early in life can result in high levels of
those stress hormones, which in turn increases the likelihood of a mood disorder later in
life (Bradley et al., 2008; Gillespie & Nemeroff, 2007).

Explore on MyPsychLab

mania A mood disorder characterized by
euphoric states, extreme physical activity,
excessive talkativeness, distractedness, and
sometimes grandiosity.

bipolar disorder A mood disorder in which
periods of mania and depression alternate,
sometimes with periods of normal mood
intervening.

Explore Bipolar Disorder
at www.mypsychlab.com

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Psychological Factors Although a number of psychological factors are thought to
play a role in causing severe depression, in recent years, researchers have focused on the
contribution of maladaptive cognitive distortions. According to Aaron Beck (1967, 1976,
1984), during childhood and adolescence, some people undergo wrenching experiences
such as the loss of a parent, severe difficulties in gaining parental or social approval, or
humiliating criticism from teachers and other adults. One response to such experience is to
develop a negative self-concept—a feeling of incompetence or unworthiness that has little
to do with reality, but that is maintained by a distorted and illogical interpretation of real
events. When a new situation arises that resembles the situation under which the self-
concept was learned, these same feelings of worthlessness and incompetence may be acti-
vated, resulting in depression. Considerable research supports Beck’s view of depression
(Alloy, Abramson, & Francis, 1999; Alloy, Abramson, Whitehouse, et al., 1999; Kwon & Oei,
2003). Therapy based on Beck’s theories has proven quite successful in treating depression.
(See Chapter 13, “Therapies.”)

Social Factors Many social factors have been linked with mood disorders, particularly
difficulties in interpersonal relationships. In fact, some theorists have suggested that the
link between depression and troubled relationships explains the fact that depression is two
to three times more prevalent in women than in men (National Alliance on Mental Illness,
2003), because women tend to be more relationship oriented than men are in our society
(Ali, 2008; Pinhas, Weaver, Bryden, Ghabbour, & Toner, 2002). Yet, not every person who
experiences a troubled relationship becomes depressed. As the systems approach would
predict, it appears that a genetic predisposition or cognitive distortion is necessary before a
distressing close relationship or other significant life stressor will result in a mood disorder
(Wichers et al., 2007).

402 Chapter 12

Person–Situation The Chicken or the Egg?
It is sometimes difficult to tease apart the relative contribution of the person’s biological or
cognitive tendencies and the social situation. People with certain depression-prone genetic
or cognitive tendencies may be more likely than others to encounter stressful life events by
virtue of their personality and behavior. For example, studies show that depressed people
tend to evoke anxiety and even hostility in others, partly because they require more emo-
tional support than people feel comfortable giving. As a result, people tend to avoid those
who are depressed, and this shunning can intensify the depression. In short, depression-
prone and depressed people may become trapped in a vicious circle that is at least partly of
their own creation (Coyne & Whiffen, 1995; Pettit & Joiner, 2006). ■

cognitive distortions An illogical and
maladaptive response to early negative life
events that leads to feelings of incompetence
and unworthiness that are reactivated whenever
a new situation arises that resembles the
original events.

CHECK YOUR UNDERSTANDING
Indicate whether the following statements are true (T) or false (F):

1. ________ People with a mood disorder always alternate between the extremes of euphoria
and sadness.

2. ________ More men attempt suicide, but more women actually kill themselves.
3. ________ Most psychologists now believe that mood disorders result from a combination

of risk factors.
4. ________ Mania is the most common mood disorder.

Answers:1. (F).2. (F).3. (T).4. (F). ISB
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Psychological Disorders 403

ANXIETY DISORDERS
How does an anxiety disorder differ from ordinary anxiety?

All of us are afraid from time to time, but we usually know why we are fearful, our fear is
caused by something appropriate and identifiable, and it passes with time. In the case of
anxiety disorders, however, either the person does not know why he or she is afraid, or the
anxiety is inappropriate to the circumstances. In either case, the person’s fear and anxiety
just don’t seem to make sense.

As shown in Figure 12–1, anxiety disorders are more common than any other form of
mental disorder. Anxiety disorders can be subdivided into several diagnostic categories,
including specific phobias, panic disorder, and other anxiety disorders, such as generalized
anxiety disorder, obsessive–compulsive disorder, and disorders caused by specific trau-
matic events.

Specific Phobias
Into what three categories are phobias usually grouped?

A specific phobia is an intense, paralyzing fear of something that perhaps should be feared,
but the fear is excessive and unreasonable. In fact, the fear in a specific phobia is so great
that it leads the person to avoid routine or adaptive activities and thus interferes with life
functioning. For example, it is appropriate to be a bit fearful as an airplane takes off or
lands, but people with a phobia about flying refuse to get on or even go near an airplane.
Other common phobias focus on animals, heights, closed places, blood, needles, and
injury. Almost 10% of people in the United States suffer from at least one specific phobia.

Most people feel some mild fear or uncertainty in many social situations, but when
these fears interfere significantly with life functioning, they are considered to be social pho-
bias. Intense fear of public speaking is a common form of social phobia. In other cases,
simply talking with people or eating in public causes such severe anxiety that the phobic
person will go to great lengths to avoid these situations.

Watch on MyPsychLab

anxiety disorders Disorders in which anxiety
is a characteristic feature or the avoidance of
anxiety seems to motivate abnormal behavior.

APPLY YOUR UNDERSTANDING

1. Bob is “down in the dumps” most of the time. He is having a difficult time dealing with any
criticism he receives at work or at home. Most days he feels that he is a failure, despite
the fact that he is successful in his job and his family is happy. Although he participates in
various activities outside the home, he finds no joy in anything. He says he is constantly
tired, but he has trouble sleeping. It is most likely that Bob is suffering from

a. clinical depression.
b. generalized anxiety disorder.
c. depersonalization disorder.
d. somatoform disorder.

2. Mary almost seems to be two different people. At times, she is hyperactive and talks
nonstop (sometimes so fast that nobody can understand her). At those times, her friends
say she is “bouncing off the walls.” But then she changes: She becomes terribly sad,
loses interest in eating, spends much of her time in bed, and rarely says a word. It is most
likely that Mary is suffering from

a. dissociative identity disorder.
b. depression.
c. bipolar disorder.
d. schizophrenia.

Answers:1. a.2. c.

L E A R N I N G O B J E C T I V E S
• Explain how anxiety disorders differ from

ordinary anxiety. Briefly describe the key
features of phobias, panic disorders,
generalized anxiety disorder, and
obsessive–compulsive disorder.

• Describe the causes of anxiety
disorders.

specific phobia Anxiety disorder characterized
by an intense, paralyzing fear of something.

social phobias Anxiety disorders characterized
by excessive, inappropriate fears connected with
social situations or performances in front of
other people.

Watch Anxiety Disorders at
www.mypsychlab.com

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Agoraphobia is much more debilitating than social phobia. This term comes from
Greek and Latin words that literally mean “fear of the marketplace,” but the disorder typi-
cally involves multiple, intense fears, such as the fear of being alone, of being in public
places from which escape might be difficult, of being in crowds, of traveling in an automo-
bile, or of going through tunnels or over bridges. The common element in all of these situ-
ations seems to be a great dread of being separated from sources of security. Some sufferers
are so fearful that they will venture only a few miles from home; others will not leave their
homes at all.

For example, consider the accomplished author, composer, pianist, and educator Allen
Shawn, who wrote in his memoir:

I don’t like heights, I don’t like being on the water. I am upset by walking across parking lots
or open parks or fields where there are no buildings. I tend to avoid bridges, unless they are
on a small scale. I respond poorly to stretches of vastness but do equally badly when I am
closed in, as I am severely claustrophobic. When I go to a theater, I sit on the aisle. I am pet-
rified of tunnels, making most train travel as well as many drives difficult. I don’t take sub-
ways. I avoid elevators as much as possible. I experience glassed-in spaces as toxic, and I find
it very difficult to adjust to being in buildings in which the windows don’t open. I don’t like
to go to enclosed malls; and if I do, I don’t venture very far into them . . . . In short, I am
afraid both of closed and of open spaces, and I am afraid, in a sense, of any form of isolation.
(Shawn, 2007, p. xviii)

Panic Disorder
How does a panic attack differ from fear?

Another type of anxiety disorder is panic disorder, characterized by recurring episodes of
a sudden, unpredictable, and overwhelming fear or terror. Panic attacks occur without any
reasonable cause and are accompanied by feelings of impending doom, chest pain, dizzi-
ness or fainting, sweating, difficulty breathing, and fear of losing control or dying. Panic
attacks usually last only a few minutes, but they may recur for no apparent reason. For
example, consider the following description:

Minday Markowitz is an attractive, stylishly dressed 25-year-old art director for a trade mag-
azine who comes to an anxiety clinic after reading about the clinic program in the newspa-
per. She is seeking treatment for “panic attacks” that have occurred with increasing frequency
over the past year, often 2 or 3 times a day. These attacks begin with a sudden intense wave of
“horrible fear” that seems to come out of nowhere, sometimes during the day, sometimes
waking her from sleep. She begins to tremble, is nauseated, feels as though she is choking,
and fears that she will lose control and do something crazy, like run screaming into the street.
(Spitzer, Gibbon, Skodol, Williams, & First, 2002, p. 202)

Panic attacks not only cause tremendous fear while they are happening, but also
leave a dread of having another panic attack, which can persist for days or even weeks
after the original episode. In some cases, this dread is so overwhelming that it can lead to
the development of agoraphobia: To prevent a recurrence, people may avoid any circum-
stance that might cause anxiety, clinging to people or situations that help keep them
calm.

Other Anxiety Disorders
How do generalized anxiety disorder and obsessive–compulsive
disorder differ from specific phobias?

In the various phobias and in panic attacks, there is a specific source of anxiety. In contrast,
generalized anxiety disorder is defined by prolonged vague but intense fears that are not
attached to any particular object or circumstance. Generalized anxiety disorder perhaps

404 Chapter 12

agoraphobia An anxiety disorder that involves
multiple, intense fears of crowds, public places,
and other situations that require separation
from a source of security such as the home.

panic disorder An anxiety disorder
characterized by recurrent panic attacks in
which the person suddenly experiences intense
fear or terror without any reasonable cause.

generalized anxiety disorder An anxiety
disorder characterized by prolonged vague but
intense fears that are not attached to any
particular object or circumstance.

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Psychological Disorders 405

comes closest to the everyday meaning attached to the term neurotic. Its symptoms include
the inability to relax, muscle tension, rapid heartbeat or pounding heart, apprehensiveness
about the future, constant alertness to potential threats, and sleeping difficulties (Hazlett-
Stevens, Pruitt, & Collins, 2009).

A very different form of anxiety disorder is obsessive–compulsive disorder (OCD).
Obsessions are involuntary thoughts or ideas that keep recurring despite the person’s
attempts to stop them, whereas compulsions are repetitive, ritualistic behaviors that a per-
son feels compelled to perform (Shader, 2003). Obsessive thoughts are often horrible and
frightening. One patient, for example, reported that “when she thought of her boyfriend,
she wished he were dead”; when her sister spoke of going to the beach with her infant
daughter, she “hoped that they would both drown” (Carson & Butcher, 1992, p. 190).
Compulsive behaviors may be equally disruptive to the person who feels driven to perform
them. Recall Jack, the engineer described at the beginning of the chapter, who couldn’t
leave his house without double- and triple-checking to be sure the doors were locked and
all the lights and appliances were turned off.

People who experience obsessions and compulsions often do not seem particularly
anxious, so why is this disorder considered an anxiety disorder? The answer is that if such
people try to stop their irrational behavior—or if someone else tries to stop them—they
experience severe anxiety. In other words, the obsessive–compulsive behavior seems to have
developed to keep anxiety under control.

Finally, two types of anxiety disorder are clearly caused by some specific highly stress-
ful event. Some people who have lived through fires, floods, tornadoes, or disasters such as
an airplane crash experience repeated episodes of fear and terror after the event itself is
over. If the anxious reaction occurs soon after the event, the diagnosis is acute stress disorder.
If it takes place long after the event is over, particularly in cases of military combat or rape,
the diagnosis is likely to be posttraumatic stress disorder, discussed in Chapter 11, “Stress
and Health Psychology” (Oltmanns & Emery, 2006).

Causes of Anxiety Disorders
What causes anxiety disorders?

Like all behaviors, phobias can be learned. Consider a young boy who is savagely attacked
by a large dog. Because of this experience, he is now terribly afraid of all dogs. In this case,
a realistic fear has become transformed into a phobia. However, other phobias are harder to
understand. As we saw in Chapter 5, “Learning,” many people get shocks from electric sock-
ets, but almost no one develops a socket phobia. Yet snake and spider phobias are common.
The reason seems to be that through evolution we have become biologically predisposed to
associate certain potentially dangerous objects with intense fears (Hofmann, Moscovitch, &
Heinrichs, 2004; Nesse, 2000; Seligman, 1971).

Psychologists working from the biological perspective point to heredity, arguing
that we can inherit a predisposition to anxiety disorders (Bolton et al., 2006; Gelernter &
Stein, 2009; Leonardo & Hen, 2006). In fact, anxiety disorders tend to run in families.
Researchers have located some specific genetic sites that may generally predispose people
toward anxiety disorders (Goddard et al., 2004; Hamilton et al., 2004). In some cases, spe-
cific genes have even been linked to specific anxiety disorders, such as obsessive hoarding
(Alonso et al., 2008).

Finally, we need to consider the role that internal psychological conflicts may play in
producing feelings of anxiety. The very fact that people suffering from anxiety disorders
often have no idea why they are anxious suggests that the explanation may be found in
unconscious conflicts that trigger anxiety. According to this view, phobias are the result of
displacement, in which people redirect their anxiety from the unconscious conflicts toward
objects or settings in the real world. (See Chapter 11, “Stress and Health Psychology,” for a
discussion of displacement.)

Watch on MyPsychLab

obsessive–compulsive disorder (OCD) An
anxiety disorder in which a person feels driven
to think disturbing thoughts or to perform
senseless rituals.

Watch Obsessive Compulsive
Test at www.mypsychlab.com

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PSYCHOSOMATIC AND
SOMATOFORM DISORDERS
What is the difference between psychosomatic disorders
and somatoform disorders?

The term psychosomatic perfectly captures the interplay of psyche (mind) and soma (body),
which characterizes these disorders. A psychosomatic disorder is a real, physical disorder,
but one that has, at least in part, a psychological cause. As we saw in Chapter 11 (“Stress and
Health Psychology”), stress, anxiety, and prolonged emotional arousal alter body chem-
istry, the functioning of bodily organs, and the body’s immune system (which is vital in
fighting infections). Thus, modern medicine leans toward the idea that all physical ailments
are to some extent “psychosomatic.”

Psychosomatic disorders involve genuine physical illnesses. In contrast, people suffering
from somatoform disorders believe that they are physically ill and describe symptoms that
sound like physical illnesses, but medical examinations reveal no organic problems. Never-
theless, the symptoms are real to them and are not under voluntary control (American
Psychological Association, 2000). For example, in one kind of somatoform disorder,
somatization disorder, the person experiences vague, recurring physical symptoms for
which medical attention has been sought repeatedly but no organic cause found. Common
complaints are back pain, dizziness, abdominal pain, and sometimes anxiety and depression.

One of the more dramatic forms of somatoform disorder involves complaints of
paralysis, blindness, deafness, seizures, loss of feeling, or pregnancy. In these conversion

406 Chapter 12

L E A R N I N G O B J E C T I V E
• Distinguish between psychosomatic

and somatoform disorders, somatization
disorder, conversion disorders,
hypochondriasis, and body dysmorphic
disorder. Explain what is meant by the
statement that “all physical ailments
are to some extent psychosomatic.”

psychosomatic disorder A disorder in which
there is real physical illness that is largely
caused by psychological factors such as stress
and anxiety.

CHECK YOUR UNDERSTANDING

1. According to the psychoanalytic view, anxiety results from ________ ________.
2. The belief that we inherit the tendency to develop some phobias more easily than others

argues that these phobias are ________ ________.
Indicate whether the following statements are true (T) or false (F):

3. ________ The fear in a specific phobia often interferes with life functions.
4. ________ People who experience obsessions and compulsions appear highly anxious.
5. ________ Research indicates that people who feel that they are not in control of stressful

events in their lives are more likely to experience anxiety than those who believe that
they have control over such events.

Answers:1. unconscious conflicts.2. prepared responses.3. (T).4. (F).5. (T).

APPLY YOUR UNDERSTANDING

1. Barbara becomes intensely fearful whenever she finds herself in crowds or in public
places from which she might not be able to escape easily. It is most likely that Barbara is
suffering from

a. generalized anxiety disorder.
b. panic disorder.
c. agoraphobia.
d. acute stress disorder.

2. A combat veteran complains of insomnia. If he does fall asleep, he often has horrible
nightmares that involve killing and blood. He may be doing something normal—for
example, riding a bicycle through a park—when frightening memories of war come upon
him as a result of some normal stimulus, like the sound of a low-flying airplane. Given this
information, you would suspect that he was suffering from

a. generalized anxiety disorder.
b. posttraumatic stress disorder.
c. panic disorder.
d. obsessive–compulsive disorder.

Answers:1. c.2. b.

somatoform disorders Disorders in which
there is an apparent physical illness for which
there is no organic basis.

somatization disorder A somatoform disorder
characterized by recurrent vague somatic
complaints without a physical cause.

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Psychological Disorders 407

disorders, no physical causes appear, yet the symptoms are very real. Yet another somato-
form disorder is hypochondriasis. Here, the person interprets some small symptom—
perhaps a cough, a bruise, or perspiration—as a sign of a serious disease. Although the
symptom may actually exist, there is no evidence that the serious illness does.

Body dysmorphic disorder, or imagined ugliness, is a recently diagnosed and poorly
understood type of somatoform disorder. Cases of body dysmorphic disorder can be very
striking. One man, for example, felt that people stared at his “pointed ears” and “large nos-
trils” so much that he eventually could not face going to work, so he quit his job. Claudia,
the woman described at the beginning of the chapter who displayed such concern about
her hair, apparently was suffering from a body dysmorphic disorder. Clearly, people who
become that preoccupied with their appearance cannot lead a normal life. Ironically, most
people who suffer body dysmorphic disorder are not ugly. They may be average looking or
even attractive, but they are unable to evaluate their looks realistically.

Somatoform disorders (especially conversion disorders) present a challenge for psy-
chological theorists because they seem to involve some kind of unconscious processes.
Freud concluded that the physical symptoms were often related to traumatic experiences
buried in a patient’s past. Cognitive–behavioral theorists look for ways in which the symp-
tomatic behavior is being rewarded. From the biological perspective, research has shown
that at least some diagnosed somatoform disorders actually were real physical illnesses that
were overlooked or misdiagnosed. Nevertheless, most cases of conversion disorder cannot
be explained by current medical science. These cases pose as much of a theoretical chal-
lenge today as they did when conversion disorders captured Freud’s attention more than a
century ago.

conversion disorders Somatoform disorders
in which a dramatic specific disability has no
physical cause but instead seems related to
psychological problems.

hypochondriasis A somatoform disorder in
which a person interprets insignificant
symptoms as signs of serious illness in the
absence of any organic evidence of such illness.

body dysmorphic disorder A somatoform
disorder in which a person becomes so
preoccupied with his or her imagined ugliness
that normal life is impossible.

CHECK YOUR UNDERSTANDING
Indicate whether the following statements are true (T) or false (F):

1. ________ Modern medicine leans toward the idea that all physical ailments are to some
extent “psychosomatic.”

2. ________ People who suffer from somatoform disorders do not consciously seek to mislead
others about their physical condition.

3. ________ Research has shown that at least some diagnosed somatoform disorders actually
were real physical illnesses that were overlooked or misdiagnosed.

4. ________ Most cases of conversion disorder can be explained by current medical science.

Answers:1. (T).2. (T).3. (T).4. (F).

APPLY YOUR UNDERSTANDING

1. Bob is concerned about a few warts that have appeared on his arms. His doctor says that
they are just warts and are not a concern, but Bob believes they are cancerous and that
he will die from them. He consults another doctor and then another, both of whom tell him
they are just normal warts, but he remains convinced they are cancerous and he is going
to die. It appears that Bob is suffering from

a. hypochondriasis.
b. a psychosomatic disorder.
c. a somatoform disorder.
d. a phobia.

2. John is a writer, but work on his latest novel has come to a halt because he has lost all
feeling in his arm and his hand. His doctor can find no physical cause for his problem;
however, there is no question that he no longer has feeling in his arm and that he can no
longer hold a pencil or type on a keyboard. It seems likely that John is suffering from

a. body dysmorphic disorder.
b. hypochondriasis.
c. conversion disorder.
d. dissociative disorder.

Answers:1. a.2. c.

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DISSOCIATIVE DISORDERS
What do dissociative disorders have in common?

Dissociative disorders are among the most puzzling forms of mental disorders, both to the
observer and to the sufferer. Dissociation means that part of an individual’s personality
appears to be separated from the rest. The disorder usually involves memory loss and a
complete, though generally temporary, change in identity. Rarely, several distinct personal-
ities appear in one person.

Loss of memory without an organic cause can occur as a reaction to an extremely
stressful event or period. During World War II, for example, some hospitalized soldiers
could not recall their names, where they lived, where they were born, or how they came
to be in battle. But war and its horrors are not the only causes of dissociative amnesia.
The person who betrays a friend in a business deal or the victim of rape may also forget,
selectively, what has happened. Total amnesia, in which people forget everything, is rare,
despite its popularity in novels and films. Sometimes an amnesia victim leaves home and
assumes an entirely new identity; this phenomenon, known as dissociative fugue, is also
very unusual.

In dissociative identity disorder, commonly known as multiple personality
disorder, several distinct personalities emerge at different times. In the true multiple
personality, the various personalities are distinct people with their own names, identi-
ties, memories, mannerisms, speaking voices, and even IQs. Sometimes the personalities
are so separate that they don’t know they inhabit a body with other “people.” At other
times, the personalities do know of the existence of other “people” and even make dis-
paraging remarks about them. Typically, the personalities contrast sharply with one
another, as if each one represents different aspects of the same person—one being the
more socially acceptable, “nice” side of the person and the other being the darker, more
uninhibited or “evil” side.

