psychology case study

case study due 5 November

PSYC 430

You will complete a total of three (3) Case Study assignments.  For each assignment, read through the case study and complete the provided answer sheet of questions, utilizing information from the Comer textbook to formulate appropriate answers.  Submit the completed document as an attachment via the assignment submission link.
Grading will be based on the accuracy and quality of answers, the demonstration of higher-level critical thinking skills, and appropriate quantity/content of the answers.  Your answers should do the following:

Be in complete sentences.

Demonstrate focus and clarity of thought.

Display grammar, spelling, and sentence structure appropriate for college-level work.

Access the case study above, navigating through it using the tabs at the top of the page and using the Previous/Next buttons on the bottom.  (The animations on this page require the Flash plug-in, version 6.0 or later.  This page works best in the Internet Explorer browser.)  Thoroughly read the case study, making sure to read the Presenting Complaint and Social/Family History tabs.  See also the DSM Criteria listed in the Diagnosis tab (Generalized Anxiety Disorder, Specific Phobia, and Panic Disorder).  Use the information from the case study and your textbook to answer the 22 questions on the Case Study: Anxiety Answer Sheet.  Do not use the question and answer blocks provided in the case study.  Answer all the questions in the document and submit your finished document for grading through the assignment submission link below

Case Study: Anxiety Answer Sheet

Diagnosing Tina

Student Name:

Diagnosing Generalized Anxiety Disorder:

1a. Refer to the DSM-IV checklist for generalized anxiety disorder. Which of Tina’s symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

1b. Based upon your review of Tina’s symptoms and the diagnostic criteria, could Tina be diagnosed with generalized anxiety disorder or not (and if not, why not)?

Diagnosing Specific Phobia:

2a. Refer to the DSM-IV checklist for specific phobia. Which of Tina’s symptoms meet any of the criteria? (Be sure to match specific symptoms with specific criteria.)

2b. Does Tina have a specific phobia and if yes, what is the feared object?

Diagnosing Panic Disorder:

3a. Refer to the DSM-IV checklist for panic disorder with agoraphobia and the checklist for panic disorder without agoraphobia. Which of Tina’s symptoms meet any of the criteria? (Be sure to match any specific symptoms with specific criteria.)

3b. Does Tina meet the diagnostic criteria for panic disorder with agoraphobia or panic disorder without agoraphobia or neither? Explain why you believe your choice is the most appropriate diagnosis.

Understanding Tina’s Disorders:

1. How would the Socio-Cultural Perspective explain Tina’s GAD?

2. Explain Tina’s GAD from the Existential Perspective.

3. Explain Tina’s GAD from the Cognitive Perspective (please identify any basic irrational assumptions that Tina is making, even if they may be unspoken).

4. Explain Tina’s Phobia from a Behavioral Perspective (please use classical conditioning as a possible example).

5. Explain Tina’s Phobia from a Psychodynamic Perspective.

6. Considering the biological correlates or causes of Tina’s panic disorder, what role does the neurotransmitter norepinephrine play in her panic disorder?

7. What does Tina’s locus ceruleus have to do with her panic disorder?

8. What role might GABA play in her symptoms?

Treating Tina

1. Which Psychodynamic technique has been found to be the most useful in the treatment of GAD?

2. Explain why a humanistic approach would be helpful in treating Tina’s GAD.

3. How might you use Rational-Emotive Therapy to treat Tina’s GAD?

4. How would Systematic Desensitization be used to treat Tina’s phobia of bridges?

5. What medications have proven useful for treatment with panic disorder?

6. What role could cognitive therapy play in Tina’s treatment for panic disorder?

7. Considering that Tina may be treated for comorbid disorders, how do you see the treatments for the various disorders complementing each other?

8. Is there any reason to think that any of the treatments would be contraindicated when utilized together? Explain why/how or why/how not.

Page 26 of 26

Models of Abnormality :1/ 57

°family systems theory°A theory that views the family as a system of interact­ing parts whose interactions exhibit consistent patterns and unstated rules.
egroup theraprA therapy format in which a group of people with similar problems meet together with a therapist to work on those problems.
eself-help groupeA group made up of people with similar problems who help and support one another without the direct leadership of a clinician. Also called a mutual
help
group.

°family therapyoA therapy format in which the therapist meets with all
members of a family and helps them to change in therapeutic ways.
­
Family-Social Treatments
The family-social perspective has helped spur the growth of several treatment ap­proaches, including group therapy, family and couple
therapy, and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models. However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.
Group Therapy Thousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. Indeed, one survey of clinical psychologists revealed that almost one-third of them devoted some portion of their practice to group therapy (Norcross & Goldfried, 2005).Typically, mem­bers of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice (Cox et al., 2008). Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.
Research suggests that group therapy is of help to many clients, often as helpful as individual therapy (Shaughnessy et al., 2007; Misters et al., 2006). The group format also has been used for purposes that are educational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.
A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (for example, bereavement, substance abuse, illness, unemployment, or divorce) come together to help and support one another without the direct leadership of a professional clinician (Mueller et al., 2007).According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by 3 to 4 percent of the population.
Family Therapy Family therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change its ways (Goldenberg & Goldenberg, 2008; Bowen, 1960). Here, the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:
WavA
Altitudes toward Therapy
F.!
• ••••• •••••••••” •••• • •
r • •
Tommy sat motionless in a chair gazing out the window. He was fourteen and a bit small
for his age. . . . Sissy was eleven. She was sitting on the couch between her Mom and Dad
with a smile on her face. Across from them sat Ms. Fargo, the family therapist.
Ms. Fargo spoke. “Could you be a little more specific about the changes you have seen
in Tommy and when they came about?”

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

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

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

“Have you ever had to hit Tommy?” Ms. Fargo inquired softly.
“Sure, a couple of times, but it didn’t seem to do any good.”

58 ://CHAPTER 2

*couple itherapy0A therapy format in which the therapist works with two peo­ple who share a long-term relationship. Also called marital therapy.

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

“Now, that’s not true, Thomas.” Mrs. Davis has a scolding expression on her face. “If you behaved yourself a little better you wouldn’t get hit. Ms. Fargo, l can’t say that 1 am
in favor of the hitting, but I understand sometimes how frustrating it may be for Bob.”

“You don’t know how frustrating it is for me, honey.” Bob seemed upset. “You don’t
have to work all day at the office and then come home to contend with all of this. Some­times 1 feel like l don’t even want to come home.”

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

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

Ms. Fargo . . . looked at each person briefly and was sure to make eye contact.
“There seems to be a lot going on. . think we are going to need to understand a lot of things to see why this is happening.”
(Sheras & Worchel, 1979, pp. 108-110)

Family therapists may follow any of the major theoretical models, but more and more of them are adopting the principles of family systems theory. Today 3 percent of all clinical psychologists, 13 percent of social workers, and 1 percent of psychiatrists identify themselves mainly as family systems therapists (Prochaska & Norcross, 2007).
As you read earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, struc­
tural family therapy, therapists try to change the family power structure, the roles each person plays, and the relationships between members (Goldenberg & Goldenberg, 2008; Minuchin, 1997, 1987, 1974). In another, conjoint family therapy, therapists try to help members recognize and change harmful patterns of communication (Sharf, 2008; Satir, 1987, 1967, 1964).
Family therapies of various kinds are often helpful to individuals,
although research has not yet clarified how helpful (Goldenberg &

Goldenberg, 2008). Some studies have found that as many as 65 percent of individuals treated with family approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others (Alexander et al., 2002).
Coupk Therapy In couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns occurring in the re­lationship (Baucom et al., 2009, 2006, 2000).A couple approach may also be used when a child’s psychological problems are traced to problems in the parents’ relationship.
Although some degree of conflict exists in any long-term relationship, many adults in our society experience serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate (Marshall & Brown, 2008). Many couples who live together without marrying apparently have similar levels of difficulty (Harway, 2005).
Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Behavioral couple therapy, for example, uses many techniques from the behavioral perspective (Shadish & Baldwin, 2005; Gurman, 2003). Therapists

r.1
-Help Groups: Too Much of a Good Thing?
, {elf-help groups are widely accepted
j in our society by consumers and clini­cians alike (Isenberg et al., 2004). Indeed, one survey of mental health professionals revealed that almost 90 percent of all thera­pists in the United States often recommend such groups to their clients as a supplement to therapy (Clifford et al., 1998).
Small wonder that the number, range, and appeal of such groups have grown rap­idly over the past several decades and that 25 million people in the United States alone are estimated to attend self-help groups over the course of their lives. And this number does not even include the millions of chat group participants who seek online support, information, and help from fellow sufferers. The self-help group movement and its impact on our society are brought to life in the fol­lowing notice that was posted in a Colorado church, listing support groups that would
be meeting at the church during the coming week (Moskowitz, 2008, 2001):
­­­­Sunday

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

5:30 p.m. Debtors Anonymous, basement
6:30 p.m. Codependents of Sex Addicts Anonymous,
2nd floor
7:00 p. m. Adult Children of Alcoholics,
2nd floor
8:00 p.m. Alcoholics Anonymous, basement
8:00 p.m. Al-Anon, 2nd floor
8:00 p.m. Alateen, basement
8:00 p.m. Cocaine Anonymous, main floor
Tuesday

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

Wednesday
5:30 p.m.
7:30 p.m.
8:00 p.m.

Thursday

7:00 p.m.
7:00 p.m.
Friday

5:30 p.m. 5:45 p.m. 7:30 p.m. 7:30 p.m. 8:00 p.m.

Saturday

10:00 a.m.
12:00 p.m.
Sex & Love Addicts Anonymous, basement Adult Children of Alcoholics, 2nd floor Cocaine Anonymous, main floor
Codependents of Sex Addicts Anonymous,
2nd floor
Women’s Cocaine Anonymous, main floor
Sex & Love Addicts Anonymous, basement Adult Overeaters Anonymous, 2nd floor Codependents Anonymous, basement Adult Children of Alcoholics, 2nd floor Cocaine Anonymous, main floor
Adult Children of Alcoholics, main floor Self-Abusers Anonymous, 2nd floor

Models of Abnormality :// 59

60 ://CHAPTER 2
help spouses recognize and change problem behaviors largely by teaching specific problem-solving and communication skills. A broader, more sociocultural version, called integrative
couple therapy, further helps partners accept behaviors that they cannot change and em­brace the whole relationship nevertheless (Christensen et al., 2006). Partners are asked to see such behaviors as an understandable result of basic differences between them.
Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who fail to receive treatment (Fraser & Solovey, 2007), but no one form of couple therapy stands out as superior to others (Snyder et al., 2006; Harway 2005). Although two-thirds of treated couples experience improved marital functioning by the end of therapy, fewer than half of those who are treated achieve “distress-free” or “happy” relationships. Moreover, one-third of success­fully treated couples may relapse within two years after therapy.
Community Treatment Community mental health treatment programs allow clients, particularly those with severe psychological difficulties, to receive treatment in familiar social surroundings as they try to recover. In 1963 President John Kennedy called for such a “bold new approach” to the treatment of mental disorders—a com­munity approach that would enable most people with psychological problems to receive services from nearby agencies rather than distant facilities or institutions. Congress passed the Community Mental Health Act soon after, launching the community mental health movement across the United States. A number of other countries have launched similar movements.
As you read in Chapter 1, a key principle of community treatment is prevention. Here clinicians actively reach out to clients rather than wait for them to seek treatment. Research suggests that such efforts are often very successful (Rage et al., 2007). Com­munity workers recognize three types of prevention, which they call primary, secondary, and tertiary.

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Primary prevention consists of efforts to improve community at­titudes and policies. Its goal is to prevent psychological disorders altogether. Community workers may, for example, consult with a local school board or offer public workshops on stress reduction (Bloom, 2008).
Secondary prevention consists of identifying and treating psycholog­ical disorders in the early stages, before they become serious. Com­munity workers may work with schoolteachers, ministers, or police to help them recognize the early signs of psychological dysfunction and teach them how to help people find treatment (Ervin et al., 2007).
The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Today community agencies across the United States do successfully offer tertiary care for millions of people with moderate psychological problems, but, as we also observed in Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances. One of the reasons for this failure is lack of funding, an issue that you will read about in later chapters (Weisman, 2004).

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How Do Multicultural Theorists Explain
Abnormal Functioning?