The origins of dissociative identity disorder are still not understood (Dell, 2006).
One theory suggests that it develops as a response to childhood abuse (Lev-Wiesel,
2008). The child learns to cope with abuse by a process of dissociation—by having the
abuse, in effect, happen to “someone else,” that is, to a personality who is not con-
scious most of the time. The fact that one or more of the multiple personalities in
almost every case is a child (even when the person is an adult) seems to support this
idea, and clinicians report a history of child abuse in more than three-quarters of
their cases of dissociative identity disorder (Kidron, 2008; C. A. Ross, Norton, &
Wozney, 1989).

Other clinicians suggest that dissociative identity disorder is not a real disorder at all,
but an elaborate kind of role-playing—faked in the beginning and then perhaps gen-
uinely believed by the patient (Lilienfeld & Lynn, 2003; H. G. Pope, Barry, Bodkin, &
Hudson, 2006). Some intriguing biological data show that in at least some patients, how-
ever, the various personalities have different blood pressure readings, different responses
to medication, different allergies, different vision problems (necessitating a different pair
of glasses for each personality), and different handedness—all of which would be diffi-
cult to feign. Each personality may also exhibit distinctly different brain-wave patterns
(Dell’Osso, 2003; Putnam, 1984).

A far less dramatic (and much more common) dissociative disorder is depersonalization
disorder, in which the person suddenly feels changed or different in a strange way. Some
people feel that they have left their bodies, whereas others find that their actions have
suddenly become mechanical or dreamlike. This kind of feeling is especially common
during adolescence and young adulthood, when our sense of ourselves and our inter-
actions with others change rapidly. Only when the sense of depersonalization becomes
a long-term or chronic problem or when the alienation impairs normal social func-
tioning can this be classified as a dissociative disorder (American Psychological Associa-
tion, 2000).

408 Chapter 12

dissociative amnesia A disorder characterized
by loss of memory for past events without
organic cause.

dissociative fugue A disorder that involves
flight from home and the assumption of a new
identity with amnesia for past identity and events.

dissociative identity disorder (Also called
multiple personality disorder.) Disorder
characterized by the separation of the personality
into two or more distinct personalities.

L E A R N I N G O B J E C T I V E
• Explain what is meant by dissociation.

Briefly describe the key features of
dissociative amnesia, dissociative
fugue, dissociative identity disorder,
and depersonalization disorder.

depersonalization disorder A dissociative
disorder whose essential feature is that the
person suddenly feels changed or different in a
strange way.

When she was found by a Florida park ranger,
Jane Doe was suffering from amnesia. She
could not recall her name, her past, or how to
read and write. She never regained her mem-
ory of the past.

dissociative disorders Disorders in which
some aspect of the personality seems separated
from the rest.

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Psychological Disorders 409

SEXUAL AND GENDER-IDENTITY
DISORDERS
What are the three main types of sexual disorders?

Sexual dysfunction is the loss or impairment of the ordinary physical responses of sexual
function (see Figure 12–3). In men, this usually takes the form of erectile disorder or erectile
dysfunction (ED), the inability to achieve or maintain an erection. In women, it often takes the
form of female sexual arousal disorder, the inability to become sexually excited or to reach
orgasm. (These conditions were once called “impotence” and “frigidity,” respectively, but pro-
fessionals in the field have rejected these terms as too negative and judgmental.) Occasional
problems with achieving or maintaining an erection in men or with lubrication or reaching
orgasm in women are common. Only when the condition is frequent or constant and when
enjoyment of sexual relationships becomes impaired should it be considered serious.

CHECK YOUR UNDERSTANDING

1. ________ ________ usually involve memory loss and a complete—though generally
temporary—change in identity.

2. Clinicians report a history of ________ ________ in over three-quarters of their cases of
dissociative identity disorder.

3. Dissociative disorders, like conversion disorders, seem to involve ________ processes.

Answers:1. dissociative disorders.2. child abuse.3. unconscious.

APPLY YOUR UNDERSTANDING

1. A person who was being interrogated by the police confessed on tape to having
committed several murders. When the alleged killer was brought to trial, his lawyers
agreed that the voice on the tape belonged to their client. But they asserted that the
person who confessed was another personality that lived inside the body of their client.
In other words, they claimed that their client was suffering from

a. depersonalization disorder.
b. dissociative identity disorder.
c. conversion disorder.
d. body dysmorphic disorder.

2. You are reading the newspaper and come across a story of a young man who was found
wandering the streets with no recollection of who he was, where he came from, or how
he got there. You suspect that he is most likely suffering from

a. depersonalization disorder.
b. dissociative amnesia.
c. conversion disorder.
d. body dysmorphic disorder.

Answers:1. b.2. b.

L E A R N I N G O B J E C T I V E
• Identify the three main types of sexual

disorders that are recognized in the
DSM-IV-TR.

sexual dysfunction Loss or impairment of the
ordinary physical responses of sexual function.

erectile disorder (or erectile dysfunction)
(ED) The inability of a man to achieve or
maintain an erection.

female sexual arousal disorder The inability
of a woman to become sexually aroused or to
reach orgasm.

Diversity–Universality What’s Normal?
Ideas about what is normal and abnormal in sexual behavior vary with the times, the indi-
vidual, and, sometimes, the culture. Throughout the late 20th century, as psychologists
became more aware of the diversity of “normal” sexual behaviors, they increasingly nar-
rowed their definition of abnormal sexual behavior. Today the DSM-IV-TR recognizes only
three main types of sexual disorders: sexual dysfunction, paraphilias, and gender-identity
disorders. We will discuss each of these in turn. ■

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410 Chapter 12

orgasmic disorders Inability to reach orgasm
in a person able to experience sexual desire and
maintain arousal.

sexual desire disorders Disorders in which
the person lacks sexual interest or has an active
distaste for sex.

Figure 12–3
Sexual dysfunction in the United States.
This graph shows the incidence of the most
common types of sexual dysfunction in men and
women, by age group.
Source: Data from National Health and Social Life
Survey published in Journal of the American Medical
Association, February 1999, reported in USA Today,
May 18, 1999, p. 7D.

18–29
30–39
40–49
50–59

18–29
30–39
40–49
50–59
18–29
30–39
40–49
50–59
18–29
30–39
40–49
50–59
18–29
30–39
40–49
50–59
18–29
30–39
40–49
50–59

Ages

Women’s problems Men’s problems

010203040 0 10 20 30 40

Lack interest in sex

32%
32%

30%
27%

26%
28%

22%
23%

27%
24%

17%
17%

16%

19%

18%

21%
27%

21%
15%

13%
8%

11%
11%

14%

13%

15%
17%

7%
7%

9%
9%

10%
8%
9%

6%
19%

7%
9%
11%

18%

30%
32%

28%
31%

17%
19%

14%
Lack interest in sex

Unable to achieve orgasm Unable to achieve orgasm

Sex not pleasurable Sex not pleasurable

Anxious about performance Anxious about performance

Trouble lubricating Trouble with erections

Pain during sex Climax too early

The incidence of ED is quite high, even among otherwise healthy men. In one survey,
25% of 40- to 70-year-old men had moderate ED. Less than half the men in this age group
reported having no ED (Lamberg, 1998). Fortunately, new medications popularly known as
Viagra, Levitra, and Cialis are extremely effective in treating ED (S. B. Levine, 2006; Meston
& Frohlich, 2000).

Although Viagra appears to help most male patients overcome ED, it is of little
value unless a man is first sexually aroused. Unfortunately, some men and women find it
difficult or impossible to experience any desire for sexual activity to begin with. Sexual
desire disorders involve a lack of interest in sex or perhaps an active distaste for it. Low
sexual desire is more common among women than among men and plays a role in per-
haps 40% of all sexual dysfunctions (R. D. Hayes, Dennerstein, Bennett, & Fairley, 2008;
Warnock, 2002). The extent and causes of this disorder in men or women is difficult to
analyze. Because some people simply have a low motivation for sexual activity, scant
interest in sex is normal for them and does not necessarily reflect any sexual disorder
(Meston & Rellini, 2008).

Other people are able to experience sexual desire and maintain arousal but are unable
to reach orgasm, the peaking of sexual pleasure and the release of sexual tension. These
people are said to experience orgasmic disorders. Male orgasmic disorder—the inability to
ejaculate even when fully aroused—is rare yet seems to be becoming increasingly common
as more men find it desirable to practice the delay of orgasm. Masters and Johnson (1970)

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Psychological Disorders 411

attributed male orgasmic disorder primarily to such psychological factors as traumatic
experiences. The problem also seems to be a side effect of some medications, such as cer-
tain antidepressants. This difficulty is considerably more common among women than
among men (see Figure 12–3).

Among the other problems that can occur during the sexual response cycle are
premature ejaculation, a fairly common disorder that the DSM-IV-TR defines as the
male’s inability to inhibit orgasm as long as desired, and vaginismus, involuntary muscle
spasms in the outer part of a woman’s vagina during sexual excitement that make inter-
course impossible. Again, the occasional experience of such problems is common; the
DSM-IV-TR considers them dysfunctions only if they are persistent and recurrent (Hunter,
Goodie, Oordt, & Dobmeyer, 2009).

A second group of sexual disorders, known as paraphilias, involves the use of uncon-
ventional sex objects or situations to obtain sexual arousal. Most people have unusual sex-
ual fantasies at some time, which can be a healthy stimulant of normal sexual enjoyment.
However, fetishism—the repeated use of a nonhuman object such as a shoe or underwear
as the preferred or exclusive method of achieving sexual excitement—is considered a sexual
disorder (Darcangelo, Hollings, & Paladino, 2008). Most people who practice fetishism are
male, and the fetish frequently begins during adolescence (Fagan, Lehne, Strand, & Berlin,
2005). Fetishes may derive from unusual learning experiences: As their sexual drive devel-
ops during adolescence, some boys learn to associate arousal with inanimate objects, per-
haps as a result of early sexual exploration while masturbating or because of difficulties in
social relationships (Bertolini, 2001).

Other unconventional patterns of sexual behavior are voyeurism, watching other peo-
ple have sex or spying on people who are nude; achieving arousal by exhibitionism, the
exposure of one’s genitals in inappropriate situations, such as to strangers; frotteurism,
achieving sexual arousal by touching or rubbing against a nonconsenting person in situa-
tions like a crowded subway car; and transvestic fetishism, wearing clothes of the opposite
sex for sexual excitement and gratification. Sexual sadism ties sexual pleasure to aggres-
sion. To attain sexual gratification, sadists humiliate or physically harm sex partners.
Sexual masochism is the inability to enjoy sex without accompanying emotional or physi-
cal pain. Sexual sadists and masochists sometimes engage in mutually consenting sex, but
at times sadistic acts are inflicted on unconsenting partners, sometimes resulting in serious
injury or even death (Purcell & Arrigo, 2006).

One of the most serious paraphilias is pedophilia, which according to DSM-IV-TR is
defined as engaging in sexual activity with a child, generally under the age of 13. Child sex-
ual abuse is shockingly common in the United States. Pedophiles are almost invariably men
under age 40 who are close to the victims rather than strangers (Barbaree & Seto, 1997).
Although there is no single cause of pedophilia, some of the most common explanations
are that pedophiles cannot adjust to the adult sexual role and have been interested exclu-
sively in children as sex objects since adolescence; they turn to children as sexual objects in
response to stress in adult relationships in which they feel inadequate; or they have records
of unstable social adjustment and generally commit sexual offenses against children in
response to a temporary aggressive mood. Studies also indicate that the majority of
pedophiles have histories of sexual frustration and failure, low self-esteem, an inability to
cope with negative emotions, tend to perceive themselves as immature, and are rather
dependent, unassertive, lonely, and insecure (L. J. Cohen & Galynker, 2002; Mandeville-
Norden & Beech, 2009).

Gender-identity disorders involve the desire to become—or the insistence that one
really is—a member of the other sex. Some little boys, for example, want to be girls instead.
They may reject boys’ clothing, desire to wear their sisters’ clothes, and play only with girls
and with toys that are considered “girls’ toys.” Similarly, some girls wear boys’ clothing and
play only with boys and “boys’ toys.” When such children are uncomfortable being a male
or a female and are unwilling to accept themselves as such, the diagnosis is gender-identity
disorder in children (Zucker, 2005).

The causes of gender-identity disorders are not known. Both animal research and the
fact that these disorders are often apparent from early childhood suggest that biological

premature ejaculation Inability of man to
inhibit orgasm as long as desired.

vaginismus Involuntary muscle spasms in the
outer part of the vagina that make intercourse
impossible.

fetishism A paraphilia in which a nonhuman
object is the preferred or exclusive method of
achieving sexual excitement.

paraphilias Sexual disorders in which
unconventional objects or situations cause
sexual arousal.

voyeurism Desire to watch others having
sexual relations or to spy on nude people.

Repeated use of nonhuman objects, such as
shoes, underwear, or leather goods, as the
preferred or exclusive method of achieving
sexual excitement is known as fetishism.

exhibitionism Compulsion to expose one’s
genitals in public to achieve sexual arousal.

frotteurism Compulsion to achieve sexual
arousal by touching or rubbing against a
nonconsenting person in public situations.

transvestic fetishism Wearing the clothes of
the opposite sex to achieve sexual gratification.

sexual sadism Obtaining sexual
gratification from humiliating or physically
harming a sex partner.

sexual masochism Inability to enjoy sex without
accompanying emotional or physical pain.

pedophilia Desire to have sexual relations with
children as the preferred or exclusive method of
achieving sexual excitement.

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412 Chapter 12

gender-identity disorders Disorders that
involve the desire to become, or the insistence
that one really is, a member of the other
biological sex.

gender-identity disorder in children
Rejection of one’s biological gender in
childhood, along with the clothing and behavior
that society considers appropriate to that gender.

PERSONALITY DISORDERS
Which personality disorder creates the most significant
problems for society?

In Chapter 10, “Personality,” we saw that despite having certain characteristic views of the
world and ways of doing things, people normally can adjust their behavior to fit different sit-
uations. But some people, starting at some point early in life, develop inflexible and mal-
adaptive ways of thinking and behaving that are so exaggerated and rigid that they cause
serious distress to themselves or problems to others. People with such personality disorders
range from harmless eccentrics to cold-blooded killers.

One group of personality disorders, schizoid personality disorder, is characterized by
an inability or desire to form social relationships and have no warm or tender feelings for
others. Such loners cannot express their feelings and appear cold, distant, and unfeeling.
Moreover, they often seem vague, absentminded, indecisive, or “in a fog.” Because their
withdrawal is so complete, persons with schizoid personality disorder seldom marry and
may have trouble holding jobs that require them to work with or relate to others (American
Psychological Association, 2000).

CHECK YOUR UNDERSTANDING

Match each of the following terms with the appropriate description:

1. _______ pedophilia

2. _______ gender-identity disorder

3. _______ female sexual arousal disorder

4. _______ paraphilias

a. The inability for a woman to become sexually
excited or to reach orgasm.

b. Involve the use of unconventional sex objects
or situations to obtain sexual arousal.

c. Recurrent, intense sexually arousing fantasies,
sexual urges, or behaviors involving sexual
activity with a prepubescent child.

d. The desire to become—or the insistence that
one really is—a member of the other biological
sex.

Answers:1. c.2. d.3. a.4. b.

APPLY YOUR UNDERSTANDING

1. Viagra and similar drugs have become best sellers because they provide temporary
relief from

a. erectile disorder.
b. paraphilias.
c. generalized anxiety disorder.
d. body dysmorphic disorder.

2. A man is arrested for stealing women’s underwear from clotheslines and adding them to
the large collection he has hidden in his home. He says that he finds the clothing sexually
exciting. It would appear that he is suffering from

a. erectile disorder.
b. gender-identity disorder.
c. pedophilia.
d. fetishism. Answers:1. a.2. d.

personality disorders Disorders in which
inflexible and maladaptive ways of thinking and
behaving learned early in life cause distress to
the person or conflicts with others.

schizoid personality disorder Personality
disorder in which a person is withdrawn and
lacks feelings for others.

L E A R N I N G O B J E C T I V E
• Identify the distinguishing

characteristic of personality disorders.
Briefly describe schizoid, paranoid,
dependent, avoidant, narcissistic,
borderline, and anti-social personality
disorders.

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factors, such as prenatal hormonal imbalances, are major contributors. Research suggests
that children with gender-identity disorder have an increased likelihood of becoming
homosexual or bisexual as adults (Wallien & Cohen-Kettenis, 2008).

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Psychological Disorders 413

People with paranoid personality disorder often see themselves as rational and objec-
tive, yet they are guarded, secretive, devious, scheming, and argumentative. They are suspi-
cious and mistrustful even when there is no reason to be; they are hypersensitive to any
possible threat or trick; and they refuse to accept blame or criticism even when it is deserved.

A cluster of personality disorders characterized by anxious or fearful behavior includes
dependent personality disorder and avoidant personality disorder. People with dependent
personality disorder are unable to make decisions on their own or to do things indepen-
dently. Rather, they rely on parents, a spouse, friends, or others to make the major choices
in their lives and usually are extremely unhappy being alone. In avoidant personality dis-
order, the person is timid, anxious, and fearful of rejection. It is not surprising that this
social anxiety leads to isolation, but unlike the schizoid type, the person with avoidant per-
sonality disorder wants to have close relationships with others.

Another cluster of personality disorders is characterized by dramatic, emotional, or
erratic behavior. People with narcissistic personality disorder, for example, display a
grandiose sense of self-importance and a preoccupation with fantasies of unlimited suc-
cess. Such people believe that they are extraordinary, need constant attention and admira-
tion, display a sense of entitlement, and tend to exploit others. They are given to envy and
arrogance, and they lack the ability to really care for anyone else (American Psychological
Association, 2000).

Borderline personality disorder is characterized by marked instability in self-
image, mood, and interpersonal relationships. People with this personality disorder tend
to act impulsively and, often, self-destructively. They feel uncomfortable being alone and
often manipulate self-destructive impulses in an effort to control or solidify their per-
sonal relationships.

One of the most widely studied personality disorders is antisocial personality disorder.
People who exhibit this disorder lie, steal, cheat, and show little or no sense of responsibil-
ity, although they often seem intelligent and charming at first. The “con man” exemplifies
many of the features of the antisocial personality, as does the person who compulsively
cheats business partners, because she or he knows their weak points. Antisocial personali-
ties rarely show any anxiety or guilt about their behavior. Indeed, they are likely to blame
society or their victims for the antisocial actions that they themselves commit. As you
might suspect, people with antisocial personality disorder are responsible for a good deal of
crime and violence.

Approximately 3% of American men and less than 1% of American women suffer
from antisocial personality disorder. It is not surprising that prison inmates show high
rates of personality disorder, with male inmates having a rate as high as 60% (Moran,
1999). Not all people with antisocial personality disorder are convicted criminals, however.
Many manipulate others for their own gain while avoiding the criminal justice system.

Antisocial personality disorder seems to result from a combination of biological predis-
position, difficult life experiences, and an unhealthy social environment (Gabbard, 2005;
Moffitt, Caspi, & Rutter, 2006). Some findings suggest that heredity is a risk factor for the
later development of antisocial behavior (Fu et al., 2002; Lyons et al., 1995). Research sug-
gests that some people with antisocial personalities are less responsive to stress and thus are
more likely to engage in thrill-seeking behaviors, such as gambling and substance abuse,
which may be harmful to themselves or others (Pietrzak & Petry, 2005; Patrick, 1994).
Another intriguing explanation for the cause of antisocial personality disorder is that it
arises as a consequence of anatomical irregularities in the prefrontal region of the brain dur-
ing infancy (Boes, Tranel, Anderson, & Nopoulos, 2008; A. R. Damasio & Anderson, 2003).

Some psychologists believe that emotional deprivation in early childhood predisposes
people to antisocial personality disorder. The child for whom no one cares, say psycholo-
gists, cares for no one. Respect for others is the basis of our social code, but when you can-
not see things from another person’s perspective, behavior “rules” seem like nothing more
than an assertion of adult power to be defied.

Family influences may also prevent the normal learning of rules of conduct in the
preschool and school years. A child who has been rejected by one or both parents is not
likely to develop adequate social skills or appropriate social behavior. Further, the high

paranoid personality disorder Personality
disorder in which the person is inappropriately
suspicious and mistrustful of others.

avoidant personality disorder Personality
disorder in which the person’s fears of rejection
by others lead to social isolation.

dependent personality disorder Personality
disorder in which the person is unable to make
choices and decisions independently and cannot
tolerate being alone.

narcissistic personality disorder Personality
disorder in which the person has an exaggerated
sense of self-importance and needs constant
admiration.

borderline personality disorder Personality
disorder characterized by marked instability
in self-image, mood, and interpersonal
relationships.

antisocial personality disorder Personality
disorder that involves a pattern of violent,
criminal, or unethical and exploitative behavior
and an inability to feel affection for others.

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414 Chapter 12

incidence of antisocial behavior in people
with an antisocial parent suggests that
antisocial behavior may be partly learned
and partly inherited. Once serious misbe-
havior begins in childhood, there is an
almost predictable progression: The
child’s conduct leads to rejection by peers
and failure in school, followed by affilia-
tion with other children who have behav-
ior problems. By late childhood or
adolescence, the deviant patterns that will
later show up as a full-blown antisocial
personality disorder are well established
(J. Hill, 2003; T. M. Levy & Orlans, 2004).
Cognitive theorists emphasize that in
addition to the failure to learn rules and
develop self-control, moral development

may be arrested in children who are emotionally rejected and inadequately disciplined
(K. Davidson, 2008; Soyguet & Tuerkcapar, 2001).

Causation

W
e have offered a number of different theories about the cause of antiso-
cial personality disorder, all supported by research. Think about each
of these theories and try to answer the following questions:

• To what extent do the different perspectives conflict? To what extent do they
support one another?

• What kind of evidence—what kinds of research studies—is offered in sup-
port of each theory?

• Which theory would be most useful from a clinical, or treatment, point of
view? Which would be most likely to spawn further research?

• Why do different theoretical perspectives exist?

CHECK YOUR UNDERSTANDING

Match the following personality disorders with the appropriate description:

1. _______ schizoid personality disorder

2. _______ paranoid personality disorder
3. _______ dependent personality disorder
4. _______ avoidant personality disorder
5. _______ borderline personality disorder

a. shows instability in self-image, mood,
and relationshps

b. is fearful and timid
c. is mistrustful even when there is no reason
d. lacks the ability to form social relationships
e. is unable to make own decisions

Answers:1. d.2. c.3. e.4. b.5. a.

APPLY YOUR UNDERSTANDING

1. John represents himself as a stockbroker who specializes in investing the life savings of
elderly people, but he never invests the money. Instead, he puts it into his own bank
account and then flees the country. When he is caught and asked how he feels about
financially destroying elderly people, he explains, “Hey, if they were stupid enough to give
me their money, they deserved what they got.” John is most likely suffering from
________ personality disorder.

a. dependent
b. avoidant
c. antisocial
d. borderline

2. Jennifer is a graduate student who believes that her thesis will completely change the
way that scientists view the universe. She believes that she is the only person intelligent
enough to have come up with the thesis, that she is not sufficiently appreciated by other
students and faculty, and that nobody on her thesis committee is sufficiently
knowledgeable to judge its merits. Assuming that her thesis is not, in fact, revolutionary, it
would appear that Jennifer is suffering from ________ personality disorder.

a. paranoid
b. narcissistic
c. borderline
d. antisocial

Answers:1. c.2. b.
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Psychological Disorders 415

SCHIZOPHRENIC DISORDERS
How is schizophrenia different from multiple-personality disorder?

Schizophrenic disorders are severe conditions marked by disordered thoughts and com-
munications, inappropriate emotions, and bizarre behavior that lasts for months or even
years (E. Walker & Tessner, 2008). People with schizophrenia are out of touch with reality,
which is to say that they are psychotic.

People with schizophrenia often suffer from hallucinations, false sensory perceptions
that usually take the form of hearing voices that are not really there. (Visual, tactile, or
olfactory hallucinations are more likely to indicate substance abuse or organic brain dam-
age.) They also frequently have delusions—false beliefs about reality with no factual
basis—that distort their relationships with their surroundings and with other people. Typ-
ically, these delusions are paranoid: People with schizophrenia often believe that someone is
out to harm them. Because their world is utterly different from reality, people with schizo-
phrenia usually cannot live a normal life unless they are successfully treated with medica-
tion. (See Chapter 13, “Therapies.”) Often, they are unable to communicate with others,
since their words are incoherent when they speak.

Types of Schizophrenic Disorders
Disorganized schizophrenia includes some of the more bizarre symptoms of schizophre-
nia, such as giggling, grimacing, and frantic gesturing. People suffering from disorganized
schizophrenia show a childish disregard for social conventions and may urinate or defecate
at inappropriate times. They are active, but aimless, and they are often given to incoherent
conversations.

In catatonic schizophrenia, motor activity is severely disturbed. People in this state
may remain immobile, mute, and impassive. They may behave in a robotlike fashion when
ordered to move, and they may even let doctors put their arms and legs into uncomfortable
positions that they maintain for hours. At the opposite extreme, they may become exces-
sively excited, talking and shouting continuously.

Paranoid schizophrenia is marked by extreme suspiciousness and complex delusions.
People with paranoid schizophrenia may believe themselves to be Napoleon or the Virgin
Mary, or they may insist that Russian spies with laser guns are constantly on their trail
because they have learned some great secret. As they are less likely to be incoherent or to
look or act “crazy,” these people can appear more “normal” than people with other schizo-
phrenic disorders when their delusions are compatible with everyday life. They may, how-
ever, become hostile or aggressive toward anyone who questions their thinking or
delusions. Note that this disorder is far more severe than paranoid personality disorder,
which does not involve bizarre delusions or loss of touch with reality.

Finally, undifferentiated schizophrenia is the classification developed for people who
have several of the characteristic symptoms of schizophrenia—such as delusions, hallucina-
tions, or incoherence—yet do not show the typical symptoms of any other subtype of the
disorder.

Causes of Schizophrenia
Because schizophrenia is a very serious disorder, considerable research has been
directed at trying to discover its causes (Keshavan, Tandon, Boutros, & Nasral-
lah, 2008; Williamson, 2006). Many studies indicate that schizophrenia has a
genetic component (Gottesman, 1991; Hashimoto et al., 2003; P. Lichtenstein
et al., 2009). People with schizophrenia are more likely than other people to have
children with schizophrenia, even when those children have lived with adoptive
parents since early in life. If one identical twin suffers from schizophrenia, the
chances are almost 50% that the other twin will also develop this disorder. In

L E A R N I N G O B J E C T I V E S
• Describe the common feature in all

cases of schizophrenia. Explain the
difference between hallucinations and
delusions. Briefly describe the key
features of disorganized, catatonic,
paranoid, and undifferentiated
schizophrenia.

• Describe the causes of schizophrenic
disorders.

psychotic Behavior characterized by a loss of
touch with reality.

schizophrenic disorders Severe disorders in
which there are disturbances of thoughts,
communications, and emotions, including
delusions and hallucinations.

delusions False beliefs about reality that have
no basis in fact.

hallucinations Sensory experiences in the
absence of external stimulation.

disorganized schizophrenia Schizophrenic
disorder in which bizarre and childlike
behaviors are common.

catatonic schizophrenia Schizophrenic disorder
in which disturbed motor behavior is prominent.

paranoid schizophrenia Schizophrenic
disorder marked by extreme suspiciousness and
complex, bizarre delusions.

undifferentiated schizophrenia Schizophrenic
disorder in which there are clear schizophrenic
symptoms that do not meet the criteria for
another subtype of the disorder.

Neuroimaging techniques, such as this PET
scan, often reveal important differences
between the brains of people with schizophre-
nia and normal volunteers. Still, neuroimaging
does not provide a decisive diagnostic test for
schizophrenia.

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416 Chapter 12

fraternal twins, if one twin has schizophrenia, the
chances are only about 17% that the other twin will
develop it as well.

Considerable research suggests that biological
predisposition to schizophrenia may involve the
faulty regulation of the neurotransmitters dopamine
and glutamate in the central nervous system
(R. Murray, Lappin, & Di Forti, 2008; Paz, Tardito,
Atzori, & Tseng, 2008). Some research also indicates
that pathology in various structures of the brain may
contribute to the onset of schizophrenia (Killgore,
Rosso, Gruber, & Yurgelun-Todd, 2009; Lawrie,
McIntosh, Hall, Owens, & Johnstone, 2008). Other
studies link schizophrenia to some form of early pre-
natal infection or disturbance (Bresnahan, Schaefer,

Brown, & Susser, 2005; Winter et al., 2008). Despite
these findings however, no laboratory tests to date can diagnose schizophrenia on the basis
of brain or genetic abnormalities alone.

Studies of identical twins have also been used to identify the importance of environ-
ment in causing schizophrenia. Because identical twins are genetically identical
and because half of the identical twins of people with schizophrenia do not develop
schizophrenia themselves, this severe and puzzling disorder cannot be caused by genetic
factors alone. Environmental factors—ranging from disturbed family relations to taking
drugs to biological damage that may occur at any age, even before birth—must also fig-
ure in determining whether a person will develop schizophrenia. Finally, although quite
different in emphasis, the various explanations for schizophrenic disorders are not mutu-
ally exclusive. Genetic factors are universally acknowledged, but many theorists believe
that only a combination of biological, psychological, and social factors produces schizo-
phrenia (van Os, Rutten, & Poulton, 2008). According to systems theory, genetic factors
predispose some people to schizophrenia; and family interaction and life stress activate
the predisposition.

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Genius and Mental Disorders

J
ean-Jacques Rousseau allegedly was paranoid. Mozart composed his
Requiem while under the delusion that he was being poisoned. Van Gogh cut
off his ear and sent it to a prostitute. Schopenhauer, Chopin, and John Stuart

Mill were depressed. Robert Burns and Lord Byron apparently were alcoholics.
Virginia Woolf suffered from bipolar disorder throughout her entire adult life.

• Do you think that creative people in general are more likely than others to
suffer from psychological problems? What leads you to believe as you do?

• What evidence would you need to have in order to answer this question in a
scientific way?

CHECK YOUR UNDERSTANDING
Indicate whether the following statements are true (T) or false (F):

1. ________ Schizophrenia is almost the same thing as multiple personality disorder.
2. ________ Psychotic symptoms, or loss of contact with reality, are indicators that a person

suffers from disorders other than schizophrenia.
3. ________ Studies indicate that a biological predisposition to schizophrenia may be inherited.
4. ________ Laboratory tests can be used to diagnose schizophrenia on the basis of brain

abnormalities.

Answers:1. (F).2. (F).3. (T).4. (F).

APPLY YOUR UNDERSTANDING

1. The book A Beautiful Mind is about John Nash, a mathematical genius. In young
adulthood, he became convinced that people were spying on him and hunting him down.
He searched for secret codes in numbers, sent bizarre postcards to friends, and made no
sense when he spoke. On the basis of this description, it seems most likely that he was
suffering from

a. disorganized schizophrenia.
b. catatonic schizophrenia.
c. undifferentiated schizophrenia.
d. paranoid schizophrenia.

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Psychological Disorders 417

CHILDHOOD DISORDERS
Why do stimulants appear to slow down hyperactive
children and adults?

Children may suffer from conditions already discussed in this chapter—for example,
depression and anxiety disorders. But other disorders are either characteristic of children
or are first evident in childhood. The DSM-IV-TR contains a long list of disorders usually
first diagnosed in infancy, childhood, or adolescence. Two of these disorders are attention-
deficit hyperactivity disorder and autistic disorder.

Attention-deficit hyperactivity disorder (ADHD) was once known simply as
hyperactivity. The new name reflects the fact that children with the disorder typically have
trouble focusing their attention in the sustained way that other children do. Instead, they are
easily distracted, often fidgety and impulsive, and almost constantly in motion. This disorder
affects about 5% of all school-age children worldwide (Polanczyk, de Lima, Horta, Biederman,
& Rohde, 2007), about 4% of adults in the United States (Kessler et al., 2006), and is much
more common in males than females. Research suggests that ADHD is present at birth, but
becomes a serious problem only after a child starts school (Monastra, 2008). The class setting
demands that children sit quietly, pay attention as instructed, follow directions, and inhibit
urges to yell and run around. The child with ADHD simply cannot conform to these demands.

We do not yet know what causes ADHD, but considerable evidence indicates biological
factors play an important role (Monastra, 2008; Nigg, 2005). Neuroimaging studies, for
example, reveal individuals with ADHD display altered brain functioning when presented
with tasks that require shifting attention. The deficiency appears to involve the frontal lobe
(see Chapter 2, “The Biological Basis of Behavior”), which normally recruits appropriate
regions of the brain to solve a problem. In people with ADHD, however, the frontal lobe
sometimes activates brain centers unrelated to solving a problem (Konrad, Neufang, Hanisch,
Fink, & Herpertz-Dahlmann, 2006; Mulas et al., 2006; Murias, Swanson, & Srinivasan, 2007).

Family interaction and other social experiences may be more important in preventing the
disorder than in causing it (C. Johnston & Ohan, 2005). That is, some exceptionally competent
parents and patient, tolerant teachers may be able to teach “difficult” children to conform to
the demands of schooling. Although some psychologists train the parents of children with
ADHD in these management skills, the most frequent treatment for these children is a type of
drug known as a psychostimulant. Psychostimulants do not work by “slowing down” hyperac-
tive children; rather, they appear to increase the children’s ability to focus their attention so that
they can attend to the task at hand, which decreases their hyperactivity and improves their aca-
demic performance (Duesenberg, 2006; Gimpel et al., 2005). Unfortunately, psychostimulants
often produce only short-term benefits; and their use and possible overuse in treating ADHD
children is controversial (LeFever, Arcona, & Antonuccio, 2003; Marc Lerner & Wigal, 2008).

A very different and profoundly serious disorder that usually becomes evident in the
first few years of life is autistic disorder. Autistic children fail to form normal attachments
to parents, remaining distant and withdrawn into their own separate worlds. As infants,
they may even show distress at being picked up or held. As they grow older, they typically

L E A R N I N G O B J E C T I V E
• Describe the key features of attention-

deficit hyperactivity disorder and
autistic spectrum disorder including
the difference between autism and
Asperger syndrome.

attention-deficit hyperactivity disorder
(ADHD) A childhood disorder characterized by
inattention, impulsiveness, and hyperactivity.

Answers:1. d.2. c.

psychostimulant Drugs that increase ability to
focus attention in people with ADHD.

autistic disorder A childhood disorder
characterized by lack of social instincts and
strange motor behavior.

2. Your roommate asks you what the difference is between “hallucinations” and
“delusions.” You tell her

a. hallucinations involve false beliefs, while delusions involve false sensory
perceptions.

b. hallucinations occur primarily in schizophrenic disorders, while delusions occur
primarily in dissociative disorders.

c. hallucinations involve false sensory perceptions, while delusions involve false
beliefs.

d. there is no difference; those are just two words for the same thing.

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418 Chapter 12

do not speak, or they develop a peculiar speech pattern called echolalia, in which they repeat
the words said to them. Autistic children typically show strange motor behavior, such as
repeating body movements endlessly or walking constantly on tiptoe. They don’t play as
normal children do; they are not at all social and may use toys in odd ways, constantly spin-
ning the wheels on a toy truck or tearing paper into strips. Autistic children often display the
symptoms of retardation (LaMalfa, Lassi, Bertelli, Salvini, & Placidi, 2004), but it is hard to
test their mental ability because they generally don’t talk (Dawson, Soulières, Gernsbacher, &
Mottron, 2007). The disorder lasts into adulthood in the great majority of cases.

In recent years, autistic disorder has come to be viewed as just one dimension of a
much broader range of developmental disorders known as autistic spectrum disorder
(ASD) (Dawson & Toth, 2006; Ming, Brimacombe, Chaaban, Zimmerman-Bier, & Wagner,
2008). Individuals with disorders in the autistic spectrum display symptoms that are simi-
lar to those seen in autistic disorder, but the severity of the symptoms is often quite
reduced. For example, high functioning children with a form of ASD known as Asperger
syndrome may show difficulty interacting with other people, but may have little or no prob-
lem with speech or intellectual development.

We don’t know what causes autism, although most theorists believe that it results
almost entirely from biological conditions (Goode, 2004; Zimmerman, Connors, &
Pardo-Villamizar, 2006). Some causes of mental retardation, such as fragile X syndrome
(see Chapter 7, “Cognition and Mental Abilities”), also seem to increase the risk of autistic
disorder. Recent evidence suggests that genetics also play a strong role in causing the
disorder (Campbell, Li, Sutcliffe, Persico, & Levitt, 2008; Rutter, 2005), though no spe-
cific gene or chromosome responsible for autistic disorder has yet been identified (Losh,
Sullivan, Trembath, & Piven, 2008).

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CHECK YOUR UNDERSTANDING
Indicate whether the following statements are true (T) or false (F):

1. ________ ADHD is much more common in boys than in girls.
2. ________ Psychostimulants work by “slowing down” hyperactive children.
3. ________ Most theorists believe that autistic disorder results almost entirely from biological

conditions.

Answers:1. (T).2. (F).3. (T).

APPLY YOUR UNDERSTANDING

1. Marie is a 7-year-old who is easily distracted and who has great difficulty concentrating.
While reading or studying, her attention will often be drawn to events going on
elsewhere. She is fidgety, impulsive, and never seems to stop moving. She finds it almost
impossible to sit quietly, pay attention, and follow directions. Marie is most likely suffering
from

a. attention-deficit hyperactivity disorder.
b. autistic disorder.
c. echolalia.
d. disorganized personality disorder.

2. Harry is a child who is usually distant and withdrawn. He doesn’t seem to form
attachments with anyone, even his parents. He plays by himself. He rarely talks; when he
does, it is usually to repeat what someone else just said to him. It is most likely that Harry
is suffering from

a. attention-deficit hyperactivity disorder.
b. autistic disorder.
c. bipolar disorder.
d. disorganized personality disorder.

Answers:1. a.2. b.

autistic spectrum disorder (ASD) A range of
disorders involving varying degrees of
impairment in communication skills, social
interactions, and restricted, repetitive, and
stereotyped patterns of behavior.

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Psychological Disorders 419

GENDER AND CULTURAL DIFFERENCES
IN PSYCHOLOGICAL DISORDERS
What are the differences between men and women
in psychological disorders?

Gender Differences
For the most part, men and women are similar with respect to mental disorders, but dif-
ferences do exist. Many studies have concluded that women have a higher rate of psycho-
logical disorders than men do, but this is an oversimplification (Cosgrove & Riddle, 2004;
Hartung & Widiger, 1998; Klose & Jacobi, 2004). We do know that more women than
men are treated for mental disorders. But this cannot be taken to mean that more women
than men have mental disorders, for in our society, it is much more acceptable for
women to discuss their emotional difficulties and to seek professional help openly (H.
Lerman, 1996).

Moreover, mental disorders for which there seems to be a strong biological compo-
nent, such as bipolar disorder and schizophrenia, are distributed fairly equally between
the sexes. Differences tend to be found for those disorders without a strong biological
component—that is, disorders in which learning and experience play a more important
role. For example, men are more likely than women to suffer from substance abuse and
antisocial personality disorder. Women, on the other hand, are more likely to suffer
from depression, agoraphobia, simple phobia, obsessive–compulsive disorder, and som-
atization disorder (Craske, 2003; Rosenfield & Pottick, 2005). These tendencies, coupled
with the fact that gender differences observed in the United States are not always seen in
other cultures (Culbertson, 1997), suggest that socialization plays a part in developing a
disorder: When men display abnormal behavior, it is more likely to take the forms of
drinking too much and acting aggressively; when women display abnormal behavior,
they are more likely to become fearful, passive, hopeless, and “sick” (Rosenfield &
Pottick, 2005).

One commonly reported difference between the sexes concerns marital status. Men
who are separated, divorced, or who have never married have a higher incidence of mental
disorders than do either women of the same marital status or married men. But married
women have higher rates than married men. What accounts for the apparent fact that mar-
riage is psychologically less beneficial for women than for men?

Here, too, socialization appears to play a role. For women, marriage, family relation-
ships, and child rearing are likely to be more stressful than they are for men (Erickson,
2005; Stolzenberg & Waite, 2005). For men, marriage and family provide a haven; for
women, they are a demanding job. In addition, women are more likely than men to be the
victims of incest, rape, and marital battering. As one researcher has commented, “for
women, the U.S. family is a violent institution” (Koss, 1990, p. 376).

We saw in Chapter 11 that the effects of stress are proportional to the extent
that a person feels alienated, powerless, and helpless. Alienation, powerlessness,
and helplessness are more prevalent in women than in men. These factors are espe-
cially common among minority women, so it is not surprising that the prevalence
of psychological disorders is greater among them than among other women
(Laganà & Sosa, 2004). In addition, these factors play an especially important role
in anxiety disorders and depression—precisely those disorders experienced most
often by women (M. Byrne, Carr, & Clark, 2004; Kessler et al., 1994). The rate of
depression among women is twice that of men, a difference that is usually ascribed
to the more negative and stressful aspects of women’s lives, including lower
incomes and the experiences of bias and physical and sexual abuse (American Psy-
chological Association, 2006; Blehar & Keita, 2003).

In summary, women do seem to have higher rates of anxiety disorders
and depression than men do; and they are more likely than men to seek

L E A R N I N G O B J E C T I V E
• Describe the differences between men

and women in psychological disorders
including the prevalence of disorders
and the kinds of disorders they are
likely to experience. Explain why these
differences exist. Explain why “it is
increasingly important for mental
health professionals to be aware of
cultural differences” in psychological
disorders.

More women than men in the United States
seek help for mental disorders, but this may
not mean mental disorders are more prevalent
in women. Women are more likely than men to
seek help for a variety of problems, physical
and mental.

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420 Chapter 12

Cultural Differences
As the U.S. population becomes more diverse, it is increasingly important for mental health
professionals to be aware of cultural differences if they are to understand and diagnose dis-
orders among people of various cultural groups. Many disorders occur only in particular
cultural groups. For example, ataque de nervios—literally translated as “attack of nerves”—
is a culturally specific phenomenon that is seen predominately among Latinos. The symp-
toms of ataque de nervios generally include the feeling of being out of control, which may
be accompanied by fainting spells, trembling, uncontrollable screaming, and crying, and, in
some cases, verbal or physical aggressiveness. Afterwards, many patients do not recall the
attack, and quickly return to normal functioning. Another example, taijin kyofusho
(roughly translated as “fear of people”), involves a morbid fear that one’s body or actions
may be offensive to others. Taijin kyofusho is rarely seen outside of Japan. Other cross-cul-
tural investigations have found differences in the course of schizophrenia and in the way
childhood psychological disorders are manifest among different cultures (Kymalainen &
Weisman de Mamani, 2008; López & Guarnaccia, 2008; Weisz, McCarty, Eastman, Chaiyasit,
& Suwanlert, 1997).

Prevalence of childhood disorders also differs markedly by culture. Of course, it is
adults—parents, teachers, counselors—who decide whether a child is suffering from a psy-
chological disorder, and those decisions are likely to be influenced by cultural expectations.
For example, in a series of cross-cultural studies, Thai children were more likely to be
referred to mental health clinics for internalizing problems, such as anxiety and depression,
compared to U.S. children, who were more likely to be referred for externalizing problems,
such as aggressive behavior (Weisz et al., 1997).

Diversity–Universality Are We All Alike?
The frequency and nature of some psychological disorders vary significantly among
the world’s different cultures (Halbreich & Karkun, 2006; López & Guarnaccia, 2000).
This suggests that many disorders have a strong cultural component, or that diagnosis is
somehow related to culture. On the other hand, disorders that are known to have a
strong genetic component generally display a more uniform distribution across different
cultures. ■

CHECK YOUR UNDERSTANDING

1. Mental disorders for which there seems to be a strong ______________ component are
distributed fairly equally between the sexes.

2. More women than men are treated for mental disorders.

Is this statement true (T) or false (F)?

3. There is greater cultural variation in those abnormal behaviors with strong genetic causes.

Is this statement true (T) or false (F)?

Answers:1. biological.2. (T).3. (F).

professional help for their problems. However, greater stress, due in part to socialization
and lower status rather than psychological weakness, apparently accounts for this statis-
tic. Marriage and family life, associated with lower rates of mental disorders among
men, introduce additional stress into the lives of women, particularly young women (25
to 45); and in some instances this added stress escalates into a psychological disorder.