Culture refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next (Matsumoto, 2007, 2001). We are, without question, a society of multiple cultures. Indeed, in the coming decades, members of racial and ethnic minority groups in the United States will, col­lectively, outnumber white Americans (Gordon, 2005; U.S. Census, 2000).
Partly in response to this growing diversity, the multicultural, or culturally diverse, perspective has emerged ( Jackson, 2006). Multicultural psychologists seek

Models of Abnormality :// 61

to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of differ­ent cultures, races, and genders differ psychologically (Alegria et al., 2009, 2007, 2004). Today’s multicultural view is differ­ent from past—less enlightened—cultural perspectives: It does not imply that members of racial, ethnic, and other minority groups are in some way inferior or culturally deprived in com­parison with a majority population (Sue & Sue, 2003). Rather, the model holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of that individual’s unique cultural context, from the values of that culture to the special external pressures faced by members of the culture.
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The groups in the United States that have received the most attention from multicultural researchers are ethnic and racial minority groups (African American, Hispanic American, Native American, and Asian American groups) and groups such as economically disadvantaged persons, homosexual individu­als, and women (although women are not technically a minority group). Each of these groups is subjected to special pressures in American society that may contribute to feel­ings of stress and, in some cases, to abnormal functioning. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is indeed mote common among poorer people than among wealthier people (Byrne et al., 2004; Draine et al., 2002). Perhaps the pressures of poverty explain this relationship. Of course, membership in these various groups overlaps. Many members of minority groups, for example, also live in poverty. The higher rates of crime, unemployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities typically experienced by poor persons may place great stress on many members of such minority groups.
Multicultural researchers have also noted that the prejudice and discrimination faced by many minority groups may contribute to certain forms of abnormal functioning (Carter, 2007; Nelson, 2006). Women in Western society receive diagnoses of anxiety and depressive disorders at least twice as often as men (McSweeney, 2004). Similarly, African Americans experience unusually high rates of anxiety disorders (Blazer et al., 1991). Hispanic Americans may have a greater vulnerability to posttraumatic stress disorder than members of other ethnic groups (Koch & Haring, 2008). And Native Americans display exceptionally high alcoholism and suicide rates (Beals et al., 2005). Although _many factors may combine to produce these differences, racial and sexual prejudice and the problems they pose may contribute to abnormal patterns of tension, unhappiness, low self-esteem, and escape (Carter, 2007; Nelson, 2006).
°community mental health treat­ment°A treatment approach that emphasizes community care.
°multicultural perspective°The view that each culture has a set of values and beliefs, as well as special external pres­sures, that help account for the behavior of its members. Also called culturally diverse perspective.

°culture-sensitive therapies® Approaches that seek to address the unique issues faced by members of minority groups.
°gender-sensitive therapies° Approaches geared to the pressures of being a woman in Western society. Also called feminist therapies.

­­
Muiticuiturai Treatments
Studies conducted throughout the world have found that members of ethnic and racial minority groups tend to show less improvement in clinical treatment (Comas-Diaz, 2006), make less use of mental health services, and stop therapy sooner than members of majority groups (Ward, 2007; Comas-Diaz, 2006; Wang et al., 2006).
A number of studies suggest that two features of treatment can increase a therapist’s effectiveness with minority clients: (1) greater sensitivity to cultural issues and (2) inclu­sion of cultural morals and models in treatment, especially in therapies for children and adolescents (Castro, Holm-Denoma, & Buckner, 2007; Lee & Sue, 2001). Given such findings, some clinicians have developed culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups (Carter, 2006; Mio et al., 2006). Therapies geared to the pressures of being female in Western society, called gender-sensitive, or feminist, therapies, follow similar principles.
Culture-sensitive approaches typically include the following elements (Prochaska & Norcross, 2007;Wyatt & Parham, 2007):

62 ://CHAPTER 2

1. Special cultural instruction of therapists in their graduate training programs
2. Awareness by the therapist of a client’s cultural values
3. Awareness by the therapist of the stress, prejudices, and stereotypes to which minority clients are exposed
4. Awareness by therapists of the hardships faced by the children of immigrants
5. Helping clients recognize the impact of both their own culture and the dominant culture on their self-views and behaviors
6. Helping clients identify and express suppressed anger and pain
7. Helping clients achieve a bicultural balance that feels right for them
8. Helping clients raise their self-esteem—a sense of self-worth that has often been damaged by generations of negative messages
Assessing the Sociocultural Model

The family-social and multicultural perspectives have added greatly to the understand­ing and treatment of abnormal functioning. Today most clinicians take family, cultural, social, and societal issues into account, factors that were overlooked just 35 years ago. In addition, clinicians have become more aware of the impact of clinical and social roles. Finally, the treatment formats offered by the socio­cultural model sometimes succeed where traditional ap­proaches have failed.
At the same time, the sociocultural model has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Indeed, research may reveal a relationship between certain family or cultural factors and a particular disorder yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not nec­essarily mean that family dysfunction causes schizophrenia. It is equally possible that family functioning is disrupted by the tension and conflict created by the psychotic behavior of a family member.

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Another limitation of the sociocultural model is its in­ability to predict abnormality in specific individuals. If, for example, social conditions such as prejudice and discrimination are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?
Given these limitations, most clinicians view the family-social and multicultural ex­planations as operating in conjunction with the biological or psychological explanations. They agree that family, social, and cultural factors may create a climate favorable to the development of certain disorders.They believe, however, that biological or psychological conditions—or both—must also be present for the disorders to evolve.
The Cociocultural
The sociocultural model looks outward to the social and cultural forces that affect members of a society. One of this model’s perspectives, the family-social perspective, points to three kinds of factors in its explanations of abnormal functioning: social labels and roles, social networks and supports, and the family system. Clinicians from the family-social perspective may practice group, family, or couple therapy or community treatment.

Models of Abnormality :1/ 63

Cultural Oyersidht
-1,
The multicultural perspective, another perspective from the sociocultural model, holds that an individual’s behavior, whether normal or abnormal, is best under­stood when examined in the light of his or her unique cultural context, including the values of that culture and the special external pressures faced by members of the culture. Practitioners of this perspective may employ culture-sensitive therapies, approaches that seek to address the unique issues faced by members of cultural minority groups.
­

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Integration of the Models
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Today’s leading models vary widely (see Table 2-2).Yet none of the models has proved consistently superior. Each helps us appreciate a key aspect of human functioning, and each has important strengths as well as serious limitations.
With all their differences, the conclusions and techniques of the various models are often compatible. Certainly our understanding and treatment of abnormal behavior are more complete if we appreciate the biological, psychological, and sociocultural aspects of a person’s problem rather than only one of them. Not surprisingly, then, a growing number of clinicians favor explanations of abnormal behavior that consider more than one kind of cause at a time. These explanations, sometimes called biopsychosocial theories, state that abnormality results from the interaction of genetic, biological, developmen­tal, emotional, behavioral, cognitive, social, cultural, and societal influences (Olson & Sameroff, 2009).A case of depression, for example, might best be explained by pointing collectively to an individual’s inheritance of unfavorable genes, traumatic losses during childhood, negative ways of thinking, and social isolation.
Some biopsychosocial theorists favor a diathesis
–
stress explanation of how the various factors work together to cause abnormal functioning (“diathesis” means a predisposed

table:

Multicultural

External pressures or cultural conflicts
Moderate
Client
Cultural advocate/ teacher
Comparing the Models

Family‑

Biological

Psychodynamic Behavioral

Cognitive

Humanistic

Existential

Social

Cause of
Biological
Underlying Maladaptive Maladaptive Self-deceit
Avoidance of
Family or
dysfunction
malfunction
conflicts learning thinking
responsibility
social stress
Research support
Strong
Modest Strong
Strong
Weak
Weak
Moderate
Consumer designation
Patient
Patient Client
Client
Patient or client
Patient or client
Client
Therapist role
Doctor
Interpreter Teacher
Persuader
Observer
Collaborator
Family/ social facilitator

Key therapist Biological Free association Conditioning Reasoning Reflection
technique intervention and interpretation
Varied social
Family/ Culture‑
sensitive
intervention intervention
Therapy goal
Biological repair
Broad psychological change
Functional
behaviors
Adaptive Self‑
thinking actualization
Authentic life
Effective family or social system
Cultural awareness and comfort

64 1/CHAPTER 2

tendency).According to this theory, people must first have a biological, psychological, or sociocultural predisposition to develop a disorder and must then be subjected to episodes of severe stress. In a case of depression, for example, we might find that unfavorable genes and related biochemical abnormalities predispose the individual to develop the disorder, while the loss of a loved one actually triggers its onset.
In a similar quest for integration, many therapists are now combining treatment techniques from several models. In fact, 29 percent of today’s clinical psychologists, 34 percent of social workers, and 53 percent of psychiatrists describe their approach as “eclectic” or “integrative” (Prochaska & Norcross, 2007). Studies confirm that clinical problems often respond better to combined approaches than to any one therapy alone. For example, as you will see, drug therapy combined with cognitive therapy is some­times the most effective treatment for depression (TADS, 2007).
Given the recent rise in biopsychosocial theories and combination treatments, our examinations of abnormal behavior throughout this book will take two directions. As different disorders are presented, we will look at how today’s models explain each disorder, how clinicians who endorse each model treat people with the disorder, and how well these explanations and treatments are supported by researchiust as important, however, we will also be observing how the explanations and treatments may build upon and strengthen each other, and we will examine current efforts toward integration of the models.

\\\ flRITICIAL THOWTHITS
///

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

–

36

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

–

50

3.
Freud’s influence on Western society has extended beyond the clinical realm. Can you think of ways that his theory has affected literature, movies, child-rearing, philosophy, and educa­tion?
pp.
37-43
4. Why might positive religious beliefs be linked to mental health? Why have so many clinicians been suspi­cious of religious beliefs for so long?

p. 53

5.

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

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

..\\\
KEY TEPqrShr

model, p. 32

neuron, p. 33

synapse,
p.
33

neurotransmitter, p. 33

endocrine system, p. 34

hormone,
p. 34
gene,
p.
34

evolution,
p. 35

psychotropic medication, p. 35

electroconvulsive therapy (ECT),
p.
36

psychosurgery, p. 36

4Y
‘
4/ 4,4
,4

unconscious, p.
37

transference, p. 41

dream, p. 41

catharsis, p. 41

working through, p. 41

short-term psychodynamic therapies,

p.
42

relational psychoanalytic therapy, p. 42

conditioning,
p. 44

operant conditioning, p. 44

modeling, p. 44

classical conditioning, p. 44

id,
p. 38

ego, p. 38

ego defense mechanism, p.
38
superego, p. 38

fixation,
p. 39

ego theory, p. 39

self theory, p.
39

object relations theory, p. 40

free association, p. 40 resistance, p. 40

/fir.
4
,
00Voi

Models of Abnormality :1/ 65

family systems theory, p. 56

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

d.)”,,•,” • • •
4. What are the key principles of the psychodynamic (pp. 37
–
43), behavioral (pp. 43-47), cognitive (pp. 47
–
50), and humanistic-existential (pp. 50
–
55) models?
5. According to psychodynamic theorists, what roles do the id, ego, and superego play in the develop­ment of both normal and abnormal behavior? What are the key tech­niques used by psychodynamic therapists? pp. 37-43
6. What forms of conditioning do behaviorists rely on in their expla­nations and treatments of abnormal behaviors? pp. 44, 45

­­­7A%
systematic desensitization, p. 45
cognitive therapy, p. 48

self-actualization, p. 50

client-centered therapy, p. 51
gestalt therapy, p. 52

existential therapy, p. 54
· `•
:•• \\\ r)U11J1( nti 17 /// :••
§ 1. What are the key regions of the
· ek./7 .: brain, and how do messages travel
throughout the brain? Describe the 45::.7C1 biological treatments for psycho‑
logical disorders. pp. 33
–
36

2. Identify the models associated with 7 spirituality (p. 53), underlying
.
learned responses (p. 44), values (p. 50), responsibility (p. 53),

4.;

.14/: conflicts (p. 37), and maladaptive
#:assumptions (p. 47).
3. Identify the treatments that use unconditional positive regard
f (p. 51), free association (p. 40),

r classical conditioning (p. 45), skill‑
ful frustration (p. 52), and dream fiolo; interpretation (p. 41).

/9:
•••• ••
.1, ,.,0, **
1.0,, ** ,41
,
*** p
..

4
7:
#
“:
,’
” .” “44′
0”..0
/
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4
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community mental health
treatment,
p. 60

multicultural perspective, p. 60
culture-sensitive therapy, p. 6 7 gender-sensitive therapy, p. 61
diathesis-stress explanation, p. 63

e.
.72;227

7. What kinds of cognitive dysfunc­tioning can lead to abnormal behavior? p. 47

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

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

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

·
*********

• • • • ** * *
.1

“or.,

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CLINICAL ASSESSMENT,
DIAGNOSIS,
AND TREATMENT
CHAPTER

TOPIC OVERVIEW

Clinical Assessment:
How and Why Does the Client Behave Abnormally?
Characteristics of Assessment Tools Clinical Interviews
Clinical Tests
Clinical Observations
Diagnosis:
Does the Client’s Syndrome Match a Known Disorder? Classification Systems
DSM-IV-TR
Is DSM-IV-TR an Effective Classification System?
Can Diagnosis and Labeling Cause Harm?
Treatment: How Might the Client Be Helped?

Treatment Decisions
The Effectiveness of Treatment
Putting It Together:
Renewed Respect Collides with Economic Pressure

ngela Savanti was 22 years old, lived at home with her mother, and was employed as
a

secretary in a large insurance company. She . . . had had passing periods of “the blues”

before, but her present feelings of despondency were of much greater proportion. She
LI was troubled by a severe depression and frequent crying spells, which had not lessened over the past two months. Angela found it hard to concentrate on her job, had great difficulty
falling asleep at night, and had o poor appetite. . . . Her depression had begun after she and
her boyfriend Jerry broke up two months previously.

(Leon, 1984, p. 109)

Her feelings of despondency led Angela Savanti to make an appointment with a therapist at a local counseling center. The first step the clinician took was to learn as much as possible about Angela and her disturbance. Who is she, what is her life like, and what precisely are her symptoms? The answers might help to reveal the causes and probable course of her present dysfunction and suggest what kinds of strategies would be most likely to help her. Treatment could then be tailored to Angela’s needs and particular pattern of abnormal functioning.
In Chapters 1 and 2 you read about how researchers in abnormal psychol­ogy build a general understanding of abnormal functioning. Clinical practitioners apply this broad information in their work, but their main focus when faced with new clients is to gather idiographic, or individual, information about them (Bornstein, 2007). To help persons overcome their problems, clinicians must fully understand them and their particular difficulties. To gather such individual infor­mation, clinicians use the procedures of assessment and diagnosis. Then they are in a position to offer treatment.

.ti‘Clinkal Assessment: How and Why
Does the Client Behave Abnormally?

Assessment is simply the collecting of relevant information in an effort to reach a conclusion. It goes on in every realm of life. We make assessments when we decide what cereal to buy or which presidential candidate to vote for. College admissions officers, who have to select the “best” of the students applying to their college, depend on academic records, recommendations, achievement test scores, interviews, and application forms to help them decide (Sackett, Borneman, & Connelly, 2008). Employers, who have to predict which applicants are most likely to be effective workers, collect information from résumés, interviews, references, and perhaps on-the-job observations.
Clinical assessment is used to determine how and why a person is behaving ab­normally and how that person may be helped. It also enables clinicians to evaluate people’s progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques
•

°idiographic understanding0An
understanding of the behavior of a particular individual.
*assessment°The process of collecting and interpreting relevant information about a client or research participant.
estandordizationeThe process in which a test is administered to a large group of people whose performance then serves as a standard or norm against which any individual’s score can be measured.
oreliabilitrA measure of the consis­tency of test or research results.
ovalidityeThe accuracy of a test’s or study’s results; that is, the extent to which the test or study actually measures or shows what it claims.
­68 •.HCHAPTER 3
and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity.

Characteristics of Assessment Tools
All clinicians must follow the same procedures when they use a particular technique of assessment. To standardize a technique is to set up common steps to be followed whenever it is administered. Similarly, clinicians must standardize the way they interpret the results of an assessment tool in order to be able to understand what a particular score means.They may standardize the scores of a test, for example, by first administering it to a group of research participants whose performance will then serve as a common standard, or norm, against which later individual scores can be measured. The group that initially takes the test must be typical of the larger population for whom the test is intended. If an aggressiveness test meant for the public at large were standardized on a group of marines, for example, the resulting “norm” might turn out to be misleadingly high.
Reliability refers to the consistency of assessment measures. A good assessment tool will always yield the same results in the same situation (Weiner & Greene, 2008). An assessment tool has high test—retest reliability, one kind of reliability, if it yields the same results every time it is given to the same people. If a woman’s responses on a particular test indicate that she is generally a heavy drinker, the test should produce the same result when she takes it again a week later. To measure test—retest reliability, participants are tested on two occasions and the two scores are correlated. The higher the correlation (see Chapter 1), the greater the test’s reliability.
An assessment tool shows high interrater (or interjudge) reliability another kind of reli­ability, if different judges independently agree on how to score and interpret it. True—false and multiple-choice tests yield consistent scores no matter who evaluates them, but other tests require that the evaluator make a judgment. Consider a test that requires the person to draw a copy of a picture, which a judge then rates for accuracy. Different judges may give different ratings to the same drawing.
Finally, an assessment tool must have validity: It must accurately measure what it is supposed to measure (Weiner & Greene, 2008). Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those read­ings are not valid, or accurate.
A given assessment tool may appear to be valid simply because it makes sense and seems reasonable. However, this sort of validity, called face validity does not by itself mean that the instrument is trustworthy.A test for depres­sion, for example, might include questions about how often a person cries. Because it makes sense that depressed people would cry, these test questions have face validity. It turns out, however, that many people cry a great deal for reasons other than depression, and some extremely depressed people fail to cry at all. Thus an assessment tool should not be used unless it has high predictive validity or concurrent validity (Sackett et al., 2008).
–
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Predictive validity is a tool’s ability to predict future characteristics or behavior. Let’s say that a test has been developed to identify elementary schoolchildren who are likely to take up cigarette smoking in high school. The test gathers information about the children’s parents—their personal characteristics, smok­ing habits, and attitudes toward smoking—and on that basis identifies high-risk children. To establish the test’s predictive validity, investigators could administer it to a group of elementary school students, wait until they were in high school, and then check to see which children actually did become smokers.

Concurrent validity is the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques. Participants’ scores on a new test designed to measure anxiety, for example, should correlate highly with their scores on other anxiety tests or with their behavior during clinical interviews.
•

Clinical Assessment, Diagnosis, and Treatment :11 69
•

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Clinical interviews
Most of us feel instinctively that the best way to get to know people is to meet with them face to face. Under these circumstances, we can see them react to what we do and say, observe as well as listen as they answer, and generally get a sense of who they are. A clinical
interview is just such a face-to-face encounter (Sommers-Flanagan & Sommers-Flanagan, 2007, 2003). If during a clinical interview a man looks as happy as can be while describing his sadness over the recent death of his mother, the clinician may suspect that the man actually has conflicting emotions about this loss.
Conducting the interview
The interview is often the first contact between client and clinician. Clinicians use it to collect detailed information about the person’s prob­lems and feelings, lifestyle and relationships, and other personal history.They may also ask about the person’s expectations of therapy and motives for seeking it.The clinician who worked with Angela Savanti began with a face-to-face interview:
Angelo was dressed neatly when she appeared for her first interview. She was attractive,
but her eyes were puffy and ringed with dark circles. She answered questions and related information about her life history in a slow, flat tone of voice, which had an impersonal
quality to it. She sat stiffly in her chair . .

The client stated that the time period just before she and her boyfriend terminated their relationship had been one of extreme emotional turmoil. She was not sure whether she wanted to marry Jerry, and he began to demand that she decide either one way or
the other. Mrs. Savanti [Angela’s mother] did not seem to like Jerry and was very cold and
aloof whenever he came to the house. Angela felt caught in the middle and unable to
make a decision about her future. After several confrontations with Jerry over whether she
would marry him or not he told her he felt that she would never decide, so he was not
going to see her anymore… .

Angelo stated that her childhood was a very unhappy period. Her father was seldom home, and when he was present, her parents fought constantly. . . .

Angela recalled feeling very guilty when Mr. Savant’ . . . She revealed that when‑

ever she thought of her father, she always felt that she hod been responsible in some way
for his leaving the family . . .

Angela described her mother as the “long-suffering type” who said that she hod sac­
rificed her life to make her children happy, and the only thing she ever got in return was
grief and unhappiness. . . When Angela and [her sister] began dating, Mrs. Savanti .. .
would make disparaging remarks about the boys they had been with and about men in
general. .

Angela revealed that she had often been troubled with depressed moods. During high
school, if she got a lower grade in a subject than she had expected, her initial response was one of anger, followed by depression. She began to think that she was not smart
enough to get good grades, and she blamed herself for studying too little. Angela also
became despondent when she got into an argument with her mother or felt that she was
being taken advantage of at work. .
‘iR

Spotting Depre5sio
The intensity and duration of the [mood change] that she experienced when she broke up with Jerry were much more severe. She was not sure why she was so depressed, but
she began to feel it was an effort to walk around and go out to work. Talking with others
become difficult. Angela found it hard to concentrate, and she began to forget things she was supposed to do. . . . She preferred to lie in bed rather than be with anyone, and she
often cried when alone.

(Leon, 1984, pp. 110-115)

•

“Can you describe this china shop?”

70 ://CHAPTER 3
Beyond gathering basic background data of this kind, clinical inter­viewers give special attention to whatever topics they consider most im­portant (Wright &Truax, 2008). Psychodynamic interviewers try to learn about the person’s needs and memories of past events and relationships. Behavioral interviewers try to pinpoint information about the stimuli that trigger responses and their consequences. Cognitive interviewers try to discover assumptions and interpretations that influence the person. Humanistic clinicians ask about the person’s self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments.
Interviews can be either unstructured or structured (O’Brien & Tabaczynski, 2007; Rabinowitz et al., 2007). In an unstructured interview, the clinician asks open-ended questions, perhaps as simple as “Would you tell me about yourself?”The lack of structure allows the interviewer to follow leads and explore relevant topics that could not be anticipated before the interview.
In a structured interview, clinicians ask prepared questions. Some­times they use a published interview schedule
—
a standard set of ques­tions designed for all interviews. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client’s awareness, orientation with regard to time and place, attention span, memory, judgment and insight, thought content and processes, mood, and appearance (Palmer, Fiorito, & Tagliareni, 2007). A struc­tured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals.
Although most clinical interviews have both unstructured and structured portions, many clinicians favor one kind over the other. Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by behavioral and cognitive clinicians, who need to pinpoint behaviors, attitudes, or thinking processes that may underlie abnormal behavior (Hersen, 2004).
What Are the Li itations of dinical interviews? Although interviews often produce valuable information about people, there are limits to what they can accomplish (Hersen & Thomas, 2007). One problem is that they sometimes lack validity, or accuracy. Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discussing embarrassing topics. Or people may be unable to give an accurate re­port in their interviews. Individuals who suffer from depression, for example, take a pes­simistic view of themselves and may describe themselves as poor workers or inadequate parents when that isn’t the case at all.
Interviewers too may make mistakes in judgments that slant the information they gather. They usually rely too heavily on first impressions, for example, and give too much weight to unfavorable information about a client (Wu & Shi, 2005). Interviewer biases, including gender, race, and age biases, may also influence the interviewers’ inter­pretations of what a client says (Ungar et al., 2006).
°mental status exameA set of interview questions and observations designed to reveal the degree and nature of a client’s abnormal functioning.
eiesteA device for gathering informa­tion about a few aspects of a person’s psychological functioning from which broader information about the person con be inferred.
°projective test®A test consisting of ambiguous material that people interpret or respond to.
­Interviews, particularly unstructured ones, may also lack reliability (Wood et al., 2002). People respond differently to different interviewers, providing, for example, less information to a cold interviewer than to a warm and supportive one (Quas et al., 2007). Similarly, a clinician’s race, gender, age, and appearance may influence a client’s responses (Springman,Wherry, & Notaro, 2006).
Because different clinicians can obtain different answers and draw different conclu­sions, even when they ask the same questions of the same person, some researchers believe that interviewing should be discarded as a tool of clinical assessment. As you’ll see, however, the two other kinds of clinical assessment methods also have serious limitations.

alnico( Assessment, Diagnosis, and Treatment :// 71

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viii.,
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9

Clinical Tests
Tests are devices for gathering information about a few aspects of a person’s psycho­logical functioning, from which broader information about the person can be inferred (Gregory, 2004). On the surface, it may look easy to design an effective test. Every month, magazines and websites present new tests that supposedly tell us about our personalities, relationships, sex lives, reactions to stress, or ability to succeed. Such tests might sound convincing, but most of them lack reliability, validity, and standardization. That is, they do not yield consistent, accurate information or say where we stand in comparison with others.
More than 500 clinical tests are currently in use throughout the United States. Cli­nicians use six kinds most often: projective tests, personality inventories, response inventories,
psychophysiological tests, neurological and )7europsychological tests, and intelligence tests.

Proiective Tests Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as “Draw a person.”Theoretically, when clues and instructions are so general, people will “project” aspects of their personality into the task. Projective tests are used primarily by psycho-dynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning (Tuber et al., 2008; Hojnoski et al., 2006).The most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence-
completion tests, and drawings.

RORSCHACH TEST In 1911 Hermann Rorschach, a Swiss psychiatrist, experimented with the use of inkblots in his clinical work. He made thousands of blots by dropping ink on paper and then folding the paper in half to create a symmetrical but wholly accidental design, such as the one shown in Figure 3-1. Rorschach found that everyone saw images in these blots. In addition, the images a viewer saw seemed to correspond in important ways with his or her psychological condition. People diagnosed with schizophrenia, for example, tended to see images that differed from those described by people experienc­ing depression.
Rorschach selected 10 inkblots and published them in 1921 with instructions for their use in assessment.This set was called the Rorschach Psychodynamic Inkblot Test. Ror­schach died just eight months later, at the age of 37, but his work was continued by others, and his inkblots took their place among the most widely used projective tests of the twentieth century.
Clinicians administer the “Rorschach,” as it is commonly called, by presenting one inkblot card at a time and asking respondents what they see, what the inkblot seems to be, or what it reminds them of. In the early years, Rorschach testers paid special atten­tion to the themes and images that the inkblots brought to mind (Weiner & Greene,

72 :Ai/CHAPTER 3
2008). Testers now also pay attention to the style of the responses: Do the clients view the design as a whole or see specific details? Do they focus on the blots or on the white spaces between them?
THEMATIC APPERCEPTION TEST The Thematic Apperception Test (TAT) is a pictorial projec­tive test (Tuber et al., 2008; Morgan & Murray, 1935). People who take the TAT are commonly shown 30 black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each card.They must tell what is happen­ing in the picture, what led up to it, what the characters are feeling and thinking, and what the outcome of the situation will be.
Clinicians who use the TAT believe that people always identify with one of the characters on each card. The stories are thought to reflect the individuals’ own circum­stances, needs, and emotions. For example, a female client seems to be revealing her own feelings in this story about the TAT picture shown in Figure 3-2, one of the few TAT pictures permitted for display in textbooks:
This is a woman
who
has
been quite troubled by
memories of a mother she was resentful
toward. She has feelings of sorrow for the way she treated her mother, her
memories of her mother plague her. These feelings seem to be increasing as
she grows older and sees her children treating her the same way that she treated her mother.
(Aiken, 1985, p. 372)

SENTENCE
–
COMPLETION TEST The sentence-completion test, first developed in the 1920s
(Payne, 1928), asks people to complete a series of unfinished sentences, such as “I wish
” or “My father ….”The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore.
DRAWINGS On the assumption that a drawing tells us something about its creator, cli­nicians often ask clients to draw human figures and talk about them. Evaluations of these drawings are based on the details and shape of the drawing, solidity of the pencil line, location of the drawing on the paper, size of the figures, features of the figures, use of background, and comments made by the respondent during the drawing task. In the Draw
–
a
–
Person
(DAP) Test, the most popular of the drawing tests, individuals are first told to draw “a person” and then are instructed to draw another person of the opposite sex.