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Psychological Disorders 421

Perspectives on Psychological
Disorders
biological model, p. 393
psychoanalytic model, p. 394
cognitive–behavioral model, p. 394
diathesis–stress model, p. 394
diathesis, p. 395
systems approach, p. 395
insanity, p. 396

Mood Disorders
mood disorders, p. 398
depression, p. 398
major depressive disorder, p. 398
dysthymia, p. 398
mania, p. 401
bipolar disorder, p. 401
cognitive distortions, p. 402

Anxiety Disorders
anxiety disorders, p. 403
specific phobia, p. 403
social phobias, p. 403
agoraphobia, p. 404
panic disorder, p. 404
generalized anxiety disorder,

p. 404
obsessive–compulsive disorder

(OCD), p. 405

Psychosomatic and
Somatoform Disorders
psychosomatic disorder, p. 406
somatoform disorders, p. 406
somatization disorder, p. 406
conversion disorders, p. 407
hypochondriasis, p. 407
body dysmorphic disorder, p. 407

Dissociative Disorders
dissociative disorders, p. 408
dissociative amnesia, p. 408
dissociative fugue, p. 408
dissociative identity disorder,

p. 408
depersonalization disorder, p. 408

Sexual and Gender-Identity
Disorders
sexual dysfunction, p. 409
erectile disorder (or erectile

dysfunction) (ED), p. 409
female sexual arousal disorder,

p. 409
sexual desire disorders, p. 410
orgasmic disorders, p. 410
premature ejaculation, p. 411
vaginismus, p. 411
paraphilias, p. 411

fetishism, p. 411
voyeurism, p. 411
exhibitionism, p. 411
frotteurism, p. 411
transvestic fetishism, p. 411
sexual sadism, p. 411
sexual masochism, p. 411
pedophilia, p. 411
gender-identity disorders, p. 411
gender-identity disorder in

children, p. 411

Personality Disorders
personality disorders, p. 412
schizoid personality disorder,

p. 412
paranoid personality disorder,

p. 413
dependent personality disorder,

p. 413

avoidant personality disorder,

p. 413
narcissistic personality

disorder, p. 413
borderline personality disorder,

p. 413
antisocial personality disorder,

p. 413

Schizophrenic Disorders
schizophrenic disorders,

p. 415
psychotic, p. 415
hallucinations, p. 415
delusions, p. 415
disorganized schizophrenia,

p. 415
catatonic schizophrenia,

p. 415

paranoid schizophrenia,

p. 415
undifferentiated schizophrenia,

p. 415

Childhood Disorders
attention-deficit hyperactivity

disorder (ADHD), p. 417
psychostimulant, p. 417
autistic disorder, p. 417
autistic spectrum disorder

(ASD), p. 418

PERSPECTIVES ON PSYCHOLOGICAL
DISORDERS
How does a mental health professional define a psychologi-
cal disorder? Mental health professionals define a psychological
disorder as a condition that either seriously impairs a person’s abil-
ity to function in life or creates a high level of inner distress, or
both. This view does not mean that the category “disordered” is
always easy to distinguish from the category “normal.” In fact, it
may be more accurate to view abnormal behavior as merely quanti-
tatively different from normal behavior.

How has the view of psychological disorders changed over
time? In early societies, abnormal behavior was often attributed to
supernatural powers. As late as the 18th century, the mentally ill
were thought to be witches or possessed by the devil. In modern
times, three approaches have helped to advance our understanding
of abnormal behavior: the biological, the psychoanalytic, and the
cognitive behavioral.

How can biology influence the development of psychologi-
cal disorders? The biological model holds that abnormal behav-
ior is caused by physiological malfunction, especially of the brain.

Researchers assume the origin of these malfunctions is often
hereditary. Although neuroscientists have demonstrated that
genetic/biochemical factors are involved in some psychological
disorders, biology alone cannot account for most mental illnesses.

What did Freud and his followers believe was the underlying
cause of psychological disorders? The psychoanalytic model orig-
inating with Freud holds that abnormal behavior is a symbolic expres-
sion of unconscious conflicts that generally can be traced to childhood.

According to the cognitive–behavioral model, what causes
abnormal behavior? The cognitive–behavior model states that psy-
chological disorders arise when people learn maladaptive ways of
thinking and acting. What has been learned can be unlearned, however.
Cognitive–behavioral therapists strive to modify their patients’ dys-
functional behaviors and distorted, self-defeating thought processes.

Why do some people with a family background of a psycholog-
ical disorder develop the disorder, whereas other family mem-
bers do not? According to the diathesis–stress model, which
integrates the biological and environmental perspectives, psycholog-
ical disorders develop when a biological predisposition is triggered by
stressful circumstances. Another attempt at integrating causes is the
systems (biopsychosocial) approach, which contends psychological

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422 Chapter 12

disorders are “lifestyle diseases” arising from a combination of bio-
logical risk factors, psychological stresses, and societal pressures.

How common are mental disorders? According to research,
15% of the population is suffering from one or more mental disor-
ders at any given point in time.

Is there a difference between “insanity” and “mental ill-
ness”? Insanity is a legal term, not a psychological one. It is typi-
cally applied to defendants who were so mentally disturbed when
they committed their offense that they either did not know right
from wrong or were unable to control their behavior.

Why is it useful to have a manual of psychological disorders?
The current fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR) provides careful descriptions of the
symptoms of different disorders so that diagnoses based on them will
be reliable and consistent among mental health professionals. The
DSM-IV-TR includes little information on causes and treatments.

MOOD DISORDERS
How do mood disorders differ from ordinary mood changes?
Most people have a wide emotional range, but in some people with
mood disorders, this range is greatly restricted. They seem stuck at
one or the other end of the emotional spectrum, or they may alter-
nate back and forth between periods of mania and depression.

How does clinical depression differ from ordinary sadness?
The most common mood disorder is depression, in which a person
feels overwhelmed with sadness, loses interest in activities, and dis-
plays such other symptoms as excessive guilt, feelings of worthless-
ness, insomnia, and loss of appetite. Major depressive disorder is
an episode of intense sadness that may last for several months; in
contrast, dysthymia involves less intense sadness but persists with
little relief for a period of 2 years or more.

What factors are related to a person’s likelihood of commit-
ting suicide? More women than men attempt suicide, but more
men succeed. Suicide attempt rates among American adolescents
and young adults have been rising. A common feeling associated
with suicide is hopelessness, which is also typical of depression.

What is mania, and how is it involved in bipolar disorder? People
suffering from mania become euphoric (“high”), extremely active,
excessively talkative, and easily distracted. They typically have unlimited
hopes and schemes, but little interest in realistically carrying them out.
At the extreme, they may collapse from exhaustion. Manic episodes
usually alternate with depression. Such a mood disorder, in which both
mania and depression are alternately present and are sometimes inter-
rupted by periods of normal mood, is known as bipolar disorder.

What causes some people to experience extreme mood
changes? Mood disorders can result from a combination of bio-
logical, psychological, and social factors. Genetics and chemical
imbalances in the brain seem to play an important role in the
development of depression and, especially, bipolar disorder.
Cognitive distortions (unrealistically negative views about the
self ) occur in many depressed people, although it is uncertain
whether these cause the depression or are caused by it. Finally,
social factors, such as troubled relationships, have also been linked
with mood disorders.

ANXIETY DISORDERS
How does an anxiety disorder differ from ordinary anxiety?
Normal fear is caused by something identifiable and the fear sub-
sides with time. With anxiety disorder, however, either the person
doesn’t know the source of the fear or the anxiety is inappropriate
to the circumstances.

Into what three categories are phobias usually grouped?
A specific phobia is an intense, paralyzing fear of something that
it is unreasonable to fear so excessively. A social phobia is exces-
sive, inappropriate fear connected with social situations or perfor-
mances in front of other people. Agoraphobia, a less common
and much more debilitating type of anxiety disorder, involves
multiple, intense fears such as the fear of being alone, of being in
public places, or of other situations involving separation from a
source of security.

How does a panic attack differ from fear? Panic disorder is char-
acterized by recurring sudden, unpredictable, and overwhelming
experiences of intense fear or terror without any reasonable cause.

How do generalized anxiety disorder and obsessive–compul-
sive disorder differ from specific phobias? Generalized anxiety
disorder is defined by prolonged vague, but intense fears that, unlike
phobias, are not attached to any particular object or circumstance.
In contrast, obsessive–compulsive disorder involves either involun-
tary thoughts that recur despite the person’s attempt to stop them or
compulsive rituals that a person feels compelled to perform. Two
other types of anxiety disorder are caused by highly stressful events.
If the anxious reaction occurs soon after the event, the diagnosis is
acute stress disorder; if it occurs long after the event is over, the diag-
nosis is posttraumatic stress disorder.

What causes anxiety disorders? Psychologists with a biological
perspective propose that a predisposition to anxiety disorders may
be inherited because these types of disorders tend to run in fami-
lies. Cognitive psychologists suggest that people who believe that
they have no control over stressful events in their lives are more
likely to suffer from anxiety disorders than other people are. Evolu-
tionary psychologists hold that we are predisposed by evolution to
associate certain stimuli with intense fears, serving as the origin of
many phobias. Psychoanalytic thinkers focus on inner psychologi-
cal conflicts and the defense mechanisms they trigger as the sources
of anxiety disorders.

PSYCHOSOMATIC AND SOMATOFORM
DISORDERS
What is the difference between psychosomatic disorders
and somatoform disorders? Psychosomatic disorders are ill-
nesses that have a valid physical basis, but are largely caused by psy-
chological factors such as excessive stress and anxiety. In contrast,
somatoform disorders are characterized by physical symptoms
without any identifiable physical cause. Examples are somatization
disorder, characterized by recurrent vague somatic complaints
without a physical cause, conversion disorder (a dramatic specific
disability without organic cause), hypochondriasis (insistence that
minor symptoms mean serious illness), and body dysmorphic dis-
order (imagined ugliness in some part of the body).

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Psychological Disorders 423

DISSOCIATIVE DISORDERS
What do dissociative disorders have in common? In
dissociative disorders, some part of a person’s personality or mem-
ory is separated from the rest. Dissociative amnesia involves the
loss of at least some significant aspects of memory. When an amne-
sia victim leaves home and assumes an entirely new identity, the
disorder is known as dissociative fugue. In dissociative identity
disorder (multiple personality disorder), several distinct personali-
ties emerge at different times. In depersonalization disorder, the
person suddenly feels changed or different in a strange way.

SEXUAL AND GENDER-IDENTITY DISORDERS
What are the three main types of sexual disorders? The DSM-
IV-TR recognizes three main types of sexual disorders: sexual dys-
function, paraphilias, and gender-identity disorders.

Sexual dysfunction is the loss or impairment of the ability to
function effectively during sex. In men, this may take the form of
erectile disorder (ED), the inability to achieve or keep an erection;
in women, it often takes the form of female sexual arousal disor-
der, the inability to become sexually excited or to reach orgasm.
Sexual desire disorders involve a lack of interest in or an active
aversion to sex. People with orgasmic disorders experience both
desire and arousal but are unable to reach orgasm. Other problems
that can occur include premature ejaculation—the male’s inability
to inhibit orgasm as long as desired—and vaginismus—involun-
tary muscle spasms in the outer part of a woman’s vagina during
sexual excitement that make intercourse impossible.

Paraphilias involve the use of unconventional sex objects or situ-
ations. These disorders include fetishism, voyeurism, exhibitionism,
frotteurism, transvestic fetishism, sexual sadism, and sexual
masochism. One of the most serious paraphilias is pedophilia, the
engaging in sexual relations with children.

Gender-identity disorders involve the desire to become, or the
insistence that one really is, a member of the other sex. Gender-
identity disorder in children is characterized by rejection of one’s
biological gender as well as the clothing and behavior society con-
siders appropriate to that gender during childhood.

PERSONALITY DISORDERS
Which personality disorder creates the most significant prob-
lems for society? Personality disorders are enduring, inflexible, and
maladaptive ways of thinking and behaving that are so exaggerated
and rigid that they cause serious inner distress or conflicts with others.
One group of personality disorders is characterized by odd or eccen-
tric behavior. People who exhibit schizoid personality disorder lack
the ability or desire to form social relationships and have no warm
feelings for other people; those with paranoid personality disorder
are inappropriately suspicious, hypersensitive, and argumentative.
Another cluster of personality disorders is characterized by anxious or
fearful behavior. Examples are dependent personality disorder (the
inability to think or act independently) and avoidant personality dis-
order (social anxiety leading to isolation). A third group of personal-
ity disorders is characterized by dramatic, emotional, or erratic
behavior. For instance, people with narcissistic personality disorder

have a highly overblown sense of self-importance, whereas those with
borderline personality disorder show much instability in self-image,
mood, and interpersonal relationships. Finally, people with antisocial
personality disorder chronically lie, steal, and cheat with little or no
remorse. Because this disorder is responsible for a good deal of crime
and violence, it creates the greatest problems for society.

SCHIZOPHRENIC DISORDERS
How is schizophrenia different from multiple-personality disor-
der? In multiple-personality disorder, consciousness is split into two
or more distinctive personalities, each of which is coherent and intact.
This condition is different from schizophrenic disorders, which
involve dramatic disruptions in thought and communication, inap-
propriate emotions, and bizarre behavior that lasts for years. People
with schizophrenia are out of touch with reality and usually cannot live
a normal life unless successfully treated with medication. They often
suffer from hallucinations (false sensory perceptions) and delusions
(false beliefs about reality). Subtypes of schizophrenic disorders
include disorganized schizophrenia (childish disregard for social con-
ventions), catatonic schizophrenia (mute immobility or excessive
excitement), paranoid schizophrenia (extreme suspiciousness related
to complex delusions), and undifferentiated schizophrenia (charac-
terized by a diversity of symptoms).

CHILDHOOD DISORDERS
Why do stimulants appear to slow down hyperactive children and
adults? DSM-IV-TR contains a long list of disorders usually first
diagnosed in infancy, childhood, or adolescence. Children with
attention-deficit hyperactivity disorder (ADHD) are highly dis-
tractible, often fidgety and impulsive, and almost constantly in motion.
The psychostimulants frequently prescribed for ADHD appear to slow
such children down because they increase the ability to focus attention
on routine tasks. Autistic disorder is a profound developmental prob-
lem identified in the first few years of life. It is characterized by a failure to
form normal social attachments, by severe speech impairment, and by
strange motor behaviors. A much broader range of developmental dis-
orders known as autistic spectrum disorder (ASD) is used to describe
individuals with symptoms that are similar to those seen in autistic dis-
order, but may be less severe as is the case in Asperger syndrome.

GENDER AND CULTURAL DIFFERENCES
IN PSYCHOLOGICAL DISORDERS
What complex factors contribute to different rates of abnor-
mal behavior in men and women? Although nearly all psycholog-
ical disorders affect both men and women, there are some gender
differences in the degree to which some disorders are found. Men are
more likely to suffer from substance abuse and antisocial personality
disorder; women show higher rates of depression, agoraphobia, sim-
ple phobia, obsessive–compulsive disorder, and somatization disor-
der. In general, gender differences are less likely to be seen in disorders
that have a strong biological component. This tendency is also seen
cross-culturally, where cultural differences are observed in disorders
not heavily influenced by genetic and biological factors. These gender
and cultural differences support the systems view that biological, psy-
chological, and social forces interact as causes of abnormal behavior.

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Therapies13

Enduring Issues in Therapie

Insight Therapies
• Psychoanalysis
• Client-Centered Therapy
• Gestalt Therapy
• Recent Developments
Behavior Therapies
• Therapies Based on

Classical Conditioning

• Therapies Based on Operant
Conditioning

• Therapies Based on Modeling
Cognitive Therapies
• Stress-Inoculation Therapy
• Rational–Emotive Therapy
• Beck’s Cognitive Therapy
Group Therapies
• Family Therapy

• Couple Therapy
• Self-Help Groups
Effectiveness
of Psychotherapy
• Which Type of Therapy Is

Best for Which Disorder?
Biological Treatments
• Drug Therapies
• Electroconvulsive Therapy
• Psychosurgery

Institutionalization
and Its Alternatives
• Deinstitutionalization
• Alternative Forms of

Treatment
• Prevention
Client Diversity and
Treatment
• Gender and Treatment
• Culture and Treatment

O V E R V I E W

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For most new mothers, giving birth results in an instant bondand feelings of immediate and unconditional love for theirnew baby. Many describe motherhood as the happiest time
in their lives and cannot imagine a life without their children.
However, for some, another reaction occurs—one of sadness
and apathy, and withdrawal from the world around them.
Brooke Shields, the well-known actress and model, was one of
these women.

In Down Came the Rain: My Journey Through Postpartum
Depression, Shields (2006) writes that she had always dreamed
of being a mother. Although she and her husband, Chris Henchy,
initially had trouble conceiving, Shields eventually became
pregnant through in vitro fertilization and gave birth to a daugh-
ter in 2003. Just as her attempt at conceiving wasn’t without
effort, easing into life as a mother wasn’t effortless, either.

Almost immediately after returning home from the hospital,
Shields began to experience symptoms of postpartum depres-
sion. Once referred to as the “baby blues,” postpartum depres-
sion has recently come to be considered a very legitimate type
of depression. Symptoms range from anxiety and tearfulness to
feelings of extreme detachment and even being suicidal.
Shields notes that her “baby blues” rapidly gave way to full-
blown depression, including thoughts of self-harm and frighten-
ing visions of harm coming to her baby. In addition to the birth of
her child, Shields was also coping with the recent death of her
father, as well as the ongoing struggle of coping with the suicide
of a close friend 2 years prior. Doctors note that postpartum
depression can be exacerbated by events such as these.

425

As Shields’s mental health began to decline, she felt more
anxious and panicky. She felt sadness greater than she’d ever
experienced, and began thinking that it would never go away.
She felt completely detached from the baby she had gone
through so much to have. This detachment depressed her fur-
ther. It became a vicious cycle, and she suffered tremendously
throughout it. It didn’t occur to Shields that she might have post-
partum depression until she heard someone comment on the
shame and depression associated with the disease. It finally hit
home and Shields sought help.

As with nearly all forms of depression, there was no quick
and easy solution. Treatment requires patience, help from a
doctor, a supportive family, and often medication. Shields began
treatment and gradually began to feel better. She eventually
was able to feel the love that mothers speak of when referring to
their children. She bonded with her baby and became tuned in
to the child’s needs instinctively. With her doctor’s guidance,
she began to wean herself off the medication. She also sought
healing through writing the book that detailed her experience,
and in 2006, she and her husband conceived again, adding
another child to their family.

Having learned about a wide range of psychological disor-
ders in Chapter 12, “Psychological Disorders,” you are probably
curious about the kinds of treatments available for them. Brooke
Shields’s treatment for depression, a combination of medication
and psychotherapy, exemplifies the help that is available. This
chapter describes a variety of treatments that mental health
professionals provide.

ENDURING ISSUES IN THERAPIES
The underlying assumption behind therapy for psychological disorders is the belief that
people are capable of changing (stability–change). Throughout this chapter are many
opportunities to think about whether people suffering from psychological disorders can
change significantly and whether they can change without intervention. In the discussion
of biological treatments for psychological disorders we again encounter the issue of
mind–body. Finally, the enduring issue of diversity–universality will arise when we discuss
the challenges therapists face when treating people from cultures other than their own.

INSIGHT THERAPIES
What do insight therapies have in common?

Although the details of various insight therapies differ, their common goal is to give peo-
ple a better awareness and understanding of their feelings, motivations, and actions in the
hope that this will lead to better adjustment (Huprich, 2009; Messer & McWilliams, 2007;
Person, Cooper, & Gabbard, 2005). In this section, we consider three major insight thera-
pies: psychoanalysis, client-centered therapy, and Gestalt therapy.

insight therapies A variety of individual
psychotherapies designed to give people a better
awareness and understanding of their feelings,
motivations, and actions in the hope that this
will help them to adjust.

L E A R N I N G O B J E C T I V E S
• Describe the common goal of all insight

therapies. Compare and contrast
psychoanalysis, client-centered
therapy, and Gestalt therapy.

• Explain how short-term psychodynamic
therapy and virtual therapy differ from
the more traditional forms of insight
therapy.

psychotherapy The use of psychological
techniques to treat personality and behavior
disorders.

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426 Chapter 13

Psychoanalysis
How does “free association” in psychoanalysis help a person to become
aware of hidden feelings?

Psychoanalysis is designed to bring hidden feelings and motives to conscious awareness so
that the person can deal with them more effectively.

In Freudian psychoanalysis, the client is instructed to talk about whatever comes to
mind. This process is called free association. Freud believed that the resulting “stream of
consciousness” would provide insight into the person’s unconscious mind. During the early
stages of psychoanalysis, the analyst remains impassive, mostly silent, and out of the person’s
sight. The analyst’s silence serves as a “blank screen” onto which the person projects uncon-
scious thoughts and feelings.

Eventually, clients may test their analyst by talking about desires and fantasies that they
have never revealed to anyone else. When clients discover that their analyst is not shocked or
disgusted by their revelations, they are reassured and transfer to their analyst feelings they
have toward authority figures from their childhood. This process is known as transference.
It is said to be positive transference when the person feels good about the analyst.

As people continue to expose their innermost feelings, they begin to feel increasingly
vulnerable. Threatened by their analyst’s silence and by their own thoughts, clients may feel
cheated and perhaps accuse their analyst of being a money grabber. Or they may suspect
that their analyst is really disgusted by their disclosures or is laughing at them behind their
backs. This negative transference is thought to be a crucial step in psychoanalysis, for it pre-
sumably reveals negative feelings toward authority figures and resistance to uncovering
repressed emotions.

As therapy progresses, the analyst takes a more active role and begins to interpret or suggest
alternative meanings for clients’ feelings, memories, and actions. The goal of interpretation is to
help people to gain insight—to become aware of what was formerly outside their awareness. As
what was unconscious becomes conscious, clients may come to see how their childhood experi-
ences have determined how they currently feel and act. By working through old conflicts, clients
have a chance to review and revise the feelings and beliefs that underlie their problems. In the
example of a therapy session that follows, the woman discovers a link between her current
behaviors and childhood fears regarding her mother, which she has transferred to the analyst.

Therapist: (summarizing and restating) It sounds as if you would like to let loose with
me, but you are afraid of what my response would be.

Patient: I get so excited by what is hap-
pening here. I feel I’m being
held back by needing to be
nice. I’d like to blast loose
sometimes, but I don’t dare.