Clinical Assessment, Diagnosis, and Treatment
:11 73

WHAT ARE THE MERITS OF PROJECTIVE TESTS? Until the 1950s, projective tests were the most common technique for assessing personality. In recent years, however, clinicians and re­searchers have relied on them largely to gain “supplementary” insights (Huprich, 2006). One reason for this shift is that practitioners who follow the newer models have less use for the tests than psychodynamic clinicians do. Even more importantly, the tests have not consistently shown much reliability or validity (Wood et al., 2002).
In reliability studies, different clinicians have tended to score the same person’s pro­jective test quite differently. Similarly, in validity studies, when clinicians try to describe a client’s personality and feelings on the basis of responses to projective tests, their con­clusions often fail to match the self-report of the client, the view of the psychotherapist, or the picture gathered from an extensive case history (Bornstein, 2007).
Another validity problem is that projective tests are sometimes biased against minor­ity ethnic groups (Costantino, Dana, & Malgady, 2007) (see Table 3-1). For example, people are supposed to identify with the characters in the TAT when they make up stories about them, yet no members of minority groups are in the TAT pictures. In re­sponse to this problem, some clinicians have developed other TAT-like tests with African American or Hispanic figures (Costantino et al., 2007).
table:

Multicultural Hot Spots in Assessment and Diagnosis

Cultural Hot Spot

m
immigrant Client

Homeland culture may differ from current country’s dominant culture
May have left homeland to escape war or oppression May have weak support systems in this country
Lifestyle (wealth and occupation) in this country may fall below lifestyle in homeland
May refuse or be unable to learn dominant language
Effect on Assessment or Diagnosis

® Dominant-Culture Assessor

May misread culture-bound reactions as pathology
May overlook client’s vulnerability to posttraumatic stress May overlook client’s heightened vulnerability to stressors May overlook client’s sense of loss and frustration
May misunderstand client’s assessment responses, or may overlook or misdiagnose client’s symptoms

m
Ethnic-Minority Client
0 Dominant-Culture Assessor

May reject or distrust members of dominant culture, including May experience little rapport with client, or may misinterpret
assessor client’s distrust as pathology
May be uncomfortable with dominant culture’s values (e.g., assertiveness, confrontation) and so find it difficult to apply clinician’s recommendations
May view client as unmotivated
j May manifest stress in culture-bound ways (e.g., somatic May misinterpret symptom patterns
symptoms such as stomachaches)
May hold cultural beliefs that seem strange to dominant culture May misinterpret cultural responses as pathology
(e.g., belief in communication with dead) (e.g., a delusion)
May be uncomfortable during assessment May overlook and feed into client’s discomfort
m
Dominant-Culture Assessor
0
Ethnic-Minority Client

May be unknowledgeable or biased about ethnic minority Cultural differences may be pathologized, or symptoms may
j culture be overlooked
!
j May nonverbally convey own discomfort to ethnic minority client May become tense and anxious

Sources: Dana, 2005, 2000; Westermeyer, 2004, 2001, 1993; Loper & Guarnaccia, 2005, 2000; Kirmayer, 2003, 2002, 2001; Sue & Sue, 2003;Tsai et al., 2001; Thakker & Ward, 1998.

74 :IICHAPTER 3

S

“I’ll say a normal word, then you say the first
sick thing that pops into your head.”

Personality Inventories An alternative way to collect information about individu­als is to ask them to assess themselves. The personality inventory asks respondents a wide range of questions about their behavior, beliefs, and feelings. In the typical person­ality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person’s personal­ity and psychological functioning.
By far the most widely used personality inventory is the Minnesota Multiphasic Person­
ality Inventory (MMPI) (Weiner & Greene, 2008). Two adult versions are available—the original test, published in 1945, and the MMPI-2, a 1989 revision which was itself revised in 2001.A special version of the test for adolescents, the NIMPI-A, is also used widely.
The MMPI consists of more than 500 self-statements, to be labeled “true,” “false,” or “cannot say.” The statements cover issues ranging from physical concerns to mood, sexual behaviors, and social activities. Altogether the statements make up 10 clinical scales, on each of which an individual can score from 0 to 120. When people score above 70 on a scale, their functioning on that scale is considered deviant.When the 10 scale scores are considered side by side, a pattern called a profile takes shape, indicating the person’s general personality.The 10 scales on the MMPI measure the following:
Hypochondriasis Items showing abnormal concern with bodily functions (“I have chest pains several times a week.”)

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Depression Items showing extreme pessimism and hopelessness (“I often feel hopeless about the future.”)
Hysteria Items suggesting that the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities (“My heart frequently pounds so hard I can feel it.”)
Psychopathic deviate Items showing a repeated and gross disregard for social customs and an emotional shallowness (“My activities and interests are often criticized by others.”)
Masculinity-femininity Items that are thought to separate male and female respondents (“I like to arrange flowers.”)
Paranoia Items that show abnormal suspiciousness and delusions of grandeur or per­secution (“There are evil people trying to influence my mind.”)
Psychasthenia Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness (“I save nearly everything I buy, even after I have no use for it.”)

Clinical Assessment, Diagnosis, and Treatment :1,/ 75

*personality inventoryoA test
designed to measure broad personality characteristics, consisting of statements about behaviors, beliefs, and feelings that people evaluate as either character­istic or uncharacteristic of them.
*response inventorieseTests designed to measure a person’s responses in one specific area of functioning,such as affect, social skills, or cognitive
processes.
­
Schizophrenia Items that show bizarre or unusual thoughts or behavior (“Things around me do not seem real.”)
Hypomania Items that show emotional excitement, overactivity, and flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent reason.”)
Social introversion Items that show shyness, little interest in people, and insecurity (“I am easily embarrassed.”)
The MMPI-2, the newer version of the MMPI, contains 567 items—many identical to those in the original, some rewritten to reflect current language (“upset stomach,” for instance, replaces “acid stomach”), and others that are new. Before being adopted, the MMPI-2 was tested on a more diverse group of people than was the original MMPI. Thus scores on the revised test are thought to be more accurate indicators of personality and abnormal functioning (Cox et al., 2009).
The MMPI and other personality inventories have several advantages over projec­tive tests (Wood et al., 2002). Because they are paper-and-pencil (or computerized) tests, they do not take much time to administer, and they are objectively scored. Most of them are standardized, so one person’s scores can be compared to those of many others. Moreover, they often display greater test-retest reliability than projective tests. For example, people who take the MMPI a second time after a period of less than two weeks receive approximately the same scores (Graham, 2006).
Personality inventories also appear to have greater validity; or accuracy, than projec­tive tests (Weiner & Greene, 2008; Lanyon, 2007). However, they can hardly be con­sidered highly valid.When clinicians have used these tests alone, they have not regularly been able to judge a respondent’s personality accurately (Braxton et al., 2007). One problem is that the personality traits that the tests seek to measure cannot be examined directly. How can we fully know a person’s character, emotions, and needs from self-reports alone?
Another problem is that despite the use of more diverse standardization groups by the MMPI-2 designers, this and other personality tests continue to have certain cultural limitations. Responses that indicate a psychological disorder in one culture may be normal responses in another (Butcher et al., 2007; Dana, 2005, 2000). In Puerto Rico, for example, where it is common to practice spiritualism, it would be normal to answer “true” to the MMPI item “Evil spirits possess me at times.” In other populations, that response could indicate psychopathology (Rogler, Malgady, & Rodriguez, 1989).
Despite such limits in validity, personality inventories continue to be popular (Weiner & Greene, 2008). Research indicates that they can help clinicians learn about people’s personal styles and disorders as long as they are used in combination with in­terviews or other assessment tools.
Response inventories Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning. For example, one such test may measure affect (emotion), another social skills, and still another cognitive processes. Clinicians can use them to de­termine the role such factors play in a person’s disorder.
Affective inventories measure the severity of such emotions as anxiety, depression, and anger (Osin.an et al., 2008). In one of the most widely used affective inventories, the Beck Depression Inventory, shown in Table 3-2 on the next page, people rate their level of sadness and its effect on their functioning. Social skills inventories, used particularly by behavioral and family-social clinicians, ask respondents to indicate how they would react in a variety of social situations (Wright & Truax, 2008). Cognitive inventories reveal a person’s typical thoughts and assumptions and can uncover counterproductive patterns of thinking (Glass & Merluzzi, 2000).They are, not surprisingly, often used by cognitive therapists and researchers.
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Both the number of response inventories and the number of clinicians who use them have increased steadily in the past 25 years (Black, 2005).At the same time, how­ever, these inventories have major limitations.With the notable exceptions of the Beck

76 :A/CHAPTER 3
Sample Items from the Beck Depression Inventory
Items
Inventory

Suicidal ideas 0 I don’t have any thoughts of killing myself.

1 I have thoughts of killing myself but I would not carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
Work inhibition 0 I can work about as well as before.
1 It takes extra effort to get started at doing something.
2 l have to push myself very hard to do anything.
3 can’t do any work at all.
Loss of libido 0 I have not noticed any recent change
1 1 am less interested in sex than I used
2 1 am much less interested in sex now.
3 I have lost interest in sex completely.

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Depression Inventory and a few others, only some of them have been subjected to care­ful standardization, reliability, and validity procedures (Weis & Smenner, 2007). Often they are created as a need arises, without being tested for accuracy and consistency.
Psychophysiological Tests Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychological problems (Vershuere et al., 2006). This practice began three decades ago after several studies sug­gested that states of anxiety are regularly accompanied by physiological changes, par­ticularly increases in heart rate, body temperature, blood pressure, skin reactions (galvanic
skin response), and muscle contraction.The measuring of physiological changes has since played a key role in the assessment of certain psychological disorders.
One psychophysiological test is the polygraph, popularly known as a lie detector (Verschuere et al., 2006). Electrodes attached to various parts of a person’s body detect changes in breathing, perspiration, and heart rate while the individual answers ques­tions. The clinician observes these functions while the person answers “yes” to control questions—questions whose answers are known to be yes, such as “Are your parents both alive?” Then the clinician observes the same physiological functions while the person answers test questions, such as “Did you commit this robbery?” If breathing, perspiration, and heart rate suddenly increase, the person is suspected of lying.
Like other kinds of clinical tests, psychophysiological tests have their drawbacks. Many require expensive equipment that must be carefully tuned and maintained. In ad­dition, psychophysiological measurements can be inaccurate and unreliable. The labora­tory equipment itself—elaborate and sometimes frightening—may arouse a participant’s nervous system and thus change his or her physical responses. Physiological responses may also change when they are measured repeatedly in a single session. Galvanic skin responses, for example, often decrease during repeated testing.
Neurological and Neuropsychological Tests Some problems in personality or behavior are caused primarily by damage to the brain or changes in brain activity. If a psychological dysfunction is to be treated effectively, it is important to know whether its primary cause is a physical abnormality in the brain.

Clinical Assessment,,piegnasis, and Treatment
77

ffi
•

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

,n movies, criminals being grilled
by the police reveal their guilt by sweating, shaking, cursing, or twitching. When they are hooked up to a polygraph (a lie detector), the needles bounce all over the paper. This image has been with us since World War I, when some clinicians developed the theory that people who are telling lies display systemic changes in their breathing, perspiration, and heart rate (Marston, 1917).
The danger of relying on polygraph tests is that, according to researchers, they do not work as well as we would like (Iacono, 2008; Vrir, 2004). The public did not pay much attention to this incon­venient fact until the mid-1980s, when the American Psychological Association of‑
ficially reported that polygraphs were often inaccurate and the United States Congress voted to restrict their use in criminal prose­cution and employment screening (Krapohl, 2002). Research indicates that 8 out of 100 truths, on average, are called lies in polygraph testing (Raskin & Hants, 2002; MacLaren, 2001). Imagine, then, how many innocent people might be convicted
­‑­of crimes if polygraph findings were taken as valid evidence in criminal trials.
Given such Findings, polygraphs are less trusted and less popular today than they once were. For example, few courts now admit results from such tests as evi­dence of criminal guilt (Daniels, 2002). Polygraph testing has by no means dis‑
­‑appeared, however. The FBI uses it exten­sively; parole boards and probation offices routinely use it to help decide whether to release convicted offenders; and in public-sector hiring (such as for police officers), the use of polygraph screening may actually be on the increase (Kokish et al., 2005).
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A number of techniques may help pinpoint brain abnormalities. Some procedures, such as brain surgery, biopsy, and X ray, have been used for many years. More recently, scientists have developed a number of neurological tests, designed to measure brain structure and activity directly. One neurological test is the electroencephalogram (EEG), which records brain waves, the electrical activity taking place within the brain as a result of neurons firing. In this procedure, electrodes placed on the scalp send brain-wave impulses to a machine that records them.
apsychophysiological testeA test that measures physical responses (such as heart rate and muscle tension) as possi­ble indicators of psychological problems.
*neurological test®A test that directly measures brain structure or activity.
oneuroimaging techniques. Neuro­logical tests that provide images of brain structure or activity, such as CT scans, PET scans, and MRIs. Also called brain
scans.

­
­
Other neurological tests actually take “pictures” of brain structure or brain activity. These tests, called neuroimaging, or brain scanning, techniques, include computer­
ized axial tomography (CAT scan or CT scan), in which X rays of the brain’s structure are taken at different angles and combined; positron emission tomography (PET scan), a computer-produced motion picture of chemical activity throughout the brain; and magnetic resonance imaging (MR1), a procedure that uses the magnetic property of certain atoms in the brain to create a detailed picture of the brain’s structure.
A more recent version of the MRI, functional magnetic resonance imaging UMRI), converts MRI pictures of brain structures into detailed pictures of neuron activity, thus offering a picture of the functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer than PET scan images, the fMRI has generated enormous enthusiasm among brain researchers since it was first developed in 1990.
Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more

78 //CHAPTER 3

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revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks and interpret abnormal performances as an indicator of underlying brain problems (Axelrod & Wall, 2007). Brain damage is especially likely to affect visual perception, memory, and visual-motor coordination, so neuropsychological tests focus particularly on these areas. The famous Bender Visual-Motor Gestalt Test, for example, consists of nine cards, each displaying a simple geometrical design. Patients look at the designs one at a time and copy each one on a piece of paper. Later they try to redraw the designs from memory. Notable errors in accuracy after age 12 are thought to reflect organic brain impairment. Clinicians often use a battery, or series, of neuro­psychological tests, each targeting a specific skill area (Reitan & Wolfson, 2005, 1996).

Clinical Assessment, Diagnosis, and Treatment :// 79

0neuropsychological testeA test that detects brain impairment by measuring a person’s cognitive, perceptual, and motor performances.
°intelligence testoA test designed to measure a person’s intellectual ability.
°intelligence quotient (IQ)°An overall score derived from intelligence tests.
Inteiligence Tests An early definition of intelligence described it as “the capacity to judge well, to reason well, and to comprehend well” (Binet & Simon, 1916, p. 192). Because intelligence is an inferred quality rather than a specific physical process, it can be measured only indirectly. In 1905 French psychologist Alfred Binet and his associate Theodore Simon produced an intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills.The general score derived from this and later intelligence tests is termed an intelligence quotient, or IQ.There are now more than 100 intelligence tests available. As you will see in Chapter 14, intelligence tests play a key role in the diagnosis of mental retardation, but they can also help clinicians identify other problems.

HOME SEND

Tests, eBay, and the Public Good

BY MICHELLE ROBERTS, ASSOCIATED PRESS, DECEMBER 18, 2007

ntelligence tests . . . are for sale on eBay Inc.’s online auction site, and the test maker is worried they will be misused.
The series of Wechsler intelligence tests, made by San Antonio-based Harcourt Assessment, Inc., are supposed to be sold to and administered by only clinical psychologists and trained professionals.
Given more than a million times a year nationwide, accord­ing to Harcourt, the intelligence tests often are among numerous tests ordered by prosecutors and defense attorneys to determine the mental competence of criminal defendants. A low 10, for ex­ample, can be used to argue leniency in sentencing.
Schools use the tests to determine whether to place a student in a special program, whether for gifted or struggling students. Harcourt officials say they fear the tests for sale on eBay will be misused for coaching by lawyers or parents.
But eBay has denied their request to restrict the sale of the tests. EBay officials say there is nothing illegal about selling the tests, and it cannot monitor every possible misuse of items sold through its network of 248 million buyers and sellers. Company spokesman Hani Durzy said eBay does prohibit the sale of items that are illegal in some states, even if they’re legal in others. And it prohibits the sale of some legal items, like teacher editions of textbooks, as matter of public good. With regard to the Harcourt tests, he said, however, “at this point, this is our response.”
Five of the tests were listed for sale … for about $175 to $900. The latest edition of the adult test, which retails for $939, was offered on eBay for $249.99.
“In order for it to maintain its integrity, there needs to be limited availability” said Harcourt spokesman Russell Schweiss…. “Misinterpreting the results [of questions and tasks on the tests], even without malicious intent, could lead to mistakes in assess­ing a child’s intelligence,” said Aurelio Prifitera, the president of Harcourt’s clinical division. .
Schweiss said Harcourt was still considering how to respond to eBay’s refusal. It has taken out a full-page ad in The National Psychologist magazine, asking clinicians and test publishers to contact eBay to express their concern, he said.
Jack King, communications director for the National Associa­tion of Criminal Defense Lawyers, said it would be very difficult to fake the results of an IQ test because cognitive and psycho­logical tests are usually given as part of a battery of tests, and in most cases, there is a profile of scores that would be considered normal for certain disabilities or disorders. “Just flunking the test is not likely to be determinative of anything, and a person can always be tested again and again,” he said. In any event, “it would be unethical to suggest to the client that they try to fudge a psychological test.”
Copyright 0 2007. Reprinted by permission.

80 ://CHAPTER 3

(At,n
PERE LIES
l’FREDERIC JONES
Intelligence tests are among the most carefully produced of all clinical tests (Kellerman & Burry, 2007;Williams et al., 2007). Because they have been standardized on large groups of people, clinicians have a good idea how each individual’s score compares with the performance of the population at large. These tests have also shown very high reliability: People who repeat the same IQ test years later receive approximately the same score. Finally, the major IQ tests appear to have fairly high validity: children’s IQ scores often correlate with their performance in school, for example.
Nevertheless, intelligence tests have some key shortcomings. Factors that have nothing to do with intelligence, such as low motivation or high anxiety, can greatly influence test performance (Gregory, 2004). In addition, IQ tests may contain cultural biases in their language or tasks that place people of one background at an advantage over those of another (Ford, 2008; Edwards & Oakland, 2006). Similarly, members of some minority groups may have little experience with this kind of test, or they may be uncomfortable with test examiners of a majority ethnic background. Either way, their performances may suffer.

Clinical Observations
In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe clients in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self
–
monitoring, clients are instructed to observe themselves.
Naturalistic and Analog Observations Naturalistic clinical observations usu­ally take place in homes, schools, institutions such as hospitals and prisons, or community settings. Most of them focus on parent-child, sibling-child, or teacher-child interactions and on fearful, aggressive, or disruptive behavior (Murdock et al., 2005). Often such observations are made by participant observers, key persons in the client’s environment, and reported to the clinician.
When naturalistic observations are not practical, clinicians may resort to analog observations, often aided by special equipment such as a videotape recorder or one-way mirror (Haynes, 2001).Analog observations often have focused on children interacting with their parents, married couples attempt­ing to settle a disagreement, speech-anxious people giving a speech, and fearful people approaching an object they find frightening.
Although much can be learned from actually witnessing behavior, clin­ical observations have certain disadvantages (Connor-Greene, 2007; Pine, 2005). For one thing, they are not always reliable. It is possible for various clinicians who observe the same person to focus on different aspects of behavior, assess the person differently, and arrive at different conclusions. Careful training of observers and the use of observer checklists can help reduce this problem.
Similarly, observers may make errors that affect the validity, or accuracy, of their observations (Aiken & Groth-Marnat, 2006). The observer may suffer from overload and be unable to see or record all of the important be­haviors and events. Or the observer may experience observer dryi, a steady decline in accuracy as a result of fatigue or of a gradual unintentional change in the standards used when an observation continues for a long period of time. Another possible problem is observer bias
—
the observer’s judgments may be influenced by information and expectations he or she already has about the person (Markin & Kivlighan, 2007).
A client’s reactivity may also limit the validity of clinical observations; that is, his or her behavior may be affected by the very presence of the

Clinical Assessment,.Piogpasis, and Treatment :1/ 81

observer (Kamphaus & Frick, 2002). If schoolchildren are aware that someone special is watching them, for example, they may change their usual classroom behavior, perhaps in the hope of creating a good impression.
Finally, clinical observations may lack cross
–
situational validity. A child who behaves aggressively in school is not necessarily aggressive at home or with friends after school. Because behavior is often specific to particular situations, observations in one setting cannot always be applied to other settings (Kagan, 2007).
Self-Monitoring As you saw earlier, personality and response inventories are tests in which persons report their own behaviors, feelings, or cognitions. In a related assessment procedure, self
–
monitoring, people observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time (Wright & Truax, 2008). How frequently, for instance, does a drug user have an urge for drugs or a head­ache sufferer have a headache? Self-monitoring is especially useful in assessing behavior that occurs so infrequently that it is unlikely to be seen during other kinds of observa­tions. It is also useful for behaviors that occur so frequently that any other method of observing them in detail would be impossible—for example, smoking, drinking, or other drug use (Tucker et al., 2007). Finally, self-monitoring may be the only way to observe and measure private thoughts or perceptions.
Like all other clinical assessment procedures, however, self-monitoring has drawbacks (Wright & Truax, 2008). Here too validity is often a problem. People do not always man­age or try to record their observations accurately. Furthermore, when people monitor themselves, they may change their behaviors unintentionally (Otten, 2004). Smokers, for example, often smoke fewer cigarettes than usual when they are monitoring themselves, and teachers give more positive and fewer negative comments to their students.

Clinical Assessment
Clinical practitioners are interested primarily in gathering individual information about their clients. They seek an understanding of the specific nature and origins of a client’s problems through clinical assessment.
Most clinical assessment methods fall into three general categories: clinical interviews, tests, and observations. A clinical interview may be either unstructured or structured. Types of clinical tests include projective, personality, response, psycho-physiological, neurological, neuropsychological, and intelligence tests. Types of ob­servation include naturalistic observation, analog observation, and self-monitoring. To be useful, assessment tools must be standardized, reliable, and valid. Each of the methods in current use falls short on at least some of these characteristics.
­

RI
:,1,1Diagnosis: Does the Client’s Syndrome
Match a Known Disorder?

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Clinicians use the information from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client’s disturbance, a construction sometimes known as a clinical picture (Kellerman & Burry, 2007). Clini­cal pictures also may be influenced to a degree by the clinician’s theoretical orientation (Garb, 2006). The psychologist who worked with Angela Savanti held a cognitive-behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Angela’s expectations, assumptions, and interpretations:

82 ://CHAPTER 3

odiagnosis0A determination that a person’s problems reflect a particular disorder.
•syndrorne0A cluster of symptoms that usually occur together.
ociossification systemeA list of disorders, along with descriptions of symptoms and guidelines for making appropriate diagnoses.
Angela was rarely reinforced for any of her accomplishments at school, but she gained her mother’s negative attention for what Mrs. Savanti judged to be poor performance at school or at home. Mrs. Savanti repeatedly told her daughter that she was incompetent, and any mishaps that happened to her were her own fault. . . . When Mr. Savanti de­
serted the family, Angela’s first response was that somehow she was responsible. From
her mother’s past behavior, Angela had learned to expect that in some way she would be
blamed. At the time that Angela broke up with her boyfriend, she did not blame Jerry for his behavior, but interpreted this event as a failing solely on her part. As a result, her level of self-esteem was lowered still more.
The type of marital relationship that Angela saw her mother and father model re­
mained her concept of what married life is like. She generalized from her observations of her parents’ discordant interactions to an expectation of the type of behavior that she
and Jerry would ultimately engage in… .
Angela’s uncertainties intensified when she was deprived of the major source of grati­
fication she hod, her relationship with Jerry. Despite the fact that she was overwhelmed
with doubts about whether to marry him or not, she had gained a great deal of pleasure through being with Jerry. Whatever feelings she had been able to express, she had shared
with him and no one else. Angela labeled ferry’s termination of their relationship as proof that she was not worthy of another person’s interest. She viewed her present unhappiness
as likely to continue, and she attributed it to some failing on her part. As a result, she be­came quite depressed.
(Leon, 1984, pp. 123-125)

With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis—that is, a determination that a person’s psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client’s pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person’s problem and the treatments that are likely to be helpful.
Classification Systems

The principle behind diagnosis is straightforward. When certain symptoms occur to­gether regularly—a cluster of symptoms is called a syndrome—and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder. If people display this particular pattern of symptoms, diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system.
In 1883 Emil Kraepelin developed the first modern classification system for abnor­mal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic
and Statistical Manual of Mental Disorders (DSV1), the classification system currently written by the American Psychiatric Association (APA, 2000). The DSM is the most widely used classification system in the United States. Most other countries use a system called the International Classification of Diseases (ICD), developed by the World Health Organization. The DSM has been changed significantly over time. The current edition, called the DSM-IV Text Revision (DSM-IV-TR), includes a combination of classifica­tion changes produced in 1994 (when it was called DSM-IV) and in 2000 (when it became DSM-IV-TR).