Therapist: Because you fear my reaction?
Patient: The worst thing would be that

you wouldn’t like me. You
wouldn’t speak to me friendly;
you wouldn’t smile; you’d feel
you can’t treat me and dis-
charge me from treatment. But
I know this isn’t so; I know it.

Therapist: Where do you think these atti-
tudes come from?

Patient: When I was 9 years old, I read
a lot about great men in his-
tory. I’d quote them and
be dramatic, I’d want a sword
at my side; I’d dress like an
Indian. Mother would scold

Explore on MyPsychLab

free association A psychoanalytic technique
that encourages the person to talk without
inhibition about whatever thoughts or fantasies
come to mind.

transference The client’s carrying over to the
analyst feelings held toward childhood
authority figures.

The consulting room where Freud met his
clients. Note the position of Freud’s chair at
the head of the couch. In order to encourage
free association, the psychoanalyst has to
function as a blank screen onto which the
client can project his or her feelings. To
accomplish this, Freud believed, the psycho-
analyst has to stay out of sight of the client.

insight Awareness of previously unconscious
feelings and memories and how they influence
present feelings and behavior.

Explore Key Components of
Therapies at www.mypsychlab.com

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Therapies 427

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 14, I fell off a horse and broke my back. I had to be in bed. Mother
told me that day not to go riding. I’d get hurt because the ground was frozen.
I was a stubborn, self-willed child. Then I went against her will and suffered
an accident that changed my life: a fractured back. Her attitude was, “I told
you so.” I was put in a cast and kept in bed for months.

Therapist: You were punished, so to speak, by this accident.
Patient: But I gained attention and love from Mother for the first time. I

felt so good. I’m ashamed to tell you this: Before I healed,
I opened the cast and tried to walk, to make myself sick again so
I could stay in bed longer.

Therapist: How does that connect with your impulse to be sick now and
stay in bed so much?

Patient: Oh. . . . (pause)
Therapist: What do you think?
Patient: Oh, my God, how infantile, how ungrownup (pause). It must be so. I want

people to love me and feel sorry for me. Oh, my God. How completely child-
ish. It is, is that. My mother must have ignored me when I was little, and I
wanted so to be loved.

Therapist: So that it may have been threatening to go back to being self-willed and
unloved after you got out of the cast (interpretation).

Patient: It did. My life changed. I became meek and controlled. I couldn’t get angry
or stubborn afterward.

Therapist: Perhaps if you go back to being stubborn with me, you would be returning to
how you were before, that is, active, stubborn, but unloved.

Patient: (excitedly) And, therefore, losing your love. I need you, but after all, you
aren’t going to reject me. But the pattern is so established now that the
threat of the loss of love is too overwhelming with everybody, and I’ve got
to keep myself from acting selfish or angry (Wolberg, 1977, pp. 560–561).

Only a handful of people who seek therapy go into traditional psychoanalysis, as this
woman did. As Freud recognized, analysis requires great motivation to change and an abil-
ity to deal rationally with whatever the analysis uncovers. Moreover, traditional analysis
may take 5 years or longer, with three, sometimes five, sessions a week. Few can afford this
kind of treatment, and fewer possess the verbal and analytical skills necessary to discuss
thoughts and feelings in this detailed way. And many want more immediate help for their
problems. For those with severe disorders, psychoanalysis is ineffective.

Since Freud’s invention around the turn of the 20th century, psychodynamic personal-
ity theory has changed significantly. Many of these changes have led to modified psychoan-
alytic techniques as well as to different therapeutic approaches (McCullough & Magill,
2009; Monti & Sabbadini, 2005). Freud felt that to understand the present we must under-
stand the past, but most neo-Freudians encourage clients to cope directly with current
problems in addition to addressing unresolved conflicts from the past. Neo-Freudians also
favor face-to-face discussions, and most take an active role in analysis by interpreting their
client’s statements freely and suggesting discussion topics.

Client-Centered Therapy
Why did Carl Rogers call his approach to therapy “client centered”?

Carl Rogers, the founder of client-centered (or person-centered) therapy, took pieces of
the neo-Freudians’ views and revised them into a radically different approach to therapy.
According to Rogers, the goal of therapy is to help people to become fully functioning, to
open them up to all of their experiences and to all of themselves. Such inner awareness is a
form of insight, but for Rogers, insight into current feelings was more important than
insight into unconscious wishes with roots in the distant past. Rogers called his approach to

Source: © The New Yorker Collection, 1989, Danny
Shanahan from cartoonbank.com. All Rights Reserved.

client-centered (or person-centered)
therapy Nondirectional form of therapy
developed by Carl Rogers that calls for
unconditional positive regard of the client by
the therapist with the goal of helping the client
become fully functioning.

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428 Chapter 13

therapy client centered because he placed the
responsibility for change on the person with the
problem. Rogers believed that people’s defensive-
ness, anxiety, and other signs of discomfort stem
from their experiences of conditional positive
regard. They have learned that love and accep-
tance are contingent on conforming to what other
people want them to be. By contrast, the cardinal
rule in person-centered therapy is for the thera-
pist to express unconditional positive regard—that
is, to show true acceptance of clients no matter
what they may say or do (Bozarth, 2007). Rogers
felt that this was a crucial first step toward clients’
self-acceptance.

Rogerian therapists try to understand things
from the clients’ point of view. They are emphati-
cally nondirective. They do not suggest reasons for
a client’s feelings or how they might better handle
a difficult situation. Instead, they try to reflect
clients’ statements, sometimes asking questions or

hinting at feelings that clients have not articulated. Rogers felt that when therapists provide
an atmosphere of openness and genuine respect, clients can find themselves, as portrayed
in the following session.

Client: I guess I do have problems at school . . . . You see, I’m chairman of the Sci-
ence Department, so you can imagine what kind of a department it is.

Therapist: You sort of feel that if you’re in something that it can’t be too good.
Is that . . .

Client: Well, it’s not that I . . . It’s just that I’m . . . I don’t think that I could run it.
Therapist: You don’t have any confidence in yourself?
Client: No confidence, no confidence in myself. I never had any confidence in

myself. I—like I told you—like when even when I was a kid I didn’t feel I
was capable and I always wanted to get back with the intellectual group.

Therapist: This has been a long-term thing, then. It’s gone on a long time.
Client: Yeah, the feeling is—even though I know it isn’t, it’s the feeling that I have

that—that I haven’t got it, that—that—that—people will find out that
I’m dumb or—or . . .

Therapist: Masquerade.
Client: Superficial, I’m just superficial. There’s nothing below the surface. Just

superficial generalities, that …
Therapist: There’s nothing really deep and meaningful to you (Hersher, 1970,

pp. 29–32).

Rogers wanted to discover those processes in client-centered therapy that were associated
with positive results. Rogers’s interest in the process of therapy resulted in important and
lasting contributions to the field; research has shown that a therapist’s emphasis on empathy,
warmth, and understanding increase success, no matter what therapeutic approach is used
(Bike, Norcross, & Schatz, 2009; Kirschenbaum & Jourdan, 2005).

Gestalt Therapy
How is Gestalt therapy different from psychoanalysis?

Gestalt therapy is largely an outgrowth of the work of Frederick (Fritz) Perls at
the Esalen Institute in California. By emphasizing the present and encouraging
face-to-face confrontations, Gestalt therapy attempts to help people become more

Carl Rogers (far right) leading a group ther-
apy session. Rogers was the founder of
client-centered therapy.

Gestalt therapy An insight therapy that
emphasizes the wholeness of the personality and
attempts to reawaken people to their emotions
and sensations in the present.

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Therapies 429

genuine in their daily interactions. The therapist is active and directive, and the
emphasis is on the whole person. (The term Gestalt means “whole.”) The therapist’s
role is to “fill in the holes in the personality to make the person whole and complete
again” (Perls, 1969, p. 2).

Gestalt therapists use various techniques to try to make people aware of their feelings.
For example, they tell people to “own their feelings” by talking in an active, rather than a
passive way: “I feel angry when he’s around” instead of “He makes me feel angry when he’s
around.” They also ask people to speak to a part of themselves that they imagine to be sit-
ting next to them in an empty chair. This empty-chair technique and others are illustrated in
the following excerpt:

Therapist: Try to describe just what you are aware of at each moment as fully as possi-
ble. For instance, what are you aware of now?

Client: I’m aware of wanting to tell you about my problem, and also a sense of
shame—yes, I feel very ashamed right now.

Therapist: Okay. I would like you to develop a dialogue with your feeling of shame.
Put your shame in the empty chair over here (indicates chair), and talk to it.

Client: Are you serious? I haven’t even told you about my problem yet.
Therapist: That can wait—I’m perfectly serious, and I want to know what you have to

say to your shame.
Client: (awkward and hesitant at first, but then becoming looser and more involved)

Shame, I hate you. I wish you would leave me—you drive me crazy, always
reminding me that I have a problem, that I’m perverse, different, shameful—
even ugly. Why don’t you leave me alone?

Therapist: Okay, now go to the empty chair, take the role of shame, and answer your-
self back.

Client: (moves to the empty chair) I am your constant companion—and I don’t
want to leave you. I would feel lonely without you, and I don’t hate you. I
pity you, and I pity your attempts to shake me loose, because you are
doomed to failure.

Therapist: Okay, now go back to your original chair and answer back.
Client: (once again as himself) How do you know I’m doomed to failure?

(spontaneously shifts chairs now, no longer needing direction from the ther-
apist; answers himself back, once again in the role of shame) I know that
you’re doomed to failure because I want you to fail and because I control
your life. You can’t make a single move without me. For all you know, you
were born with me. You can hardly remember a single moment when you
were without me, totally unafraid that I would spring up and suddenly
remind you of your loathsomeness (Shaffer, 1978, pp. 92–93).

In this way, the client becomes more aware of conflicting inner feelings and,
with insight, can become more genuine. Psychoanalysis, client-centered therapy,
and Gestalt therapy differ in technique, but all use talk to help people become more
aware of their feelings and conflicts, and all involve fairly substantial amounts of time.
More recent developments in therapy seek to limit the amount of time people spend in
therapy.

Recent Developments
What are some recent developments in insight therapies?

Although Freud, Rogers, and Perls originated the three major forms of insight therapy, oth-
ers have developed hundreds of variations on this theme. Most involve a therapist who is
far more active and emotionally engaged with clients than traditional psychoanalysts
thought fit. These therapists give clients direct guidance and feedback, commenting on
what they are told rather than just neutral listening.

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Another general trend in recent years is toward shorter-term “dynamic therapy.” For
most people, this usually means meeting once a week for a fixed period. In fact, short-
term psychodynamic therapy is increasingly popular among both clients and mental
health professionals (Abbass, Joffres, & Ogrodniczuk, 2008; McCullough & Magill, 2009).
Insight remains the goal, but the course of treatment is usually limited—for example, to
25 sessions. With the trend to a time-limited framework, insight therapies have become
more problem- or symptom-oriented, with greater focus on the person’s current life situ-
ation and relationships. Although contemporary insight therapists do not discount child-
hood experiences, they view people as being less at the mercy of early childhood events
than Freud did.

Perhaps the most dramatic and controversial change in insight therapies is virtual
therapy. For a hundred years or so, people who wanted to see a therapist have literally gone
to see a therapist—they have traveled to the therapist’s office, sat down, and talked through
their problems. In recent years, however, some people have started connecting with their
therapists by telephone (S. Williams, 2000). Others pay their visits via cyberspace. The
delivery of health care over the Internet or through other electronic means is part of a
rapidly expanding field known as telehealth.

Although most therapists believe that online therapy is no substitute for face-to-
face interactions (Almer, 2000; Rabasca, 2000c), evidence suggests that telehealth may
provide cost-effective opportunities for delivery of some mental health services (J. E.
Barnett & Scheetz, 2003). Telehealth is a particularly appealing alternative for people
who live in remote or rural areas (Hassija & Gray, 2009; Stamm, 2003). For example, a
university-based telehealth system in Kentucky provides psychological services to rural
schools (Thomas Miller et al., 2003), and video-conferencing therapy has been used suc-
cessfully to treat posttraumatic stress disorder in rural Wyoming (Hassija & Gray,
2009). Clearly, research is needed to determine under what, if any, circumstances vir-
tual therapy is effective, as such services are likely to proliferate in the future (Melnyk,
2008; Zur, 2007).

Even more notable than the trend toward short-term and virtual therapy has been the
proliferation of behavior therapies during the past few decades. In this next section, we
examine several types.

CHECK YOUR UNDERSTANDING

1. ____________ therapies focus on giving people clearer understanding of their feelings,
motives, and actions.

2. ____________ ____________ is a technique in psychoanalysis whereby the client lets
thoughts flow without interruption or inhibition.

3. The process called ____________ involves having clients project their feelings toward
authority figures onto their therapist.

4. Rogerian therapists show that they value and accept their clients by providing them with
____________ ____________ regard.

Indicate whether the following statements are true (T) or false (F):

a. _____ Psychoanalysis is based on the belief that problems are symptoms of inner

conflicts dating back to childhood.
b. _____ Rogers’s interest in the process of therapy was one avenue of exploration that

did not prove very fruitful.
c. _____ In Gestalt therapy, the therapist is active and directive.
d. _____ Gestalt therapy emphasizes the client’s problems in the present.

Answers:1. Insight.2. Free association.3. transference.4. unconditional positive.a.(T).
b. (F).c. (T).d. (T).short-term psychodynamic therapy Insight

therapy that is time limited and focused on
trying to help clients correct the immediate
problems in their lives.

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Therapies 431

BEHAVIOR THERAPIES
What do behaviorists believe should be the focus of psychotherapy?

Behavior therapies sharply contrast with insight-oriented approaches. They are focused
on changing behavior, rather than on discovering insights into thoughts and feelings.
Behavior therapies are based on the belief that all behavior, both normal and abnormal, is
learned (D. Richards, 2007). People suffering from hypochondriasis learn that they get
attention when they are sick; people with paranoid personalities learn to be suspicious of
others. Behavior therapists also assume that maladaptive behaviors are the problem, not
symptoms of deeper underlying causes. If behavior therapists can teach people to behave in
more appropriate ways, they believe that they have cured the problem. The therapist does
not need to know exactly how or why a client learned to behave abnormally in the first
place. The job of the therapist is simply to teach the person new, more satisfying ways of
behaving on the basis of scientifically studied principles of learning, such as classical condi-
tioning, operant conditioning, and modeling (Zinbarg & Griffith, 2008).

Therapies Based on Classical Conditioning
How can classical conditioning be used as the basis of treatment?

Classical conditioning involves the repeated pairing of a neutral stimulus with one that
evokes a certain reflex response. Eventually, the formerly neutral stimulus alone comes to
elicit the same response. The approach is one of learned stimulus-response associations.
Several variations on classical conditioning have been used to treat psychological problems.

Desensitization, Extinction, and Flooding Systematic desensitization, a method
for gradually reducing fear and anxiety, is one of the oldest behavior therapy techniques
(Wolpe, 1990). The method works by gradually associating a new response (relaxation) with
anxiety-causing stimuli. For example, an aspiring politician might seek therapy because he is

L E A R N I N G O B J E C T I V E S
• Explain the statement that “Behavior

therapies sharply contrast with insight-
oriented approaches.”

• Describe the processes of
desensitization, extinction, flooding,
aversive conditioning, behavior
contracting, token economies, and
modeling.

APPLY YOUR UNDERSTANDING

1. Consider the following scenario: The client lies on a couch, and the therapist sits out of
sight. The therapist gets to know the client’s problems through free association and then
encourages the client to “work through” his or her problems. What kind of therapy is this?

a. psychoanalysis
b. client-centered therapy
c. Gestalt therapy
d. rational–emotive therapy

2. Which of the following choices illustrates client-centered therapy with a depressed
person?

a. The client is encouraged to give up her depression by interacting with a group of
people in an encounter group.

b. The therapist tells the client that his depression is self-defeating and gives the
client “assignments” to develop self-esteem and enjoy life.

c. The therapist encourages the client to say anything that comes into her head, to
express her innermost fantasies, and to talk about critical childhood events.

d. The therapist offers the client her unconditional positive regard and, once this open
atmosphere is established, tries to help the client discover why she feels
depressed.

Answers:1. a.2. d.

behavior therapies Therapeutic approaches
that are based on the belief that all behavior,
normal and abnormal, is learned, and that the
objective of therapy is to teach people new,
more satisfying ways of behaving.

systematic desensitization A behavioral
technique for reducing a person’s fear and
anxiety by gradually associating a new response
(relaxation) with stimuli that have been causing
the fear and anxiety.

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anxious about speaking to crowds. The therapist
explores the kinds of crowds that are most threatening:
Is an audience of 500 worse than one of 50? Is it harder
to speak to men than it is to women? Is there more anx-
iety facing strangers than a roomful of friends? From
this information the therapist develops a hierarchy of
fears—a list of situations from the least to the most
anxiety provoking. The therapist then teaches tech-
niques for relaxation, both mentally and physically.
Once the client has mastered deep relaxation, she or he
begins work at the bottom of the hierarchy of fears. The
person is told to relax while imagining the least threat-
ening situation on the list, then the next most threaten-
ing, and so on, until the most fear-arousing one is
reached and the client can still remain calm.

Numerous studies show that systematic desensiti-
zation helps many people overcome their fears and
phobias (Hazel, 2005; D. W. McNeil & Zvolensky,
2000). The key to success may not be the learning of a
new conditioned relaxation response, but rather the
extinction of the old fear response through mere expo-

sure. Recall that in classical conditioning, extinction occurs when the learned, conditioned
stimulus is repeatedly presented without the unconditioned stimulus following it. Thus, if
a person repeatedly imagines a frightening situation without encountering danger, the
associated fear should gradually decline. Desensitization is most effective when clients
gradually confront their fears in the real world rather than merely in their imaginations.

The technique of flooding is a less familiar and more frightening desensitization
method. It involves full-intensity exposure to a feared stimulus for a prolonged period of
time (Moulds & Nixon, 2006; Wolpe, 1990). Someone with a fear of snakes might be forced
to handle dozens of snakes. Though flooding may seem unnecessarily harsh, remember
how debilitating many untreated anxiety disorders can be.

Aversive Conditioning Another classical conditioning technique is aversive condi-
tioning, in which pain and discomfort are associated with the behavior that the client
wants to unlearn. Aversive conditioning has been used with limited success to treat alco-
holism, obesity, smoking, and some psychosexual disorders. For example, the taste and
smell of alcohol are sometimes paired with drug-induced nausea and vomiting. Before
long, clients feel sick just seeing a bottle of liquor. A follow-up study of nearly 800 people
who completed alcohol-aversion treatment found that 63% had maintained continuous
abstinence for at least 12 months (Sharon Johnson, 2003; Wiens & Menustik, 1983). The
long-term effectiveness of this technique has been questioned; if punishment no longer
follows, the undesired behavior may reemerge. Aversive conditioning is a controversial
technique because of its unpleasant nature.

Therapies Based on Operant Conditioning
How could “behavior contracting” change an undesirable behavior?

In operant conditioning, a person learns to behave a certain way because that behavior is
reinforced. One therapy based on the principle of reinforcement is called behavior con-
tracting. The therapist and the client agree on behavioral goals and on the reinforcement
that the client will receive when he or she reaches those goals. These goals and reinforce-
ments are often written in a contract that “legally” binds both the client and the therapist.
A contract to help a person stop smoking might read: “For each day that I smoke fewer than
20 cigarettes, I will earn 30 minutes of time to go bowling. For each day that I exceed the
goal, I will lose 30 minutes from the time that I have accumulated.”

The clients in these photographs are over-
coming a simple phobia: fear of snakes. After
practicing a technique of deep relaxation,
clients in desensitization therapy work from
the bottom of their hierarchy of fears up to
the situation that provokes the greatest fear
or anxiety. Here, clients progress from han-
dling rubber snakes (top left) to viewing live
snakes through a window (top center) and
finally to handling live snakes. This procedure
can also be conducted vicariously in the ther-
apist’s office, where clients combine relax-
ation techniques with imagining
anxiety-provoking scenes.

aversive conditioning Behavioral therapy
techniques aimed at eliminating undesirable
behavior patterns by teaching the person to
associate them with pain and discomfort.

behavior contracting Form of operant
conditioning therapy in which the client and
therapist set behavioral goals and agree on
reinforcements that the client will receive on
reaching those goals.

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Therapies 433

Another therapy based on operant conditioning is called the token economy. Token
economies are usually used in schools and hospitals, where controlled conditions are most
feasible (Boniecki & Moore, 2003; Comaty, Stasio, & Advokat, 2001). People are rewarded
with tokens or points for appropriate behaviors, which can be exchanged for desired items
and privileges. In a mental hospital, for example, improved grooming habits might earn
points that can be used to purchase special foods or weekend passes. The positive changes
in behavior, however, do not always generalize to everyday life outside the hospital or clinic,
where adaptive behavior is not always reinforced and maladaptive behavior is not always
punished.

token economy An operant conditioning
therapy in which people earn tokens
(reinforcers) for desired behaviors and exchange
them for desired items or privileges.

CHECK YOUR UNDERSTANDING

1. The therapeutic use of rewards to encourage desired behavior is based on a form of
learning called ____________ ____________.

2. When client and therapist agree on a written set of behavioral goals, as well as a specific
schedule of reinforcement when each goal is met, they are using a technique called
____________ ____________.

3. Some therapy involves learning desired behaviors by watching others perform those
actions, which is also known as ____________.

4. A ____________ ____________ is an operant conditioning technique whereby people
earn some tangible item for desired behavior, which can then be exchanged for more
basic rewards and privileges.

5. The technique of ____________ involves intense and prolonged exposure to something
feared.

Answers:1. operant conditioning.2. behavior contracting.3. modeling.4. token economy.
5. flooding.

APPLY YOUR UNDERSTANDING

1. Maria is in an alcoholism treatment program in which she must take a pill every
morning. If she drinks alcohol during the day, she immediately feels nauseous. This
treatment is an example of

a. transference.
b. flooding.
c. aversive conditioning.
d. desensitization.

2. Robert is about to start a new job in a tall building; and he is deathly afraid of riding in
elevators. He sees a therapist who first teaches him how to relax. Once he has mastered
that skill, the therapist asks him to relax while imagining that he is entering the office
building. Once he can do that without feeling anxious, the therapist asks him to relax while
imagining standing in front of the elevator doors, and so on until Robert can completely
relax while imagining riding in elevators. This therapeutic technique is known as

a. transference.
b. desensitization.
c. behavior contracting.
d. flooding.