Clinical Assessment, Diagnosis, and Treatment :11 83

DSM-IV-TR
DSM-IV-TR lists approximately 400 mental disorders (see Figure 3-3) . Each entry describes the criteria for diagnos­ing the disorder and its key clinical features.The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by text information (that is, background information) such as research findings; age, culture, or gender trends; and each disorder’s prevalence, risk, course, complications, predispos­ing factors, and family patterns.
DSM-IV-TR requires clinicians to evaluate a client’s condition on five separate axes, or branches of information, when making a diagnosis. First, they must decide whether the person is displaying one or more of the disorders found on Axis I, an extensive list of clinical syndromes that typi‑
­­
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No disorders

18.7%
One disorder
10.4%
Two disorders
17.3%
Three or more disorders

tally cause significant impairment. Some of the most frequently diagnosed disorders listed on this axis are the anxiety disorders and mood disorders, problems you will read about later.
‘L
Anxiety disorders People with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder), anxiety centered on a specific situation or object (phobias), periods of panic (panic disorder), persistent thoughts or repetitive behaviors or both (obsessive-compulsive disorder), or lingering anxiety reactions to un­usually traumatic events (acute stress disorder and posttraumatic stress disorder).

Mood disorders People with mood disorders feel excessively sad or elated for long periods of time. These disorders include major depressive disorder and bipolar disorders (in which episodes of mania alternate with episodes of depression).
Next, diagnosticians must decide whether the person is displaying one of the dis­orders listed on Axis II, which includes long-standing problems that are frequently overlooked in the presence of the disorders on Axis I. There are only two groups of Axis II disorders, mental retardation and personality disorders. You will also read about these patterns in later chapters.
Mental retardation People with this disorder display significantly subaverage intellec­tual functioning and poor adaptive functioning by 18 years of age.
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Personality disorders People with these disorders display a very rigid maladaptive pat­tern of inner experience and outward behavior that has continued for many years. People with antisocial personality disorder; for example, persistently disregard and violate the rights of others. People with dependent personality disorder are persistently depen­dent on others, clinging, obedient, and very afraid of separation.

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Although people usually receive a diagnosis from either Axis I or Axis II, they may receive diagnoses from both axes. Angela Savanti would first receive a diagnosis of major
depressive disorder from Axis I (a mood disorder). Let’s suppose that the clinician judged that Angela also displayed a life history of dependent behavior. She might then also receive an Axis II diagnosis of dependent personality disorder:

The remaining axes of DSM-IV-TR guide diagnosticians in reporting other fac­tors. Axis III asks for information concerning relevant general medical conditions from which the person is currently suffering. Axis IV asks about special psychosocial or environmental problems the person is facing, such as school or housing problems. And Axis V requires the diagnostician to make a global assessment of functioning (GAF), that is, to rate the person’s psychological, social, and occupational functioning overall.
If Angela Savanti had diabetes, for example, the clinician might include that under Axis III information. Angela’s recent breakup with her boyfriend would be noted on

84 ://CHAPTER 3

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Axis I: Major depressive disorder
Axis II: Dependent personality disorder
Axis III: Diabetes
Axis IV: Problem related to the social environment (termination of engagement) Axis V: GAF = 55 (current)

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A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were at best moderately reliable (Spiegel, 2005; Malik & Beutler, 2002). In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, indepen­dently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement.
DSM-IV-TR appears to have greater reliability than the early DSMs (Keenan et al., 2007; Lyneham, Abbott, & Rapee, 2007). Its framers conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. They then developed a number of new diagnostic criteria and categories and ran field
trials to make sure that the new criteria and categories were in fact reliable. Nevertheless, research indicates that DSM-IV-TR does contain certain reliability problems (Black, 2005; Beutler & Malik, 2002). Many clinicians, for example, have difficulty distinguish­ing one kind of anxiety disorder from another.The disorder of a particular client may be classified as generalized anxiety disorder by one clinician, agoraphobia (fear of traveling outside of one’s home) by another, and social phobia (fear of social situations) by yet another.
The validity of a classification system is the accuracy of the information that its di­agnostic categories provide. Categories are of most use to clinicians, for example, when

Clinical Assessment, Diagnosis; and Treatment
:11 85

DeL’ Sites
s you have seen, clinicians try
to combat psychological dis­orders,either by preventive efforts or, if those fail, through assessment, diagnosis, and effective treatment. Unfortunately, today there are also other—more sinister—forces operat­ing that run counter to the work of mental health professionals. Among the most common are so-called dark
sites on the Internet—sites with the goal of promoting behaviors that the clinical community, and most of society, consider abnormal and destructive. Pro-anorexia sites and suicide
sites are two examples.
Pro-Anorexia Sites
The Eating Disorders Association reports that there are more than 500 pro-anorexia Internet sites with names such as “Dying
to Be Thin” and “Starving for Perfection” (Caton, 2007). Users of these sites ex­change tips on how they can starve them­selves and disguise their weight loss from family, friends, and doctors. The sites also offer support and feedback about starva­tion diets. One site of this kind sponsors
a contest, “The Great Ana Competition,” and awards a diploma to the girl who consumes the fewest calories in a two-week period (Caton, 2007). Another site
endorses what it calls the Pro
–
Anorexia Ten
Commandments
—
assertions such as “Being thin is more important than being healthy” and “Thou shall not eat without feeling guilty” (Barrett, 2000).
Suicide Sites
Suicide sites are another Internet phenom­enon. Suicide forums and chat rooms vary in their messages, but they pose clear risks to depressed or impressionable users. Some pro-suicide websites celebrate former users who have committed suicide; others help set up appointments for joint or partner sui­cides; and several offer specific instructions about suicide methods and locations and writing suicide notes (Becker & Schmidt, 2004).
During a two-month period in 2008, for example, 30 people committed suicide across Japan, all of them involving the use of detergent mixtures that produce a deadly hydrogen sulfide gas—a technique repeatedly described
and encouraged on Internet suicide sites (CNN, 2008). A 31-year-old man took his life in a car using
a mixture of detergent and bath salts, a 42-year-old woman killed herself in her bathroom using toilet cleaner and bath powder, and a 14-year-old girl mixed laundry detergent with cleanser to commit suicide in her apartment. Such detergent mixtures release powerful fumes that can also endanger in­nocent bystanders, so almost all of those who killed themselves in this way hung warning signs at the locations of their suicide saying “Stay Away” or “Poisonous Gas Being Emitted”—warnings apparently also suggested on the Internet suicide sites.
Many individuals worry that Internet sui­cide sites place vulnerable people at great risk, and they have called for the banning of these sites. Others argue, however, that de­spite their dangers,the sites represent basic freedoms that should not be violated—free­dom of speech, for example, and perhaps even the freedom to do oneself harm.

they demonstrate predictive validity—that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or exces­sive sleep. When clinicians give Angela Savanti a diagnosis of major depressive disorder, they expect that she may eventually develop sleep problems even if none are present now. In addition, they expect her to respond to treatments that are effective for other depressed persons.The more often such predictions are accurate, the greater a category’s predictive validity.
DSM-IV-TR’s framers tried to ensure the validity of their new version of the DSM
by again conducting extensive reviews of research and running many field studies. As a
result, its criteria and categories appear to have stronger validity than those of the earlier
versions of the DSM (Reeb, 2000).Yet, again, many of today’s clinical theorists argue that
at least some of the criteria and categories in DSM-IV-TR are based on weak research
and that others reflect gender or racial bias (Lowe et al., 2008;Vieta & Phillips, 2007).
Beyond these concerns about the reliability and validity of certain categories, a
growing number of clinical theorists believe that two fundamental problems weaken
the current edition of the DSM (Widiger, 2007). One problem is DSM-IV-TR’s basic

86 ://CHAPTER 3

assumption that clinical disorders are qualitatively different from normal behavior. Per­haps this assumption is incorrect. It may be, for example, that the feelings of dejection occasionally experienced by everyone differ from clinical depression in degree only. If certain psychological disorders actually differ from normal behavior in degree rather than kind, many of today’s criteria and categories are, at the very least, misleading.
A related criticism centers on DSM-IV-TR’s use of discrete diagnostic categories, with each category of pathology considered to be separate from all the others. Some crit­ics believe that certain of its categories reflect, in fact, variations of a single, fundamental dimension of functioning rather than separate disorders. Let’s consider the dimension of negative emotionality, for example. Perhaps this dimension should be used when describ­ing abnormal patterns. When one individual’s negative emotionality is extreme and maladaptive, it may take on an appearance of high anxiety. Alternatively, another person’s negative emotionality may take on the appearance of depression. In short, rather than distinguish two kinds of disorders—an anxiety disorder versus a depressive disorder—it may be that the classification should list each pattern as a variation of a key dimension, negative emotionality. In support of this dimensional argument, research has often found high anxiety levels among clinically depressed people and high depression levels among clinically anxious people. If the dimensional view is appropriate, DSM-IV-TR is, once again, misleading clinicians when it asks them to determine whether persons are display­ing an anxiety disorder or a mood disorder.
Given such concerns, there is little doubt that DSM-V, the next edition of DSM, will include some key changes.A DSM-V task force has been assembled and is actively con­sidering a range of issues and research findings, and indications are that classifications of the anxiety disorders and the personality disorders are particularly likely to see changes in DSM-V (Regier et al., 2009), as you will see in Chapters 4 and 13. The new clas­sification system will not, however, be completed until 2012 or later (Garber, 2008).

Can Diagnosis and Labeling Cause Harm?
Even with trustworthy assessment data and reliable and valid clas­sification categories, clinicians will sometimes arrive at a wrong conclusion (Rohrer, 2005). Like all human beings, they are flawed information processors. Studies show that they are overly influ­enced by information gathered early in the assessment process (Dawes, Faust, & Meehl, 2002; Meehl, 1996, 1960). They some­times pay too much attention to certain sources of information, such as a parent’s report about a child, and too little to others, such as the child’s point of view (McCoy, 1976). Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status, to name just a few (Vasquez, 2007). Given the limitations of assessment tools, assessors, and classifica­tion systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals (Caetano & Babor, 2007).

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Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. As you read in Chapter 2, for example, many family-social theorists believe that diagnostic labels can become self-fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be viewed and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Spagnolo, Murphy, & Librera, 2008; Corrigan, 2007). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time.
Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classification and diagnosis are critical to understanding and treating people in distress.

Clinical Assessment, Diagnosis, and Treatment
87

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Cutting Financial Ties
Diagnosis
After collecting assessment information, clinicians form a clinical picture and decide upon a diagnosis. The diagnosis is chosen from a classification system. The system used most widely in the United States is the Diagnostic and Statistical Manual of Mental Disorders iDSM). The most recent version of the DSM, known as DSM-IV-TR, lists approximately 400 disorders and includes five axes. The reliability and validity of this edition continue to be criticized by a number of clinical theorists.
Even with trustworthy assessment data and reliable and valid classification categories, clinicians will not always arrive at the correct conclusion. Moreover, the prejudices that labels arouse may be damaging to the person who is diagnosed.

Mreatment: How Might the Client Be Helped?

Over the course of 10 months,Angela Savanti was treated for depression and related symp­toms. She improved considerably during that time, as the following report describes:
Angela’s depression eased as she began to make progress in therapy. A few months before the termination of treatment, she and Jerry resumed dating. Angela discussed with Jerry
her greater comfort in expressing her feelings and her hope that Jerry would also become
more expressive with her. They discussed the reasons why Angela was ambivalent about getting married, and they began to talk again about the possibility of marriage. Jerry, how ever, was not making demands for a decision by a certain date, and Angela felt that she was not as frightened about marriage as she previously had been…
Psychotherapy provided Angela with the opportunity to learn to express her feelings to the persons she was interacting with, and this was quite helpful to her. Most important, she was able to generalize from some of the learning experiences in therapy and modify
her behavior in her renewed relationship with Jerry. Angela still had much progress to make
in terms of changing the characteristic ways she interacted with others, but she had al­ready made a number of important steps in a potentially happier direction.

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Clearly, treatment helped Angela, and by its conclusion she was a happier, more func­tional person than the woman who had first sought help 10 months earlier. But how did her therapist decide on the treatment program that proved to be so helpful?
Treatment Decisions
Angela’s therapist began, like all therapists, with assessment information and diagnostic decisions. Knowing the specific details and background of Angela’s problem (idiographic
data) and combining this individual information with broad information about the na­ture and treatment of depression, the clinician arrived at a treatment plan for her.
Yet the rapists may be influenced by additional factors when they make treatment decisions. Their treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy (Sharf, 2008).As therapists apply a favored model in case after case, they become more and more familiar with its principles and treatment techniques and tend to use them in work with still other clients.
Current research may also play a role. Most clinicians say that they value research as a guide to practice (Beutler et al., 1995). However, not all of them actually read research

88 ://CHAPTER 3

Culture-Bound Abnor di/1r
Red Bear sits up wild-eyed, his body drenched in sweat,
every muscle tensed. The horror of the dream is still with
him; he is choked with fear. Fighting waves of nausea,
he stares at his young wife lying asleep on the far side of
the wigwam, illuminated by the dying embers.

His troubles began several days before, when he come back from a hunting expedition empty-handed.
Ashamed of his failure, he fell prey to a deep, lingering
depression. . . . The signs of windigo were all there:
depression, lack of appetite, nausea, sleeplessness and,
now, the dream. Indeed, there could be no mistake.

He had dreamed of the windigo—the monster with a heart of ice—and the dream sealed his doom. Cold­
ness gripped his own heart. The ice monster had entered
his body and possessed him. He himself had become a
windigo, and he could do nothing to avert his fate.

Suddenly, the form of Red Bear’s sleeping wife
begins to change. He no longer sees a woman, but a
deer. His eyes flame. Silently, he draws his knife from under the blanket and moves stealthily toward the
motionless figure. . . A powerful desire to eat raw flesh
consumes him.

With the body of the “deer” at his feet, Red Sear raises the knife high, preparing the strike. Unexpectedly,
the deer screams and twists away. But the knife flashes
down, again and again. Too late, Red Bear’s kinsmen
rush into the wigwam. . . . Mhey drag him outside into
the cold night air and swiftly kill him.

(LINDHOLM & LINDHOLM, 1981, P. 52)
Red Bear was suffering from windigo, a disorder once common among Algonquin Indian hunters. They believed in a super­natural monster that ate human beings and had the power to bewitch them and turn them into cannibals. Red Bear was among the few afflicted hunters who actually did kill and eat members of their households.
Windigo is but one of numerous un­usual mental disorders discovered around the world, each unique to a particular culture, each apparently growing from that culture’s pressures, history, institutions, and ideas (Floskerud, 2009; Draguns, 2006).
Such disorders remind us that the classifica­tions and diagnoses applied in one culture may not always be appropriate in another.
Susto, a disorder found among mem­bers of Indian tribes in Central and South America and Hispanic natives of the Andean highlands of Peru, Bolivia, and Colombia, is most likely to occur in infants and young children. The symptoms are ex­treme anxiety, excitability, and depression, along with Foss of weight, weakness, and rapid heartbeat. The culture holds that this disorder is caused by contact with super­natural beings or with frightening strangers or by bad air from cemeteries.
People affected with amok, a disorder found in Malaysia, the Philippines, Java, and some parts of Africa, jump around violently, yell loudly, grab knives or other weapons, and attack any people and objects they encounter. Within the culture, amok is thought to be caused by stress, severe shortage of sleep, alcohol consump­tion, and extreme heat.
Koro is a pattern of anxiety found in Southeast Asia in which a man suddenly becomes intensely fearful that his penis will withdraw into his abdomen and that he will die as a result. Cultural lore holds that the disorder is caused by an imbalance
of “yin” and “yang,” two natural forces believed to be the fundamental components of life. Accepted forms of treatment include having the individual keep a firm hold on his penis until the fear passes, often with the assistance of family members or friends, and clamping the penis to a wooden box.
Latch is a disorder found in Malaysia. Certain circumstances (hearing someone say “snake” or being tickled, for example) trigger a fright reaction that is marked
by repeating the words and acts of other people, uttering obscenities, and doing the opposite of what others ask.

articles, so they cannot be directly influenced by them (Stewart & Chambless, 2007). In fact, according to surveys, therapists gather most of their information about the latest developments in the field from colleagues, professional newsletters, workshops, confer­ences, books, and the like (Carrie & Callanan, 2001). Unfortunately, the accuracy and usefulness of these sources vary widely.

Clinical Assessment, Diagnosis,
and
Treatment :1/ 89

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To help clinicians become more familiar with and apply research findings, there is an ever-growing movement in the United States, the United Kingdom, and elsewhere called empirically supported, or evidence-based, treatment (Pope & Wedding, 2008; Nathan & Gorman, 2007). Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such informa­tion to clinicians. Critics of the movement worry that such efforts have thus far been simplistic, biased, and, at times, misleading (Weinberger & Rasco, 2007; Mahrer, 2005; Westen et al., 2005). However, the empirically supported treatment movement has been gaining momentum in recent years.

The Effectiveness of Treatment
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Altogether, more than 400 forms of therapy are currently practiced in the clinical field (Corsini, 2008). Naturally, the most important question to ask about each of them is whether it does what it is supposed to do. Does a particular treatment really help people overcome their psychological problems? On the surface, the question may seem simple. In fact, it is one of the most difficult questions for clinical researchers to answer.

The first problem is how to define “success.” If, as Angela’s therapist suggests, she still has much progress to make at the conclusion of therapy, should her recovery be considered successful? The second problem is how to measure improvement (Markin & Kivlighan, 2007; Luborsky, 2004). Should researchers give equal weight to the reports of clients, friends, relatives, therapists, and teachers? Should they use rating scales, inven­tories, therapy insights, observations, or some other measure?
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Perhaps the biggest problem in determining the effectiveness of treatment is the variety and complexity of the treatments currently in use. People differ in their problems, personal styles, and motivations for therapy.Therapists differ in skill, experience, orienta­tion, and personality. And therapies differ in theory, format, and setting. Because an indi­vidual’s progress is influenced by all these factors and more, the findings of a particular study will not always apply to other clients and therapists.
Proper research procedures address some of these problems. By using control groups, random assignment, matched research participants, and the like, clinicians can draw certain conclusions about various therapies. Even in studies that are well designed, how­ever, the variety and complexity of treatment limit the conclusions that can be reached (Kazdin, 2006, 2004, 1994).
Despite these difficulties, the job of evaluating therapies must be done, and clinical researchers have plowed ahead with it. Investigators have, in fact, conducted thousands of

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*empirically supported treatment® A movement in the clinical field that seeks to identify which therapies have received clear research support for each disorder, to develop corresponding treat­ment guidelines, and to spread such information to clinicians. Also known as evidence-based treatment.

“Are we there yet?”

90 //CHAPTER 3

What Is the Difference between Treatment Efficacy. and Treatment Effectiveness?
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therapy outcome studies, studies that measure the effects of various treatments. The studies typically ask one of three questions: (1) Is therapy in general effective? (2) Are particular therapies generally effective? (3) Are particular therapies effective for particular problems?
Therapy Generally Effective? Studies suggest that therapy often is more help­ful than no treatment or than placebos. A pioneering review examined 375 controlled studies, covering a total of almost 25,000 people seen in a wide assortment of therapies (Smith, Glass, & Miller, 1980; Smith & Glass, 1977).The reviewers combined the findings of these studies by using a special statistical technique called meta
–
analysis. According to this analysis, the average person who received treatment was better off than 75 percent of the untreated persons (see Figure 3-4). Other meta-analyses have found similar relation­ships between treatment and improvement (Bickman, 2005).
Some clinicians have concerned themselves with an important related question: Can therapy be harmful? A number of studies suggest that more than 5 percent of patients actually seem to get worse because of therapy (Nolan et al., 2004; Lambert & Bergin, 1994).Their symptoms may become more intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy (Lambert et al., 1986; Hadley & Strupp, 1976).
Are Particul r Therapies Generally Effective? The studies you have read
about so far have lumped all therapies together to consider their general effectiveness. Many researchers, however, consider it wrong to treat all therapies alike. Some critics suggest that these studies are operating under a uniformity myth
—
a false belief that all therapies are equivalent despite differences in the therapists’ training, experience, theo­retical orientations, and personalities (Good & Brooks, 2005; Kiesler, 1995, 1966).
Thus, an alternative approach examines the effectiveness ofparticular therapies (Rickman, 2005). Most research of this kind shows each of the major forms of therapy to be superior to no treatment or to placebo treatment (Prochaska & Norcross, 2006). A number of other studies have compared particular therapies with one another and found that no one form of therapy generally stands out over all others (Luborsky et al., 2003, 2002, 1975).
If different kinds of therapy have similar successes, might they have something in common? A rapprochement movement has tried to identify a set of common strate­gies that may run through the work of all effective therapists, regardless of the clinicians’ particular orientation (Portnoy, 2008; Castonguay & l3eutler, 2006). Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their cli­ents are interacting, and try to promote self-mastery in their clients. In short, effective therapists of any type may practice more similarly than they preach.
Are Particul r Therapies Effective for Particul tr Problems? People with
different disorders may respond differently to the various forms of therapy (Corsini,
2008). In an oft-quoted statement, influential clinical theorist Gordon Paul said decades

Clinical Assessment, Diagnosis, and Treatment :1/ 91

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ago that the most appropriate question regarding the effectiveness of therapy may be “What specific treatment, by whom, is most effective for this individual with that specific problem, and under mthich set of circumstances?” (Paul, 1967, p. 111). Researchers have investigated how effective particular therapies are at treating particular disorders, and they often have found sizable differences among the various therapies. Behavioral therapies, for example, appear to be the most ef­fective of all in treating phobias (Wilson, 2008), whereas drug therapy is the single most effective treatment for schizophrenia (Awad & Voruganti, 2007).
As you read previously, studies also show that some clinical problems may respond better to combined approaches (de Maat et al., 2007; TADS, 2007). Drug therapy is sometimes combined with certain forms of psychotherapy, for example, to treat depression. In fact, it is now common for clients to be seen by two therapists—one of them a psychopharmacologist, a psychiatrist who primarily prescribes medications, and the other a psychologist, social worker, or other therapist who conducts psychotherapy.
Obviously, knowledge of how particular therapies fare with particular disorders can help therapists and clients alike make better decisions about treatment (Clinton et al., 2007; Beutler, 2002, 2000) (see Figure 3-5).Thus this is a question to which this book will keep returning as it examines the various disorders.

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Treatment
The treatment decisions of therapists may be influenced by assessment information, the diagnosis, the clinician’s theoretical orientation and familiarity with research, and the field’s state of knowledge.
Determining the effectiveness of treatment is difficult. Nevertheless, therapy
outcome studies have led to three general conclusions: (1) People in therapy usually are better off than people with similar problems who receive no treatment, (2) the various therapies do not appear to differ dramatically in their general effectiveness, and (3) certain therapies or combinations of therapies do appear to be more effec‑
t five than others for certain disorders.
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Renewed Respect Collides with Economic Pressure
In Chapter 2 you read that today’s leading models of abnormal behavior often differ widely in their assumptions, conclusions, and treatments. It should not surprise you, then, that clinicians also differ considerably in their approaches to assessment and diag­nosis.Yet when all is said and done, no assessment technique stands out as superior to the rest. Each of the hundreds of available tools has major limitations, and each produces at best an incomplete picture of how a person is functioning and why.
°rapprochement movement0An
effort to identify a set of common strat­egies that run t rough the work of all effective therapists.
opsychopharmacologisteA psychiatrist who primarily prescribes medications.
­In short, the present state of assessment and diagnosis argues against relying exclu­sively on any one approach. As a result, more and more clinicians now use batteries of assessment tools in their work (Iverson et al., 2007). Such batteries already are providing invaluable Guidance in the assessment of Alzheimer’s disease and certain other disorders that are particularly difficult to diagnose, as you shall see later.
Attitudes toward clinical assessment have shifted back and forth over the past several decades. Be fore the 1950s, assessment was a highly regarded part of clinical practice. As

92 ://CHAPTER 3

•
\\\ THOUrTHTS///
the number of clinical models grew during the 1960s and 1970s, however, followers of each model favored certain tools over others, and the practice of assessment became fragmented. Meanwhile, research began to reveal that a number of tools were inaccurate or inconsistent. In this atmosphere, many clinicians lost confidence in and abandoned systematic assessment and diagnosis.
Today, however, respect for assessment and diagnosis is on the rise once again. One reason for this renewal of interest is the development of more precise diagnostic criteria, as presented in DSM-IV-TR.Another is the drive by researchers for more rigorous tests to help them select appropriate participants for clinical studies. Still another factor is the clinical field’s growing awareness that certain disorders can be properly identified only after careful assessment procedures.
Along with heightened respect for assessment and diagnosis has come increased research. Indeed, today’s researchers are carefully examining every major kind of assess­ment tool—from projective tests to personality inventories.This work is helping many clinicians perform their work with more accuracy and consistency—welcome news for people with psychological problems.
Ironically, just as today’s clinicians and researchers are rediscovering systematic assess­ment, rising costs and economic factors seem to be discouraging the use of assessment tools. In particular, managed care insurance plans, which emphasize lower costs and shorter treatments, often refuse to provide coverage for extensive clinical testing or observations (Wood et al., 2002).Which of these forces will ultimately have a greater in­fluence on clinical assessment and diagnosis—promising research or economic pressure? Only time will tell.