Answers:1. c.2. b.

modeling A behavior therapy in which the
person learns desired behaviors by watching
others perform those behaviors.

Therapies Based on Modeling
What are some therapeutic uses of modeling?

Modeling—learning a behavior by watching someone else perform it—can also be used
to treat problem behaviors. In a now classic demonstration of modeling, Albert Bandura
and colleagues helped people to overcome a snake phobia by showing films in which

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434 Chapter 13

models gradually moved closer and closer to snakes (Bandura, Blanchard, & Ritter,
1969). Modeling techniques have also been successfully used as part of job training pro-
grams (P. J. Taylor, Russ-Eft, & Chan, 2005) and have been used extensively with people
with mental retardation to teach job and independent living skills (Cannella-Malone et
al., 2006; Farr, 2008).

COGNITIVE THERAPIES
How can people overcome irrational and self-defeating beliefs?

Cognitive therapies are based on the belief that if people can change their distorted ideas
about themselves and the world, they can also change their problem behaviors and make
their lives more enjoyable (Bleijenberg, Prins, & Bazelmans, 2003). A cognitive therapist’s
goal is to identify erroneous ways of thinking and to correct them. Three popular forms of
cognitive therapy are stress-inoculation therapy, rational–emotive therapy, and Aaron
Beck’s cognitive approach.

Stress-Inoculation Therapy
How can self-talk help us deal with difficult situations?

As we go about our lives, we talk to ourselves constantly—proposing courses of action,
commenting on our performance, expressing wishes, and so on. Stress-inoculation ther-
apy makes use of this self-talk to help people cope with stressful situations. The client is
taught to suppress any negative, anxiety-evoking thoughts and to replace them with pos-
itive, “coping” thoughts. A student facing anxiety with an exam may think, “Another test;
I’m so nervous. I’m sure I won’t know the answers. If only I’d studied more. If I don’t get
through this course, I’ll never graduate!” This pattern of thought is dysfunctional
because it only makes anxiety worse. With the help of a cognitive therapist, the student
learns a new pattern of self-talk: “I studied hard, and I know the material well. I looked at
the textbook last night and reviewed my notes. I should be able to do well. If some ques-
tions are hard, they won’t all be, and even if it’s tough, my whole grade doesn’t depend on
just one test.” Then the person tries the new strategy in a real situation, ideally one of
only moderate stress (like a short quiz). Finally, the person is ready to use the strategy in
a more stressful situation, like a final exam (Sheehy & Horan, 2004). Stress-inoculation
therapy works by turning the client’s thought patterns into a kind of vaccine against
stress-induced anxiety.

Rational–Emotive Therapy
What irrational beliefs do many people hold?

Another type of cognitive therapy, rational–emotive therapy (RET), developed by
Albert Ellis (1973, 2001), is based on the view that most people in need of therapy hold a
set of irrational and self-defeating beliefs (Macavei, 2005; Overholser, 2003). They believe
that they should be competent at everything, always treated fairly, quick to find solutions
to every problem, and so forth. Such beliefs involve absolutes—“musts” and “shoulds”—
and make no room for mistakes. When people with such irrational beliefs come up
against real-life struggles, they often experience excessive psychological distress.

Rational–emotive therapists confront such dysfunctional beliefs vigorously, using a
variety of techniques, including persuasion, challenge, commands, and theoretical argu-
ments (A. Ellis & MacLaren, 1998). Studies have shown that RET often enables people to

L E A R N I N G O B J E C T I V E S
• Describe the common beliefs that

underlie all cognitive therapies.
• Compare and contrast stress-inoculation

therapy, rational–emotive therapy, and
Beck’s cognitive therapy.

cognitive therapies Psychotherapies that
emphasize changing clients’ perceptions of their
life situation as a way of modifying their behavior.

stress-inoculation therapy A type of
cognitive therapy that trains clients to cope with
stressful situations by learning a more useful
pattern of self-talk.

According to cognitive therapists, the confi-
dence this person is showing stems from the
positive thoughts she has about herself.
Stress-inoculation therapy helps replace
negative, anxiety-evoking thoughts with con-
fident self-talk.

rational–emotive therapy (RET) A directive
cognitive therapy based on the idea that clients’
psychological distress is caused by irrational and
self-defeating beliefs and that the therapist’s job
is to challenge such dysfunctional beliefs.

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Therapies 435

reinterpret negative beliefs and experiences more positively, decreasing the likelihood of
depression (Blatt, Zuroff, Quinlan, & Pilkonis, 1996; Bruder et al., 1997).

Beck’s Cognitive Therapy
How can cognitive therapy be used to combat depression?

One of the most important and promising forms of cognitive therapy for treating depres-
sion is known simply as cognitive therapy (J. Cahill et al., 2003). Sometimes it is referred to
as “Beck’s cognitive therapy,” after developer Aaron Beck (1967), to distinguish between the
broader category of cognitive therapies.

Beck believes that depression results from inappropriately self-critical patterns of
thought. Self-critical people have unrealistic expectations, magnify failures, make sweeping
negative generalizations based on little evidence, notice only negative feedback from the
outside world, and interpret anything less than total success as failure. Although Beck’s
assumptions about the cause of depression are very similar to those underlying RET, the
style of treatment differs considerably. Cognitive therapists are much less challenging and
confrontational than rational–emotive therapists (Dozois, Frewen, & Covin, 2006).
Instead, they try to help clients examine each dysfunctional thought in a supportive, but
objectively scientific manner (“Are you sure your whole life will be totally ruined if you
break up with Frank? What is your evidence for that? Didn’t you once tell me how happy
you were before you met him?”). Like RET, Beck’s cognitive therapy tries to lead the person
to more realistic and flexible ways of thinking. Watch on MyPsychLab

CHECK YOUR UNDERSTANDING

1. Developing new ways of thinking that lead to more adaptive behavior lies at the heart of all
____________ therapies.

2. An important form of cognitive therapy used to combat depression was developed by Aaron
____________.

3. The immediate focus in cognitive therapies is to help clients change their behaviors. Is this
statement true (T) or false (F)?

Answers:1. cognitive.2. Beck.3. (F).

APPLY YOUR UNDERSTANDING

1. Larry has difficulty following his boss’s directions. Whenever his boss asks him to do
something, Larry panics. Larry enters a stress-inoculation program. Which is most likely
to be the first step in this program?

a. Have Larry volunteer to do a task for his boss.
b. Show Larry a film in which employees are asked to do tasks and they perform well.
c. Ask Larry what he says to himself when his boss asks him to perform a task.
d. Ask Larry how he felt when he was a child and his mother asked him to do something.

2. Sarah rushes a sorority but isn’t invited to join. She has great difficulty accepting this fact
and as a consequence she becomes deeply depressed. She sees a therapist who
vigorously challenges and confronts her in an effort to show her that her depression
comes from an irrational, self-defeating belief that she must be liked and accepted by
everyone. This therapist is most likely engaging in

a. rational–emotive therapy.
b. stress-inoculation therapy.
c. flooding.
d. desensitization therapy.

Answers:1. c.2. a. cognitive therapy Therapy that depends on
identifying and changing inappropriately
negative and self-critical patterns of thought.

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GROUP THERAPIES
What are some advantages of group therapies?

Some therapists believe that treating several people simultaneously is preferable to individ-
ual treatment. Group therapy allows both client and therapist to see how the person acts
around others. If a person is painfully anxious and tongue-tied, chronically self-critical, or
hostile, these tendencies show up quickly in a group.

Group therapies have the other advantage of social support—a feeling that one is
not the only person in the world with problems. Group members can help one another
learn useful new behaviors, like how to disagree without antagonizing others. Group
interactions can lead people toward insights into their own behavior, such as why they

are defensive or feel compelled to complain constantly. Because
group therapy consists of several clients “sharing” a therapist, it is
less expensive than individual therapy (Fejr, 2003; N. Morrison,
2001).

There are many kinds of group therapy. Some groups follow the
general outlines of the therapies we have already mentioned. Others are
oriented toward a specific goal, such as stopping smoking or drinking.
Others may have a more open-ended goal—for example, a happier
family or romantic relationship.

Family Therapy
Who is the client in family therapy?

Family therapy is one form of group therapy (Lebow, 2006; Snow,
Crethar, & Robey, 2005). Family therapists believe that if one person in the family is
having problems, it’s a signal that the entire family needs assistance. Therefore, it
would be a mistake to treat a client without attempting to meet the person’s parents,
spouse, or children. Family therapists do not try to reshape the personalities of family
members (Gurman & Kniskern, 1991), rather, they attempt to improve communica-
tion, encourage empathy, share responsibilities, and reduce family conflict. To achieve
these goals, all family members must believe that they will benefit from behavioral
changes.

Although family therapy is appropriate when there are problems between husband
and wife or parents and children, it is increasingly used when only one family member has
a clear psychological disorder (Keitner, Archambault, Ryan, & Miller, 2003; Mueser, 2006).
The goal of treatment in these circumstances is to help mentally healthy members of the
family cope more effectively with the impact of the disorder on the family unit, which in
turn, helps the troubled person. Family therapy is also called for when a person’s progress
in individual therapy is slowed by the family (often because other family members have
trouble adjusting to that person’s improvement).

Couple Therapy
What are some techniques used in couple therapy?

Another form of group therapy is couple therapy, which is designed to assist partners who
are having relationship difficulties. Previously termed marital therapy, the term “couple
therapy” is considered more appropriate today because it captures the broad range of part-
ners who may seek help (Lebow, 2006; Sheras & Koch-Sheras, 2006).

group therapy Type of psychotherapy in
which clients meet regularly to interact and
help one another achieve insight into their
feelings and behavior.

L E A R N I N G O B J E C T I V E S
• Describe the potential advantages of group

therapy compared to individual therapy.
• Compare and contrast family therapy,

couple therapy, and self-help groups.

Group therapy can help to identify problems
that a person has when interacting with other
people. The group also offers social support,
helping people to feel less alone with their
problems.

family therapy A form of group therapy that
sees the family as at least partly responsible for
the individual’s problems and that seeks to
change all family members’ behaviors to the
benefit of the family unit as well as the troubled
individual.

couple therapy A form of group therapy
intended to help troubled partners improve
their problems of communication and
interaction.

Therapies 437

Most couple therapists concentrate on improving patterns of communication and
mutual expectations. In empathy training, each member of the couple is taught to share inner
feelings and to listen to and understand the partner’s feelings before responding. This tech-
nique requires more time spent listening, grasping what is really being said, and less time in
self-defensive rebuttal. Other couple therapists use behavioral techniques, such as helping a
couple develop a schedule for exchanging specific caring actions, like helping with chores or
making time to share a special meal together. This approach may not sound romantic, but
proponents say it can break a cycle of dissatisfaction and hostility in a relationship, and hence,
it is an important step in the right direction (N. B. Epstein, 2004). Couple therapy for both
partners is generally more effective than therapy for just one (Fraser & Solovey, 2007; Susan
Johnson, 2003).

Self-Help Groups
Why are self-help groups so popular?

An estimated 57 million Americans suffer some kind of psychological problem (Kessler,
Chiu, Demler, & Walters, 2005). Since individual treatment can be expensive, more and
more people faced with life crises are turning to low-cost self-help groups. Most groups are
small, local gatherings of people who share a common problem and who provide mutual
support. Alcoholics Anonymous is perhaps the best-known self-help group, but self-help
groups are available for virtually every life problem.

Do these self-help groups work? In many cases, they apparently do. Alcoholics Anony-
mous has developed a reputation for helping people cope with alcoholism. Most group mem-
bers express strong support for their groups, and studies have demonstrated that they can
indeed be effective (Galanter, Hayden, Castañeda, & Franco, 2005; Kurtz, 2004; McKellar,
Stewart, & Humphreys, 2003).

Such groups also help to prevent more serious psychological disorders by reaching out
to people who are near the limits of their ability to cope with stress. The social support they
offer is particularly important in an age when divorce, geographic mobility, and other factors
have reduced the ability of the family to comfort people. A list of some self-help organiza-
tions is included in “Applying Psychology: How to Find Help.”

CHECK YOUR UNDERSTANDING

1. Which of the following is an advantage of group therapy?
a. The client has the experience of interacting with other people in a therapeutic setting.
b. It often reveals a client’s problems more quickly than individual therapy.
c. It can be cheaper than individual therapy.
d. All of the above.

Answers:1. d.

APPLY YOUR UNDERSTANDING

1. You are talking to a clinical psychologist who explains that, in her view, it is a mistake to
try to treat a client’s problems in a vacuum. Quite often, well-adjusted members of a
family can help the client cope more effectively. Other times, the client’s progress is
slowed due to other people in the family. She is most likely a

a. self-help therapist.
b. family therapist.
c. proximity therapist.
d. social-attribution therapist.

438 Chapter 13

How to Find Help

The attitude that seeking help for psy-chological problems is a sign of“weakness” is very common in our
society. But the fact is that millions of peo-
ple, including students, are helped by psy-
chological counseling and therapy every
year. Therapy is a common, useful aid in
coping with daily life.

College is a time of stress and anxiety for
many people. The competition for grades,
the exposure to many different kinds of
people with unfamiliar views, the tension of
relating to peers all can take a psychological
toll, especially for students away from home
for the first time. Most colleges and univer-
sities have their own counseling services,
and many are as sophisticated as the best
clinics in the country. Most communities
also have mental health programs. As an aid
to a potential search for the right counseling
service, we include here a list of some of the
available resources for people who seek the
advice of a mental health professional.
Many of these services have national offices
that can provide local branch information
and the appropriate people to contact.

FOR ALCOHOL AND DRUG
ABUSE

National Clearinghouse for Alcohol
and Drug Information

Rockville, MD (800) 729-6686

General Service Board
Alcoholics Anonymous, Inc.
New York, NY (212) 870-3400

FOR FRIENDS OR RELATIVES
OF THOSE WITH AN ALCOHOL
PROBLEM

Al-Anon Family Groups
Virginia Beach, VA
(888) 4alanon (meeting information)
(757) 563-1600 (personal assistance)
Web site: www.al-anon.alateen.org

National Association for Children
of Alcoholics

Rockville, MD
(301) 468-0985

FOR DEPRESSION AND SUICIDE
Mental Health Counseling Hotline
New York, NY
(212) 734-5876

Heartbeat (for survivors of suicides)
Colorado Springs, CO
(719) 596-2575

FOR SEXUAL AND SEX-RELATED
PROBLEMS

Sex Information and Education Coun-
cil of the United States (SIECUS)

New York, NY
(212) 819-9770

National Organization for Women
Legislative Office
Washington, DC
(202) 331-0066

FOR PHYSICAL ABUSE
Child Abuse Listening and Mediation

(CALM)
Santa Barbara, CA
(805) 965-2376

FOR HELP IN SELECTING
A THERAPIST

National Mental Health Consumer
Self-Help Clearinghouse

(215) 751-1810

FOR GENERAL INFORMATION
ON MENTAL HEALTH
AND COUNSELING

The National Alliance for the Mentally Ill
Arlington, VA
(703) 524-7600

The National Mental Health
Association

Alexandria, VA
(703) 684-7722

The American Psychiatric Association
Washington, DC
(703) 907-7300

The American Psychological Association
Washington, DC
(202) 336-5500

The National Institute of Mental Health
Rockville, MD
(301) 443-4513

Answers:1. b.2. d.

2. Imagine that you believe most problems between partners arise because they don’t
share their inner feelings and they don’t truly listen to and try to understand each other.
You meet with them together and teach them to spend more time listening to the other
person and trying to understand what the other person is really saying. Your beliefs are
closest to which of the following kinds of therapists?

a. Gestalt therapists.
b. rational–emotive therapists.
c. family therapists.
d. couple therapists.

Therapies 439

L E A R N I N G O B J E C T I V E S
• Summarize the research evidence that

psychotherapy is, in fact, more effective
than no therapy at all. Briefly describe
the five major results of the Consumer
Reports study.

• Describe the common features shared by
all forms of psychotherapy that may
account for the fact that there is little or
no overall difference in their
effectiveness. Explain the statement that
“Some kinds of psychotherapy seem to
be particularly appropriate for certain
people and problems”; include examples.

EFFECTIVENESS OF PSYCHOTHERAPY
How much better off is a person who receives psychotherapy than one
who gets no treatment at all?

We have noted that some psychotherapies are generally effective, but how much better are
they than no treatment at all? Researchers have found that roughly twice as many people
(two-thirds) improve with formal therapy than with no treatment at all (Borkovec &
Costello, 1993; M. J. Lambert, 2001). Furthermore, many people who do not receive formal
therapy get therapeutic help from friends, clergy, physicians, and teachers. Thus, the recov-
ery rate for people who receive no therapeutic help at all is quite possibly even less than
one-third. Other studies concur on psychotherapy’s effectiveness (Hartmann & Zepf, 2003;
M. J. Lambert & Archer, 2006; Leichsenring & Leibing, 2003), although its value appears to
be related to a number of other factors. For instance, psychotherapy works best for rela-
tively mild psychological problems (Kopta, Howard, Lowry, & Beutler, 1994) and seems to
provide the greatest benefits to people who really want to change such as Brooke Shields
(Orlinsky & Howard, 1994).

Finally, one very extensive study designed to eval-
uate the effectiveness of psychotherapy was reported
by Consumer Reports. Largely under the direction of
psychologist Martin E. P. Seligman (1995), this investi-
gation surveyed 180,000 Consumer Reports subscribers
on everything from automobiles to mental health.
Approximately 7,000 people from the total sample
responded to the mental health section of the ques-
tionnaire that assessed satisfaction and improvement
in people who had received psychotherapy, with the
following results.

First, the vast majority of respondents reported
significant overall improvement after therapy
(Seligman, 1995). Second, there was no difference in
the overall improvement score among people who
had received therapy alone and those who had com-
bined psychotherapy with medication. Third, no
differences were found between the various forms of
psychotherapy. Fourth, no differences in effectiveness
were indicated between psychologists, psychiatrists, and social workers, although mar-
riage counselors were seen as less effective. Fifth, people who received long-term therapy
reported more improvement than those who received short-term therapy. This last
result, one of the most striking findings of the study, is illustrated in Figure 13–1.
Though the Consumer Reports study lacked the scientific rigor of more traditional inves-
tigations designed to assess psychotherapeutic efficacy (Jacobson & Christensen, 1996;
Seligman, 1995, 1996), it does provides broad support for the idea that psychotherapy
works.

Which Type of Therapy Is Best for Which Disorder?
An important question is whether some forms of psychotherapy are more effective than
others (Lyddon & Jones, 2001). Is behavior therapy, for example, more effective than
insight therapy? In general, the answer seems to be “not much” (J. A. Carter, 2006; Hanna,
2002; Wampold et al., 1997). Most of the benefits of treatment seem to come from being in
some kind of therapy, regardless of the particular type.

As we have seen, the various forms of psychotherapy are based on very different views
about what causes mental disorders and, at least on the surface, approach the treatment of
mental disorders in different ways. Why, then, is there no difference in their effectiveness?
To answer this question, some psychologists have focused their attention on what the various

Survey Results

The text states that the Consumer Reports study lacked the scientificrigor of more traditional investigations. Think about the followingquestions:
• How were the respondents selected? How does that compare to the

way in which scientific surveys select respondents (see Chapter 1, “The
Science of Psychology”)?

• How did the study determine whether the respondents had improved?
• How would a psychologist conduct a more scientific study of the effec-

tiveness of psychotherapy? What variables would need to be defined?
How would the participants be chosen? What ethical issues might need
to be considered?

440 Chapter 13

forms of psychotherapy have in common, rather than emphasizing their differences (J. A.
Carter, 2006; A. H. Roberts, Kewman, Mercer, & Hovell, 1993):

1. All forms of psychotherapy provide people with an explanation for their problems.
Along with this explanation often comes a new perspective, providing people with
specific actions to help them cope more effectively.

2. Most forms of psychotherapy offer people hope. Because most people who seek
therapy have low self-esteem and feel demoralized and depressed, hope and the
expectation for improvement increase their feelings of self-worth.

3. All major types of psychotherapy engage the client in a therapeutic alliance with a
therapist. Although their therapeutic approaches may differ, effective therapists
are warm, empathetic, and caring people who understand the importance of
establishing a strong emotional bond with their clients that is built on mutual
respect and understanding (Norcross, 2002; Wampold, 2001).

Together, these nonspecific factors common to all forms of psychotherapy appear to
help explain why most people who receive any form of therapy show some benefits, com-
pared with those who receive none at all (D. N. Klein et al., 2003).

Some kinds of psychotherapy seem to be particularly appropriate for certain people
and problems. Insight therapy, for example, though reasonably effective with a wide range
of mental disorders (de Maat, de Jonghe, Schoevers, & Dekker, 2009), seems to be best
suited to people seeking profound self-understanding, relief of inner conflict and anxiety,
or better relationships with others. It has also been found to improve the basic life skills of
people suffering from schizophrenia (Maxine Sigman & Hassan, 2006). Behavior therapy is
apparently most appropriate for treating specific anxieties or other well-defined behavioral
problems, such as sexual dysfunctions. Couple therapy is generally more effective than
individual counseling for the treatment of drug abuse (Fals-Stewart & Lam, 2008; Liddle &
Rowe, 2002).

Figure 13–1
Duration of therapy and improvement.
One of the most dramatic results of the
Consumer Reports (1995) study on the effective-
ness of psychotherapy was the strong relation-
ship between reported improvement and the
duration of therapy.
Source: Adapted from “The Effectiveness of
Psychotherapy: The Consumer Reports Study” by
M. E. P. Seligman, American Psychologist, 50
(1995), pp. 965–974. Copyright © 1995 by American
Psychological Association.

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Therapies 441

BIOLOGICAL TREATMENTS
What are biological treatments, and who can provide them?

Biological treatments—a group of approaches including medication, electroconvulsive
therapy, and psychosurgery—may be used to treat psychological disorders in addition to,
or instead of, psychotherapy. Clients and therapists opt for biological treatments for several
reasons. First, some people are too agitated, disoriented, or unresponsive to be helped by
psychotherapy. Second, biological treatment is virtually always used for disorders with a
strong biological component. Third, biological treatment is often used for people who are
dangerous to themselves and to others.

Traditionally, the only mental health professionals licensed to offer biological treat-
ments were psychiatrists, who are physicians. However, some states now permit specially
trained psychologists to prescribe drugs. Therapists without such training often work with
physicians who prescribe medication for their clients. In many cases where biological treat-
ments are used, psychotherapy is also recommended; medication and psychotherapy used

CHECK YOUR UNDERSTANDING

1. There is a trend among psychotherapists to combine treatment techniques in what is called
____________.

2. Most researchers agree that psychotherapy helps about ____________ ____________ of
the people treated.

3. Psychotherapy works best for relatively ____________ disorders, as compared with
____________ ones.

Answers:1. eclecticism.2. two-thirds.3. mild, severe.

APPLY YOUR UNDERSTANDING

1. Your friend is experiencing anxiety attacks, but doesn’t want to see a therapist because
“they don’t do any good.” Which of the following replies most accurately reflects what
you have learned about the effectiveness of therapy?

a. “You’re right. Psychotherapy is no better than no treatment at all.”
b. “Actually, even just initiating therapy has a beneficial effect compared with doing

nothing.”
c. “You’re at least twice as likely to improve if you see a therapist than if you don’t.”
d. “Therapy could help you, but you’d have to stick with it for at least a year before it

has any effect.”

2. John is suffering from moderate depression. Which of the following therapies is most
likely to help him?

a. insight therapy
b. cognitive therapy
c. behavioral contracting
d. group therapy

Answers:1. c.2. b.

L E A R N I N G O B J E C T I V E S
• Explain why some clients and

therapists opt for biological treatment
instead of psychotherapy.

• Describe the major antipsychotic and
antidepressant drugs including their
significant side effects.

• Describe electroconvulsive therapy
and psychosurgery, their effectiveness
in treating specific disorders, and their
potential side effects. Explain why
these are “last resort treatments” that
are normally used only other
treatments have failed.

eclecticism Psychotherapeutic approach that
recognizes the value of a broad treatment
package over a rigid commitment to one
particular form of therapy.

biological treatments A group of approaches,
including medication, electroconvulsive therapy,
and psychosurgery, that are sometimes used to
treat psychological disorders in conjunction
with, or instead of, psychotherapy.

Cognitive therapies have been shown to be effective treatments for depression (Ham-
dan-Mansour, Puskar, & Bandak, 2009; Leahy, 2004) and anxiety disorders (M. A. Stanley
et al., 2009), and even show some promise in reducing suicide (Wenzel, Brown, & Beck,
2009). In addition, cognitive therapies have been used effectively to treat people with per-
sonality disorders by helping them change their core beliefs and reducing their automatic
acceptance of negative thoughts (McMain & Pos, 2007; S. Palmer et al., 2006; Tarrier,
Taylor, & Gooding, 2008). The trend in psychotherapy is toward eclecticism—that is,
toward recognition of the value of a broad treatment package, rather than commitment to
a single form of therapy (J. A. Carter, 2006; Slife & Reber, 2001).

442 Chapter 13

together generally are more effective for treating major depression and for preventing a
recurrence than either treatment used alone (M. B. Keller et al., 2000; Manber et al., 2008).

Drug Therapies
What are some of the drugs used to treat psychological disorders?

Medication is frequently and effectively used to treat a number of psychological problems.
(See Table 13–1.) In fact, Prozac, a drug used to treat depression, today is one of the best
selling of all prescribed medications. Two major reasons for the widespread use of drug
therapies today are the development of several very effective psychoactive medications and
the fact that drug therapies can cost less than psychotherapy. Critics suggest, however, that
another reason is our society’s “pill mentality,” or belief that we can take a medicine to fix
any problem.

Antipsychotic Drugs Before the mid-1950s, drugs were not widely used to treat psy-
chological disorders, because the only available sedatives induced sleep as well as calm.
Then the major tranquilizers reserpine and the phenothiazines were introduced. In addition
to alleviating anxiety and aggression, both drugs reduce psychotic symptoms, such as hal-
lucinations and delusions; for that reason, they are called antipsychotic drugs. Antipsy-
chotic drugs are prescribed primarily for very severe psychological disorders, particularly
schizophrenia. They are very effective for treating schizophrenia’s “positive symptoms,” like
hallucinations, but less effective for the “negative symptoms,” like social withdrawal. The
most widely prescribed antipsychotic drugs are known as neuroleptics, which work by
blocking the brain’s receptors for dopamine, a major neurotransmitter (Leuner & Müller,
2006; Oltmanns & Emery, 2006). The success of antipsychotic drugs in treating schizophre-
nia supports the notion that schizophrenia is linked in some way to an excess of this neuro-
transmitter in the brain. (See Chapter 12, “Psychological Disorders.”)

Antipsychotic medications sometimes have dramatic effects. People with schizophre-
nia who take them can go from being perpetually frightened, angry, confused, and plagued
by auditory and visual hallucinations to being totally free of such symptoms. These drugs
do not cure schizophrenia; they only alleviate the symptoms while the person is taking the

Explore on MyPsychLab

Table 13–1 MAJOR TYPES OF PSYCHOACTIVE MEDICATIONS

Therapeutic Use Chemical Structure Trade Name*

Antipsychotics Phenothiazines Thorazine, Therazine, Olanzapine,
Risperdal, Clozapine

Antidepressants Tricyclics Elavil
MAO inhibitors Nardil
SSRIs Paxil, Prozac, Zoloft
SNRI Effexor

Psychostimulants Amphetamines Dexedrine
Other Ritalin, Adderall

Antiseizure Carbamazepine Tegretol
Antianxiety Benzodiazepines Valium
Sedatives Barbiturates
Antipanic Tricyclics Tofranil
Antiobsessional Tricyclics Anafranil

*The chemical structures and especially the trade names listed in this table are representative examples,
rather than an exhaustive list, of the many kinds of medications available for the specific therapeutic use.

Source: Klerman et al., 1994 (adapted and updated).antipsychotic drugs Drugs used to treat very
severe psychological disorders, particularly
schizophrenia.

Explore Drugs Commonly
Used to Treat Psychiatric Disor-
ders at www.mypsychlab.com

Therapies 443

drug (Oltmanns & Emery, 2006; P. Thomas et al., 2009). Moreover, antipsychotic drugs can
have a number of undesirable side effects (H.-Y. Lane et al., 2006., Roh, Ahn, & Nam, 2006).
Blurred vision, weight gain, and constipation are among the common complaints, as are
temporary neurological impairments such as muscular rigidity or tremors. A very serious
potential side effect is tardive dyskinesia, a permanent disturbance of motor control, partic-
ularly of the face (uncontrollable smacking of the lips, for instance), which can be only par-
tially alleviated with other drugs (Chong, Tay, Subramaniam, Pek, & Machin, 2009;
Eberhard, Lindström, & Levander, 2006). In addition, some of the antipsychotic medica-
tions that are effective with adults are not as well tolerated by children who experience an
increased risk for many of the side effects described above (Kumra et al., 2008). Another
problem is that antipsychotics are of little value in treating the problems of social adjust-
ment that people with schizophrenia face outside an institutional setting. Because many
discharged people fail to take their medications, relapse is common. However, the relapse
rate can be reduced if drug therapy is effectively combined with psychotherapy.

Mind–Body Combining Drugs and Psychotherapy
For some disorders a combination of drugs and psychotherapy works better than either
approach used independently. This underscores the fact that the relationship between
mind and body is highly complex. The causes of depression have not yet been fully
determined, but they will probably be found to include a mixture of genetic predisposi-
tion, chemical changes in the brain, and life situation (see Chapter 12, “Psychological
Disorders”). ■

Antidepressant Drugs A second group of drugs, known as antidepressants, is used to
combat depression like that experienced by Brooke Shields. Until the end of the 1980s, there
were only two main types of antidepressant drugs: monoamine oxidase inhibitors (MAO
inhibitors) and tricyclics. Both drugs work by increasing the concentration of the neuro-
transmitters serotonin and norepinephrine in the brain (McKim, 2007; A. V. Terry, Bucca-
fusco, & Wilson, 2008). Both are effective for most people with serious depression, but both
produce a number of serious and troublesome side effects.

In 1988, Prozac (fluoxetine) came onto the market. This drug works by reducing the
uptake of serotonin in the nervous system, thus increasing
the amount of serotonin active in the brain at any given
moment. (See Figure 13–2.) For this reason, Prozac is part of
a group of psychoactive drugs known as selective serotonin
reuptake inhibitors (SSRIs). (See Chapter 2, “The Biological
Basis of Behavior.”) Today, a number of second-generation
SSRIs are available to treat depression, including Paxil
(paroxetine), Zoloft (sertraline), and Effexor (venlafaxine
HCl). For many people, correcting the imbalance in these
chemicals in the brain reduces their symptoms of depression
and also relieves the associated symptoms of anxiety. More-
over, because these drugs have fewer side effects than do
MAO inhibitors or tricyclics (Nemeroff & Schatzberg, 2002),
they have been heralded in the popular media as “wonder
drugs” for the treatment of depression.

Today, antidepressant drugs are not only used to treat
depression, but also have shown promise in treating general-
ized anxiety disorder, panic disorder, obsessive–compulsive dis-
order, social phobia, and posttraumatic stress disorder (M. H.
Pollack & Simon, 2009; Ralat, 2006). Antidepressant drugs

Figure 13–2
How do the SSRIs work?
Antidepressants like Prozac, Paxil, and Zoloft
belong to a class of drugs called SSRIs (selec-
tive serotonin reuptake inhibitors). These drugs
reduce the symptoms of depression by blocking
the reabsorption (or reuptake) of serotonin in
the synaptic space between neurons. The
increased availability of serotonin to bind to
receptor sites on the receiving neuron is
thought to be responsible for the ability of these
drugs to relieve the symptoms of depression.

Terminal
button

Dendrite or cell body

Synaptic
space

Synaptic vesicles
release serotonin into

synaptic space

SSRIs block
the reuptake of
excess serotonin

Normal path
for serotonin

reuptake

Serotonin in
receptor site of

receiving neuron

444 Chapter 13

like the SSRIs do not work for everyone, however. At least a quarter of the patients with
major depressive disorder do not respond to antidepressant drugs (Shelton & Hollon, 2000).
Moreover, for some patients, these drugs produce unpleasant side effects, including nausea,
weight gain, insomnia, headaches, anxiety, and impaired sexual functioning (Demyttenaere &
Jaspers, 2008). They can also cause severe withdrawal symptoms in patients who abruptly stop
taking them (Kotzalidis et al., 2007).

Lithium Bipolar disorder is frequently treated with lithium carbonate. Lithium is not a
drug, but a naturally occurring salt that is generally quite effective in treating bipolar disor-
der (Gnanadesikan, Freeman, & Gelenberg, 2003) and in reducing the incidence of suicide
in bipolar patients (Grandjean & Aubry, 2009). We do not know exactly how lithium works,
but recent studies with mice indicate that it may act to stabilize the levels of specific neuro-
transmitters (Dixon & Hokin, 1998) or alter the receptivity of specific synapses (G. Chen &
Manji, 2006). Unfortunately, some people with bipolar disorder stop taking lithium when
their symptoms improve—against the advice of their physicians; this leads to a relatively
high relapse rate (Gershon & Soares, 1997; M. Pope & Scott, 2003).

Other Medications Several other medications can be used to alleviate the symptoms
of various psychological problems. (See Table 13–1.) Psychostimulants heighten alertness
and arousal. Some psychostimulants, such as Ritalin, are commonly used to treat children
with attention-deficit hyperactivity disorder (Ghuman, Arnold, & Anthony, 2008). In these
cases, they have a calming, rather than stimulating effect. Some professionals worry that
psychostimulants are being overused, especially with young children (S. Rose, 2008).
Antianxiety medications, such as Valium, are commonly prescribed as well. Quickly produc-
ing a sense of calm and mild euphoria, they are often used to reduce general tension and
stress. Because they are potentially addictive, however, they must be used with caution.
Sedatives produce both calm and drowsiness, and are used to treat agitation or to induce
sleep. These drugs, too, can become addictive.

Electroconvulsive Therapy
How is modern electroconvulsive therapy different from that of the past?

Electroconvulsive therapy (ECT) is most often used for cases of prolonged and severe
depression that do not respond to other forms of treatment (Birkenhaeger, Pluijms, &
Lucius, 2003; Tess & Smetana, 2009). The technique involves briefly passing a mild electric
current through the brain or, more recently, through only one of its hemispheres (S. G.
Thomas & Kellner, 2003). Treatment normally consists of 10 or fewer sessions of ECT.

No one knows exactly why ECT works, but its effectiveness has been clearly demon-
strated. In addition, the fatality rate for ECT is markedly lower than for people taking anti-
depressant drugs (Henry, Alexander, & Sener, 1995). Still, ECT has many critics and its use
remains controversial (Krystal, Holsinger, Weiner, & Coffey, 2000; Shorter & Healy, 2007).
Side effects include brief confusion, disorientation, and memory impairment, though
research suggests that unilateral ECT produces fewer side effects and is only slightly less
effective than the traditional method (Bajbouj et al., 2006). In view of the side effects, ECT
is usually considered a “last-resort” treatment after all other methods have failed.

Psychosurgery
What is psychosurgery, and how is it used today?

Psychosurgery refers to brain surgery performed to change a person’s behavior and emo-
tional state. This is a drastic step, especially because the effects of psychosurgery are diffi-
cult to predict. In a prefrontal lobotomy, the frontal lobes of the brain are severed from the
deeper centers beneath them. The assumption is that in extremely disturbed people, the

Explore on MyPsychLab

electroconvulsive therapy (ECT) Biological
therapy in which a mild electrical current is
passed through the brain for a short period,
often producing convulsions and temporary
coma; used to treat severe, prolonged
depression.

psychosurgery Brain surgery performed to
change a person’s behavior and emotional state;
a biological therapy rarely used today.

Explore Drug Therapy at
www.mypsychlab.com

Therapies 445

frontal lobes intensify emotional impulses from the lower brain centers (chiefly, the thala-
mus and hypothalamus). Unfortunately, lobotomies can work with one person and fail
completely with another—possibly producing permanent, undesirable side effects, such as
the inability to inhibit impulses or a near-total absence of feeling.

Prefrontal lobotomies are rarely performed today (Greely, 2007). In fact, very few psy-
chosurgical procedures are done, except as desperate attempts to control such conditions as
intractable psychoses, Parkinson’s disease, epilepsy that does not respond to other treat-
ments (see Chapter 2, “Biological Bases of Behavior”), severe obsessive–compulsive disor-
ders, and pain in a terminal illness (Shawanda Anderson & Booker, 2006; Weingarten &
Cummings, 2001).

The “Summary Table: Major Perspectives on Therapy” captures the key characteristics
of the wide variety of psychological and biological mental health treatments.

MAJOR PERSPECTIVES ON THERAPY

Type of Therapy Cause of Disorder Goal Techniques

Insight therapies

Psychoanalysis Unconscious conflicts and motives;
repressed problems from childhood.

To bring unconscious thoughts and
feeling to consciousness; to gain insight.

Free association, dream analysis,
interpretation, transference.

Client-centered therapy Experiences of conditional positive
regard.

To help people become fully functioning
by opening them up to all of their
experiences.

Regarding clients with
unconditional positive regard.

Gestalt therapy Lack of wholeness in the personality. To get people to “own their feelings”
and to awaken to sensory experience
in order to become whole.

Active rather than passive talk;
empty chair techniques,
encounter groups.

Behavior therapies Reinforcement for maladaptive
behavior.

To learn new and more adaptive
behavior patterns.

Classical conditioning (systematic
desensitization, extinction,
flooding); aversive conditioning
(behavior contracting, token
economies); modeling.

Cognitive therapies Misconceptions; negative,
self-defeating thinking.

To identify erroneous ways of
thinking and to correct them.

Rational–emotive therapy; stress
inoculation therapy; Beck’s
cognitive therapy.

Group therapies Personal problems are often
interpersonal problems.

To develop insight into one’s personality
and behavior by interacting with
others in the group.

Group interaction and mutual
support; family therapy; couple
therapy; self-help therapy.

Biological treatments Physiological imbalance or malfunction. To eliminate symptoms; prevent
recurrence.

Drugs, electroconvulsive therapy,
psychosurgery.

CHECK YOUR UNDERSTANDING

1. Traditionally, the only mental health professionals licensed to provide drug therapy were
____________.

2. Bipolar disorder (also called manic–depressive illness) is often treated with ____________.
3. Which of the following is true of psychosurgery?

a. It never produces undesirable side effects.
b. It is useless in controlling pain.
c. It is widely used today.
d. Its effects are hard to predict.

4. Although it is considered effective in treating depression, electroconvulsive therapy (ECT) is
considered a treatment of last resort because of its potential negative side effects. Is this
statement true (T) or false (F)?
Match the following antidepressant medications with the neurotransmitter(s) that each is
believed to influence. They may be more than one answer for each medication.

Lacking adequate funding and staff, mental
hospitals frequently were crowded and failed to
provide adequate treatment to their residents.

446 Chapter 13

INSTITUTIONALIZATION
AND ITS ALTERNATIVE
How were people with severe psychological disorders cared
for in the past?

For persons with severe mental illness, hospitalization has been the treatment of choice in
the United States for the past 150 years. Several different kinds of hospitals offer such care.
General hospitals admit many affected people, usually for short-term stays until they can
be released to their families or to other institutional care. Private hospitals—some non-
profit and some for profit—offer services to people with adequate insurance. Veterans
Administration hospitals admit veterans with psychological disorders.

When most people think of “mental hospitals,”however, large, state-run institutions come
to mind. These public hospitals, many with beds for thousands of patients, were often built in
rural areas in the 19th century. The idea was that a country setting would calm patients and
help to restore their mental health. Despite the good intentions behind the establishment of
these hospitals, in general they have not provided adequate care or therapy for their residents,
as they are perpetually underfunded and understaffed. Except for new arrivals, who were often
intensively treated in the hope of quickly discharging them, patients received little therapy
besides drugs; and most spent their days watching television or staring into space. Under these
conditions, many patients became completely apathetic and accepted a permanent “sick role.”

The development of effective drug therapies starting in the 1950s led to a number of
changes in state hospitals (Shorter, 1997). First, people who were agitated could now be
sedated with drugs, which was considered an improvement over the use of physical restraints.
The second major, and more lasting, result of the new drug therapies was the widespread
release of people with severe psychological disorders back into the community—a policy
called deinstitutionalization.

APPLY YOUR UNDERSTANDING

1. Blue Haven is a (fictional) state mental hospital where five therapists are responsible for
hundreds of patients. These patients are often violent. The therapy most likely to be used
here is

a. psychoanalysis.
b. biological therapy.
c. cognitive therapy.
d. client-centered therapy.

2. Brian is suffering from schizophrenia. Which of the following biological treatments is most
likely to be effective in reducing or eliminating his symptoms?

a. any drug, such as a phenothiazine, that blocks the brain’s receptors for dopamine
b. selective serotonin reuptake inhibitors (SSRIs), such as Paxil and Prozac
c. lithium carbonate
d. electroconvulsive therapy

Answers:1. b.2. a.

L E A R N I N G O B J E C T I V E
• Describe the process of

deinstitutionalization and the problems
that have resulted from it. Identify
alternatives to deinstitutionalization
including the three forms of prevention.

deinstitutionalization Policy of treating
people with severe psychological disorders in
the larger community or in small residential
centers such as halfway houses, rather than in
large public hospitals.

Answers:1. psychiatrists.2. lithium.3. d.4. (T).5. a and b.6. a and b.7. b.

5. ___ monoamine oxidase inhibitors a. norepinephrine
6. ___ tricyclics 2. serotonin
7. ___ SSRIs 3. epinephrine

Therapies 447

Deinstitutionalization
What problems have resulted from deinstitutionalization?

The practice of placing people in smaller, more humane facilities or returning them under
medication to care within the community intensified during the 1960s and 1970s. By 1975,
600 regional mental health centers accounted for 1.6 million cases of outpatient care.

In recent years, however, deinstitutionalization has created serious challenges (Lamb
& Weinberger, 2001). Discharged people often find poorly funded community mental health
centers—or none at all. Many are not prepared to live in the community and they receive lit-
tle guidance in coping with the mechanics of daily life. Those who return home can become
a burden to their families, especially when follow-up care is inadequate. The quality of resi-
dential centers such as halfway houses can vary, with many providing poor care and minimal
contact with the outside world. Insufficient sheltered housing forces many former patients
into nonpsychiatric facilities—often rooming houses located in dirty, unsafe, isolated neigh-
borhoods. The patients are further burdened by the social stigma of mental illness, which
may be the largest single obstacle to their rehabilitation. Many released patients have been
unable to obtain follow-up care or housing and are incapable of looking after their own
needs. Consequently, many have ended up literally on the streets. Without supervision, they
have stopped taking the drugs that made their release possible in the first place and their
psychotic symptoms have returned. Perhaps one of the most tragic outcomes of the deinsti-
tutionalization movement is the increase in the suicide rate among deinstitutionalized
patients (Goldney, 2003). In addition, surveys indicate that nearly 40% of homeless people
are mentally ill (Burt et al., 1999). Obviously, providing adequate mental health care to the
homeless presents many challenges (Bhui, Shanahan, & Harding, 2006).

Alternative Forms of Treatment
Are there any alternatives to deinstitutionalization other than
rehospitalizing patients?

For several decades, Charles Kiesler (1934–2002) argued for a shift from the focus on institu-
tionalization to forms of treatment that avoid hospitalization altogether (Kiesler & Simpkins,
1993). Kiesler (1982b) examined 10 controlled studies in which seriously disturbed people
were randomly assigned either to hospitals or to an alternative program. The alternative pro-
grams took many forms: training patients living at home to cope with daily activities; assign-
ing patients to a small, homelike facility in which staff and residents share responsibility for
residential life; placing patients in a hostel, offering therapy and crisis intervention; providing
family-crisis therapy and day-care treatment; providing visits from public-health nurses
combined with medication; and offering intensive outpatient counseling combined with
medication. All alternatives involved daily professional contact and skillful preparation of the
community to receive the patients. Even though the hospitals to which some people in these
studies were assigned provided very good patient care—probably substantially above average
for institutions in the United States—9 out of the 10 studies found that the outcome was
more positive for alternative treatments than for the more expensive hospitalization.

Prevention
What is the difference between primary, secondary, and tertiary
prevention?

Another approach to managing mental illness is attempting prevention. This requires
finding and eliminating the conditions that cause or contribute to mental disorders and
substituting conditions that foster well-being. Prevention takes three forms: primary, sec-
ondary, and tertiary.

Primary prevention refers to efforts to improve the overall environment so that new
cases of mental disorders do not develop. Family planning and genetic counseling are two

Beginning in the 1950s and 1960s, the policy
of deinstitutionalization led to the release of
many individuals, who, without proper follow-
up care, ended up living on the streets.
Although not all homeless people are men-
tally ill, estimates suggest that nearly 40% of
homeless persons suffer from some type of
mental disorder.

primary prevention Techniques and programs
to improve the social environment so that new
cases of mental disorders do not develop.

448 Chapter 13

examples of primary prevention programs. Other
primary prevention programs aim at increasing per-
sonal and social competencies in a wide variety of
groups. For example, there are programs designed to
help mothers encourage problem-solving skills in
their children and programs to enhance competence
and adjustment among elderly persons. Current cam-
paigns to educate young people about drugs, alcohol
abuse, violence, and date rape are examples of pri-
mary prevention (Foxcroft, Ireland, Lister, Lowe, &
Breen, 2003; Schinke & Schwinn, 2005).

Secondary prevention involves identifying high
risk groups—for example, abused children, people
who have recently divorced, those who have been laid
off from their jobs, veterans, and victims of terrorist
incidents. Intervention is the main thrust of sec-
ondary prevention—that is, detecting maladaptive

behavior early and treating it promptly. One form of intervention is crisis intervention,
which includes such programs as suicide hotlines (R. K. James & Gilliland, 2001), or short-
term crisis facilities where therapists can provide face-to-face counseling and support.

The main objective of tertiary prevention is to help people adjust to community life after
release from a mental hospital. For example, hospitals often grant passes to encourage people
to leave the institution for short periods of time before their release. Other tertiary prevention
measures are halfway houses, where people find support and skills training during the period
of transition between hospitalization and full integration into the community, and nighttime
and outpatient programs that provide supportive therapy while people live at home and hold
down full-time jobs. Tertiary prevention also includes community education.

Prevention has been the ideal of the mental health community since at least 1970, when
the final report of the Joint Commission on Mental Health of Children called for a new focus
on prevention in mental health work. Ironically, because preventive programs are usually long
range and indirect, they are often the first to be eliminated in times of economic hardship.

Suicide hotlines and other crisis intervention
programs are secondary prevention mea-
sures designed to serve individuals and
groups at high risk for mental disorders.

Access to Mental Health Care

A friend feels overwhelmed by sadness and is exhibiting depressive symp-toms. He comes to you for advice. How likely would you be to suggest thatyour friend seek psychotherapy or drug treatment? Think about the follow-
ing questions:

• Would you seek therapy yourself in a similar situation?
• What would you think of a friend who you knew was seeing a therapist?
• Would your friend be able to obtain therapy services? Would he be able to

afford these kinds of services?

• Do you think that mental illness and physical illness are equivalent and
should be treated the same by insurance companies?

secondary prevention Programs to identify
groups that are at high risk for mental disorders
and to detect maladaptive behavior in these
groups and treat it promptly.

tertiary prevention Programs to help people
adjust to community life after release from a
mental hospital.

CHECK YOUR UNDERSTANDING

1. The practice of treating severely mentally ill people in large, state-run facilities is known as
____________.

2. Many people released from mental hospitals have ended up homeless and on the streets. Is
this statement true (T) or false (F)?

3. The development of effective antipsychotic drugs and the establishment of a network of
community mental health centers starting in the 1950s led to ____________, which
increased throughout the 1960s and 1970s, and continues today.

Answers:1. institutionalization.2. (T)3. deinstitutionalization.

APPLY YOUR UNDERSTANDING

1. Harold argues that institutionalizing people suffering from serious mental illnesses is not only
the most effective way to treat them, but also the least expensive. On the basis of what you
have learned in this chapter, which of the following would be the most appropriate reply?

a. “Mental institutions are indeed the least expensive form of treatment, but they are
also the least effective treatment option.”

b. “You’re right. Mental institutions are both the least expensive form of treatment and
the most effective treatment option.”

c. “Actually, mental institutions are not only the most expensive form of treatment,
they are also the least effective treatment option.”

d. “Actually, mental institutions are the most expensive form of treatment, but they are
the most effective treatment option.”

Therapies 449

CLIENT DIVERSITY AND TREATMENT
Do particular groups of people require special treatment
approaches for psychological problems?

A major topic of this book is the wide range of differences that exist in human beings.
Do such human differences affect the treatment of psychological problems? Two areas
that researchers have explored to answer this question are gender differences and cul-
tural differences.

Gender and Treatment
How can gender stereotypes be avoided in treatment?

There are significant gender differences in the prevalence of many psychological disor-
ders. In part, this is because women have traditionally been more willing than men
to admit that they have psychological problems and need help to solve them (Addis
& Mahalik, 2003; Cochran & Rabinowitz, 2003), and because psychotherapy is
more socially accepted for women than for men (Mirkin, Suyemoto, & Okun, 2005).
However, the number of males willing to seek psychotherapy and counseling has
increased (W. S. Pollack & Levant, 1998). Researchers attribute this growth to the
changing roles of men in today’s society: Men are increasingly expected to provide
emotional as well as financial support for their families.

If gender differences exist in the prevalence of psychological disorders, are there gen-
der differences in their treatment as well? In most respects, the treatment given to women
is the same as that given to men, a fact that has become somewhat controversial in recent
years (Ogrodniczuk, Piper, & Joyce, 2004; Ogrodniczuk & Staats, 2002). Critics of “equal
treatment” have claimed that women in therapy are often encouraged to adopt tradi-
tional, male-oriented views of what is “appropriate”; male therapists may urge women to
adapt passively to their surroundings. They may also be insufficiently sensitive to the fact
that much of the stress that women experience comes from trying to cope with a world in
which they are not treated equally (Tone, 2007). Because of this, there has been an
increased number of “feminist therapists.” These therapists help their female clients to
become aware of the extent to which their problems derive from external controls and
inappropriate sex roles, to become more conscious of and attentive to their own needs
and goals, and to develop a sense of pride in their womanhood, rather than passively
accepting or identifying with the status quo. Consistent with this position, the American
Psychological Association has developed a detailed set of guidelines to help psychologists
meet the special needs of female patients which include exposure to interpersonal vic-
timization and violence, unrealistic media images and work inequities (American Psy-
chological Association, 2007).

2. Your community is especially aware of the importance of preventing psychological
disorders. So far, financial support has been provided for family planning, genetic
counseling, increasing competence among the elderly, and educational programs aimed
at reducing the use of drugs and acts of violence. From this description, it is clear that
your community is putting its emphasis on

a. primary prevention efforts.
b. secondary prevention efforts.
c. tertiary prevention efforts.

Answers:1. c.2. a

L E A R N I N G O B J E C T I V E
• Explain how gender and cultural

differences can affect the treatment of
psychological problems and the
training of therapists.

Because most traditional therapeutic pro-
grams are male oriented, many female clients
seek out female therapists who are more
sensitive to their situation.

450 Chapter 13

Culture and Treatment
How can a therapist interact appropriately with clients from different cultures?

When a client and a therapist come from different cultural backgrounds or belong to dif-
ferent racial or ethnic groups, misunderstandings can arise in therapy.

Diversity–Universality On Being Culture Bound
Imagine the following scenario: As a Native American client is interviewed by a psychologist,
the client stares at the floor. He answers questions politely, but during the entire consulta-
tion, he looks away continually, never meeting the therapist’s eye. This body language might
lead the psychologist to suppose that the man is depressed or has low self-esteem—unless
the psychologist knows that in the person’s culture, avoiding eye contact is a sign of respect.

This example shows how culture bound are our ideas of what constitutes normal
behavior. When psychotherapist and client come from different cultures, misunderstand-
ings of speech, body language, and customs are almost inevitable (Hays, 2008). Even when
client and therapist are of the same nationality and speak the same language, there can be
striking differences if they belong to different racial and ethnic groups (Casas, 1995). Some
Black people, for example, are wary of confiding in a White therapist—so much so that their
wariness is sometimes mistaken for paranoia. In addition, Black patients often perceive
Black therapists as being more understanding and accepting of their problems than White
therapists (V. L. S. Thompson & Alexander, 2006). For this reason, many Black people seek
out a Black therapist, a tendency that is becoming more common as larger numbers of Black
middle-class people enter therapy (Diala et al., 2000; Snowden & Yamada, 2005). ■

Many African American clients are more
comfortable dealing with a therapist of the
same racial background.

One of the challenges for U.S. therapists in recent years has been to treat immigrants,
many of whom have fled such horrifying circumstances that they arrive in the United States
exhibiting PTSD (Paunovic & Oest, 2001). These refugees must overcome the effects of past
trauma, and the new stresses of settling in a strange country—separation from their families,
ignorance of the English language, and inability to practice their traditional occupations.
Therapists in such circumstances must learn something of their clients’ culture. Often they
have to conduct interviews through an interpreter—hardly an ideal circumstance for therapy.

Therapists need to recognize that some disorders that afflict people from other cul-
tures may not exist in Western culture at all. For example, as we saw in Chapter 12, “Psy-
chological Disorders,” taijin kyofusho involves a morbid fear that one’s body or actions may
be offensive to others. Because this disorder is rarely seen outside Japan, American thera-
pists require specialized training to identify it.

Ultimately, the best solution to the difficulties of serving a multicultural population is
to train therapists of many different backgrounds so that members of ethnic, cultural, and
racial minorities can choose therapists of their own group if they wish to do so (Bernal &
Castro, 1994). Research has shown that psychotherapy is more likely to be effective when
the client and the therapist share a similar cultural background (Gibson & Mitchell, 2003;
Pedersen & Carey, 2003). Similarly, efforts aimed at preventing mental illness in society
must also be culturally aware.

CHECK YOUR UNDERSTANDING
Indicate whether the following statements are true (T) or false (F):

1. ___ Men are more likely to be in psychotherapy than women.
2. ___ Our ideas about what constitutes normal behavior are culture bound.
3. ___ Trained mental health professionals rarely misinterpret the body language of a client

from another culture.

Answers:1. (F).2. (T)3. (F).

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Therapies 451

psychotherapy, p. 425

Insight Therapies
insight therapies, p. 425
free association, p. 426
transference, p. 426
insight, p. 426
client-centered (or person-

centered) therapy,
p. 427

Gestalt therapy, p. 428
short-term psychodynamic

therapy, p. 430

Behavior Therapies
behavior therapies, p. 431
systematic desensitization,

p. 431
aversive conditioning, p. 432
behavior contracting, p. 432
token economy, p. 433
modeling, p. 433

Cognitive Therapies
cognitive therapies,

p. 434

stress-inoculation therapy,

p. 434

rational–emotive therapy (RET),
p. 434

cognitive therapy, p. 435

Group Therapies
group therapy, p. 436
family therapy, p. 436
couple therapy, p. 436

Effectiveness of
Psychotherapy
eclecticism, p. 441

Biological Treatments
biological treatments, p. 441
antipsychotic drugs, p. 442
electroconvulsive therapy

(ECT), p. 444
psychosurgery, p. 444

Institutionalization and its
Alternatives
deinstitutionalization, p. 446
primary prevention, p. 447
secondary prevention, p. 448
tertiary prevention, p. 448

APPLY YOUR UNDERSTANDING

1. An immigrant from the Middle East who speaks very little English seeks assistance from
an American psychotherapist who only speaks English. Which of the following problems
may interfere with the therapeutic process?

a. misunderstanding body language
b. the therapist’s lack of familiarity with the cultural norms and values of the

immigrant’s home country
c. need for an interpreter
d. all of the above

2. Preventing and treating psychological disorders is especially challenging in a society
such as ours, which has a culturally diverse population. Which of the following is NOT a
constructive way of dealing with this challenge?

a. Therapists need to recognize that some disorders that afflict people from other
cultures may not exist in Western culture at all.

b. Therapists from many different backgrounds need to receive training so that people
who wish to do so can be treated by a therapist who shares their cultural background.

c. Clients should be treated by therapists who represent the dominant culture so that
they can best adapt to their new environment.

d. Intervention programs need to take into account the cultural norms and values of
the group being served.

Answers:1. d.2. c.

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INSIGHT THERAPIES
What do insight therapies have in common? The various types
of insight therapy share the common goal of providing people
with better awareness and understanding of their feelings, motiva-
tions, and actions to foster better adjustment. Among these are psy-
choanalysis, client-centered therapy, and Gestalt therapy.

How does “free association” in psychoanalysis help a per-
son to become aware of hidden feelings? Psychoanalysis is
based on the belief that psychological problems stem from feelings

and conflicts repressed during childhood. These repressed feelings
can be revealed through free association, a process in which the
client discloses whatever thoughts or fantasies come to mind with-
out inhibition. As therapy progresses, the analyst takes a more
active interpretive role.

Why did Carl Rogers call his approach to therapy “client cen-
tered”? Carl Rogers believed treatment for psychological problems
should be based on the client’s view of the world rather than that of the
therapist. The therapist’s most important task in his approach, called

Listen to an audio file of your chapter. www.mypsychlab.com

452 Chapter 13

client-centered or person-centered therapy, is to provide uncondi-
tional positive regard for clients so they will learn to accept themselves.

How is Gestalt therapy different from psychoanalysis? Gestalt
therapy helps people become more aware of their feelings and thus,
more genuine. Unlike Freud, who sat quietly out of sight while his
clients recalled past memories, the Gestalt therapist confronts the
patient, emphasizes the present, and focuses on the whole person.

What are some recent developments in insight therapies?
Contemporary insight therapists are more actively involved than
traditional psychoanalysts, offering clients direct guidance and
feedback. An especially significant development is the trend toward
short-term psychodynamic therapy, in which treatment time is
limited and oriented toward current life situations and relation-
ships, rather than childhood traumas.

BEHAVIOR THERAPIES
What do behaviorists believe should be the focus of psy-
chotherapy? Behavior therapies are based on the belief that all
behavior is learned and that people can be taught more satisfying
ways of behaving. Maladaptive behaviors are the focus of behav-
ioral psychotherapy, rather than the deeper underlying conflicts
that presumably are causing them.

How can classical conditioning be used as the basis of treat-
ment? When new conditioned responses are evoked to old stimuli,
classical conditioning principles are being used as a basis for treat-
ment. One therapeutic example is systematic desensitization, in
which people learn to remain in a deeply relaxed state while con-
fronting feared situations. Flooding, which exposes phobic people to
feared situations at full intensity for a prolonged period, is a harsh but
effective method of desensitization. In aversive conditioning, the goal
is to eliminate undesirable behavior by associating it with pain and
discomfort.

How could “behavior contracting” change an undesirable
behavior? Therapies based on operant conditioning encourage
or discourage behaviors by reinforcing or punishing them. In
behavior contracting, client and therapist agree on certain behav-
ioral goals and on the reinforcement that the client will receive on
reaching them. In the token economy technique, tokens that can be
exchanged for rewards are used for positive reinforcement of adap-
tive behaviors.

What are some therapeutic uses of modeling? In modeling, a
person learns new behaviors by watching others perform them.
Modeling has been used to teach fearless behaviors to phobic peo-
ple and job skills to mentally retarded people.

COGNITIVE THERAPIES
How can people overcome irrational and self-defeating
beliefs about themselves? Cognitive therapies focus not so
much on maladaptive behaviors as on maladaptive ways of think-
ing. By changing people’s distorted, self-defeating ideas about
themselves and the world, cognitive therapies help to encourage
better coping skills and adjustment.

How can self-talk help with difficult situations? The things we
say to ourselves as we go about our daily lives can encourage success
or failure, a self-confidence or anxiety. With stress-inoculation
therapy, clients learn how to use self-talk to “coach” themselves
through stressful situations.

What irrational beliefs do many people hold?
Rational–emotive therapy (RET) is based on the idea that emo-
tional problems derive from a set of irrational and self-defeating
beliefs that people hold about themselves and the world. They must
be liked by everyone, competent at everything, always be treated
fairly, never be stymied by a problem. The therapist vigorously chal-
lenges these beliefs, enabling clients to reinterpret their experiences
in a more positive light.

How can cognitive therapy be used to combat depression?
Aaron Beck believes that depression results from thought patterns
that are strongly and inappropriately self-critical. Like RET but in a
less confrontational manner, Beck’s cognitive therapy tries to help
such people think more objectively and positively about themselves
and their life situations.

GROUP THERAPIES
What are some advantages of group therapies? Group thera-
pies are based on the idea that psychological problems are partly
interpersonal and therefore, best approached in a group. Group
therapies offer a circle of support and shared insight, as well as psy-
chotherapy at a lower cost. Examples include self-help groups, fam-
ily therapy, and couple therapy.

Who is the client in family therapy? Family therapy is based
on the belief that a person’s psychological problems often signal
family problems. Therefore, the therapist treats the entire family,
rather than just the troubled individual, with the primary goals
of improving communication and empathy and reducing family
conflict.

What are some techniques used in couple therapy?
Couple therapy concentrates on improving patterns of com-
munication and interaction between partners. It attempts to
change relationships, rather than individuals. Empathy training
and scheduled exchanges of rewards are two techniques used to
improve relationships.

Why are self-help groups so popular? Owing to the high cost of
private psychotherapy, low-cost self-help groups have become
increasingly popular. In groups like Alcoholics Anonymous, people
share their concerns and feelings with others who are experiencing
similar problems.

EFFECTIVENESS OF PSYCHOTHERAPY
Is a person who receives psychotherapy better off than
one who gets no treatment at all? Formal psychotherapy helps
about two-thirds of people treated. Although there is some
debate over how many untreated people recover, the consensus is
that those who get therapy are generally better off than those
who don’t.

Therapies 453

Which type of therapy is best for which disorder? Although
each kind of therapy works better for some problems than for oth-
ers, most treatment benefits derive from the therapeutic experi-
ence, regardless of the therapist’s particular perspective. All
therapies provide an explanation of problems, hope, and an alliance
with a caring, supportive person. The general trend in psychother-
apy is toward eclecticism, the use of whatever treatment works best
for a particular problem.

BIOLOGICAL TREATMENTS
What are biological treatments, and who can provide
them? Biological treatments—including medication, electro-
convulsive therapy, and psychosurgery—are sometimes used
when people are too agitated or disoriented to respond to psy-
chotherapy, when there is a strong biological component to the
psychological disorder, and when people are dangerous to them-
selves and others. Medication is often used in conjunction with
psychotherapy. Traditionally, psychiatrists were the only mental
health professionals licensed to offer biological treatments. How-
ever, some states now extend that privilege to specially trained
clinical psychologists.

What are some of the drugs used to treat psychological dis-
orders? Drugs are the most common form of biological therapy.
Antipsychotic drugs are valuable in treating schizophrenia. They
do not cure the disorder, but they reduce its symptoms, though side
effects can be severe. Many types of medications are used to treat
psychological disorders, including antidepressants, antimanic and
antianxiety drugs, sedatives, and psychostimulants.

How is modern electroconvulsive therapy different from that
of the past? Electroconvulsive therapy (ECT) is used for cases of
severe depression that do not respond to other treatments. An elec-
tric current is briefly passed through a patient’s brain. Newer forms
of ECT are given to only one side of the brain.

What is psychosurgery, and how is it used today?
Psychosurgery is brain surgery performed to change a person’s
behavior and emotional state. Rarely used today, it is a final, desper-
ate measure on people who have severe and intractable problems
and don’t respond to any other form of treatment.

INSTITUTIONALIZATION
AND ITS ALTERNATIVES
How were people with severe psychological disorders cared
for in the past? For 150 years, institutionalization in large mental
hospitals was the most common approach. Patients with serious
mental disorders were given shelter and some degree of treatment,
but many never recovered enough to be released. With the advent of
antipsychotic drugs in the 1950s, a trend began toward
deinstitutionalization.

What problems have resulted from deinstitutionalization?
Poorly funded community mental health centers and other support

services have proved inadequate in caring for previously institu-
tionalized patients with mental disorders. Many patients stopped
taking their medication, became psychotic, and ended up homeless
on the streets. Although the concept of deinstitutionalization may
have been good in principle, in practice it has failed for many
patients and for society.

Are there any alternatives to deinstitutionalization other
than rehospitalizing patients? Alternatives to rehospitalization
include living at home with adequate supports provided to all
family members; living in small, homelike facilities in which resi-
dents and staff share responsibilities; living in hostels with ther-
apy and crisis intervention provided; and receiving intensive
outpatient counseling or frequent visits from public health
nurses. Most alternative treatments involve daily professional
contact and skillful preparation of the family and community.
Most studies have found more positive outcomes for alternative
treatments than for hospitalization.

What is the difference between primary, secondary, and ter-
tiary prevention? Prevention refers to efforts to reduce the inci-
dence of mental illness before it arises. Primary prevention
consists of improving the social environment through assistance to
parents, education, and family planning. Secondary prevention
involves identifying high-risk groups and intervention thereof.
Tertiary prevention involves helping hospitalized patients return
to the community and community education.

CLIENT DIVERSITY AND TREATMENT
Are there particular groups of people who may require spe-
cial approaches in the treatment of psychological problems?
Given that humans differ as much as they do, it isn’t surprising that
a one-size-fits-all concept isn’t always appropriate in the treatment
of psychological problems. In recent years, the special needs of
women and people from other cultures have particularly occupied
the attention of mental health professionals.

How can gender stereotypes be avoided in treatment?
Women are more likely than men to be in psychotherapy, and are
more likely prescribed psychoactive medication. Because, in tradi-
tional therapy, women are often expected to conform to gender
stereotypes in order to be pronounced “well,” many women have
turned to “feminist therapists.” The American Psychological Associ-
ation has issued guidelines to ensure that women receive treatment
that is not tied to traditional ideas about appropriate behavior for
the sexes.

How can a therapist interact appropriately with clients from
different cultures? When a client and therapist come from differ-
ent cultural backgrounds or belong to different racial or ethnic
groups, misunderstandings can arise in therapy. Therapists must
recognize that cultural differences exist in the nature of the psycho-
logical disorders that affect people. Treatment and prevention must
be tailored to the beliefs and cultural practices of the person’s eth-
nic group.

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