1. How would you grade the tests you take in school? That is, how reliable and valid are they? What about the tests you see on the Web or in maga­zines? pp. 68, 71, 76
2. Just about everybody has heard of and knows about the Rorschach, even though the test has limited reli­ability and validity. How might you explain the fame and popularity of this test throughout Western society? pp. 71-72, 73
3. How might 10 scores be misused by school officials, parents, or other individuals? Why do you think our society is so preoccupied with the concept of intelligence and with IQ scores? pp. 79-80

4. Many people argue for a “people first” approach to clinical labeling. For example, they recommend using the phrase “a person with schizophre­nia” rather than “a schizophrenic.”
Why might this approach to labeling be preferable? p. 86

5. A newspaper columnist has observed, “Newspapers usually take great care not to mention the race or religion of those accused of violent crimes. But how many times have you seen the sentence, ‘He had a history of men­tal illness’?” What does this double standard suggest about the status and rights of people with psychological disorders? p. 86

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standardization, p. 68

§
reliability, p. 68

·
A validity, p. 68

§ clinical interview, p. 69
mental status exam, p. 70

test, p. 71

7,
1
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••’

EEG, CAT, PET, MR1, fMR1, p. 77 neuroimaging techniques, p. 77 neuropsychological test, p. 78
battery, p. 78

intelligence test, p. 79
intelligence quotient (10), p. 79 naturalistic obsesrvation, p. 80
analog observation, p. 80

projective test, p. 71

Rorschach test, p. 71

Thematic Apperception Test (TAT), p. 72
personality inventory, p. 74
MMPI, p. 74

response inventories, p. 75 psychophysiological
test, p. 76 neurological tests, p. 77

:eixe

ClinicalAssessmont, Diagnosis, and Treatment :// 93

self-monitoring, p. 81

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DSM-IV-TR, p. 83

empirically supported treatment, p. 89

therapy outcome study, p. 90
rapprochement movement, p. 90
psychopharmacololgist, p. 91

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2. What are the strengths and
7 weaknesses of structured and
unstructured interviews? p. 70

3. What are the strengths and weak­nesses4.:
j,. nesses of projective tests (p. 73),
; personality inventories (p. 75),
and other kinds of clinical tests
1.; (pp. 75-80)?

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List and describe today’s leading projective tests. pp. 71-72

5. What are the key features of the MMPI? pp. 74-75

6. How do clinicians determine whether psychological problems are linked to brain damage? pp. 76-78
7. Describe the ways in which clini­cians may make observations of clients’ behaviors. pp. 80-81

8. What is the purpose of clinical diagnoses? pp. 81-82

9. Describe DSM-IV-TR. What prob­lems may accompany the use of classification systems and the process of clinical diagnosis? pp. 83-86

10. According to therapy outcome studies, how effective is therapy? pp. 89-91

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Fundamentals of Abnormal Psychology
Video Tool Kit www.worthpublishers.com/apvik

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ANXIETY DISORDERS
CHAPTER

TOPIC OVERVIEW

Generalized Anxiety Disorder
The Sociocultural Perspective: Societal and Multicultural Factors
The Psychodynamic Perspective The Humanistic Perspective
The Cognitive Perspective The Biological Perspective
Phobias
Specific Phobias
Social Phobias
What Causes Phobias? How Are Phobias Treated?
Panic Disorder
The Biological Perspective
The Cognitive Perspective Obsessive-Compulsive Disorder
What Are the Features of Obsessions and Compulsions?
The Psychodynamic Perspective The Behavioral Perspective
The Cognitive Perspective The Biological Perspective
Putting It Together: Diathesis-Stress in Action

ob Donaldson was a 22-year-old carpenter
referred to the psychiatric outpatient depart­ment of
a community hospital. . . .
During the
initial interview Bob was visibly distressed. ;He appeared tense, worried, and frightened. He sat on the edge of his chair, tapping
his foot and fidgeting with a pencil on the psychiatrist’s desk. He sighed frequently, took

deep breaths between sentences, and periodically
exhaled audibly and changed his position as

he attempted to relate his story:

Bob: It’s been an awful month. I can’t seem to do anything. 1 don’t know
whether I’m coming or going. I’m afraid I’m going crazy or something. Doctor: What makes you think that?

Bob: I can’t concentrate. My boss tells me to do something and I start to do it, but before I’ve taken five steps I don’t know what I started out to do. I get dizzy and I can feel my heart beating and everything looks like it’s shim­
mering or far away from me or something—it’s unbelievable.

Doctor: What thoughts come to mind when you’re feeling like this?

Bob: I just think, “Oh, Christ, my heart is really beating, my head is swimming,
my ears are ringing—I’m either going to die or go crazy.”

Doctor: What happens then?
Bob: Well, it doesn’t last more than a few seconds, I mean that intense feeling.
I come back down to earth, but then I’m worrying what’s the matter with
me all the time, or checking my pulse to see how fast it’s going, or feeling my palms to see if they’re sweating.
Doctor: Can others see what you’re going through?

Bob: You know, I doubt it. I hide it. I haven’t been seeing my friends. You know, they say “Let’s stop for a beer” or something after work and I give them
some excuse—you know, like I have to do something around the house or with my car. I’m not with them when l’m with them anyway-1’m just
sitting there worrying. My friend Pat said I was frowning all the time. So,
anyway, I just go home and turn on the TV or pick up the sports page, but
I can’t really get into that either.
Bob went on to say that he had stopped playing softball because of fatigability and trouble concentrating. On several occasions during the post two weeks he was unable to go to work
because he was “too nervous.”

(Spitzer et al., 1983, pp. 11
–
12)

You don’t need to be as troubled as Bob Donaldson to experience fear and anxiety.
Think about a time when your breathing quickened, your muscles tensed, and your heart pounded with a sudden sense of dread. Was it when your car almost skidded off the road in the rain? When your professor announced a pop quiz? What about when the person you were in love with went out with someone else, or your boss suggested that your job performance ought to improve? Any time you face what seems to be a serious threat to your well-being, you may react with the state of immediate alarm known as fear (Garrett, 2009). Sometimes you cannot pinpoint a specific cause for your alarm, but still you feel tense and edgy,

96 ://CHAPTER 4

Two or more independent anxiety disorders (26%)
Two or more anxiety disorders, one caused by the other (55%)
•
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as if you expect something unpleasant to happen. The vague sense of being in danger is usually called anxiety, and it has the same features—the same increase in breathing, muscular tension, perspiration, and so forth—as fear.
Although everyday experiences of fear and anxiety are not pleasant, they often are useful: They prepare us for action—for “fight or flight”—when danger threatens. They may lead us to drive more cautiously in a storm, keep up with our reading assignments, treat our dates more sensitively, and work harder at our jobs. Unfortunately, some people suffer such disabling fear and anxiety that they cannot lead normal lives (Koury & Rapaport, 2007). Their discomfort is too severe or too frequent, lasts too long, or is triggered too easily. These people are said to have an anxiety disorder or a related kind of disorder.
Anxiety disorders are the most common mental disorders in the United States. In any given year around 18 percent of the adult population suffer from one or another of the six anxiety disorders identified by DSM-IV-TR, while close to 29 percent of all people develop one of the disorders at some point in their lives (Kessler et al., 2009, 2005). Only around one-fifth of these individuals seek treatment (Wang et al., 2005).
People with generalized anxiety disorder experience general and persistent feelings of worry and anxiety. People with phobias experience a persistent and irrational fear of a specific object, activity, or situation. Individuals with panic disorder have recurrent attacks of terror. Those with obsessive
–
compulsive disorder feel overrun by recurrent thoughts that cause anxiety or by the need to perform repetitive actions to reduce anxiety. And those with acute stress disorder and posttraumatic stress disorder are tormented by fear and related symptoms well after a traumatic event (for example, military combat, rape, tor­ture) has ended. Most individuals with one anxiety disorder suffer from a second one as well (see Figure 4-1). Bob Donaldson, for example, experiences the excessive worry found in generalized anxiety disorder and the repeated attacks of terror that mark panic disorder.
This chapter will look at generalized anxiety disorder, phobias, panic disorder, and obsessive-compulsive disorder. The other anxiety disorders—acute and posttraumatic stress disorders—will be examined in the next chapter, which considers the effects that particularly intense or ongoing stress have on both our psychological and physical functioning.
0Generaiized Anxiety Disorder
People with generalized anxiety disorder experience excessive anxiety under most circumstances and worry about practically anything. In fact, their problem is sometimes described asfree-floating
anxiety. Like the young carpenter Bob Donaldson, they typically feel restless, keyed up, or on edge; tire easily; have difficulty concentrating; suffer from muscle tension; and have sleep problems (see Table 4-1). The symptoms last at least six months. Nevertheless, most people with the disorder are able, although with some dif­ficulty, to carry on social relationships and job activities.
Generalized anxiety disorder is common in Western society. Surveys suggest that around 3 percent of the U.S. population have the symptoms of this disorder in any given year, a rate that holds across Canada, Britain, and other Western countries (Ritter, Blackmore, & Heimberg, 2010; Kessler et al., 2005). Altogether, close to 6 percent of all people develop generalized anxiety disorder sometime during their lives. It may emerge at any age, but usually it first appears in childhood or adolescence. Women diagnosed with the disorder outnumber men 2 to 1. Around one-quarter of individuals with gen­eralized anxiety disorder are currently in treatment (Burijon, 2007; Wang et al., 2005).
A variety of factors have been cited to explain the development of this disorder. Here you will read about the views and treatments offered by the sociocultural, psy­chodynamic, humanistic, cognitive, and biological models. The behavioral perspective will be examined when we turn to phobias later in the chapter because that model ap­proaches generalized anxiety disorder and phobias in basically the same way.

Anxiety Disorders
:// 97

The Sociocultural Perspective: Societal and Multicultural Factors
According to sociocultural theorists, generalized anxiety disorder is most likely to develop in people who are faced with ongoing societal conditions that are danger­ous. Studies have found that people in highly threatening environments are indeed more likely to develop the general feelings of tension, anxiety, and fatigue and the sleep disturbances found in this disorder (Andrews & Wilding, 2004).
Take, for example, a classic study that was done on the psychological impact of living near the Three Mile Island nuclear power plant after the nuclear reac­tor accident of March 1979 (Baum et al., 2004; Wroble & Baum, 2002). In the months following the accident, local mothers of preschool children were found to display five times as many anxiety or depression disorders as mothers living elsewhere. Although the number of disorders decreased during the next year, the Three Mile Island mothers still displayed high levels of anxiety or depression a year later. Similarly, a study conducted more recently found that in the months and years following Hurricane Katrina in 2005, the rate of generalized and other anxiety disorders was twice as high among area residents who lived through the disaster as among unaffected persons living elsewhere (Galea et al., 2007).
One of the most powerful forms of societal stress is poverty. People without financial means are likely to live in run-down communities with high crime rates, have fewer educational and job opportunities, and run a greater risk for health problems (Lopez & Guarnaccia, 2008, 2005, 2000). As sociocultural theorists would predict, such people also have a higher rate of generalized anxiety disorder. In the United States, the rate is twice as high among people with low incomes as among those with higher incomes (Kessler et al., 2005; Blazer et al., 1991). As wages de­crease, the rate of generalized anxiety disorder steadily increases (see Table 4-2).
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0anxiety0The central nervous system’s physiological and emotional response to a vague sense of threat or danger.
°generalized anxiety disorderoA
disorder marked by persistent and exces­sive feelings of anxiety and worry about numerous events and activities.
­Since race is closely tied to income and job opportunity in the United States, it is not surprising that it is sometimes also tied to the prevalence of generalized anxiety disorder (Blazer et al., 1991). In any given year approximately 6 percent of all African Americans suffer from this disorder, compared to 3.1 percent of white Americans. African American women, perhaps the country’s most socially stressed group, have the highest rate of all-6.6 percent.
Multicultural researchers have not found a heightened rate of generalized anxiety disorder among Hispanics in the United States. They have, however, noted that many Hispanics in both the United States and Latin American suffer from nervios (“nerves”), a

Eye on Culture: Anxiety Disorders

Prevalence of Anxiety Disorders (Compared to Rate in Total Population)

Low
African
Hispanic

Female
Income
American
American
Elderly
Generalized anxiety disorder
Higher
Higher
Higher
Same
Higher
Specific phobias
Higher
Higher
Higher
Higher
Lower
Social phobia
Higher
Higher
Higher
Same
Lower
Panic disorder
Higher
Higher
Same
Same
Lower
Obsessive-compulsive disorder
Same
Higher
Same
Same
Lower
Source: Hopko et al., 2008; Nazarian & Craske, 2008; Schultz e: al., 2008; Kessler et al., 2005; Lopez & Guarnaccia, 2005, 2000; Glazer et al., 2004.

98 ://CHAPTER 4

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culture-bound disorder that bears great similarity to generalized anxiety disorder (Lopez & Guarnaccia, 2005, 2000; APA, 2000). People with nervios experience enormous emo­tional distress, somatic symptoms such as headaches and stomachaches, so-called brain aches marked by poor concentration and nervousness, and symptoms of irritability, tearfulness, and trembling.
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Although poverty and various societal and cultural pressures may help create a climate in which generalized anxiety disorder is more likely to develop, sociocultural variables are not the only factors at work. After all, most people in poor or dangerous environments do not develop this disorder. Even if sociocultural factors play a broad role, theorists still must explain why some people develop the disorder and others do not. The psychodynamic, humanistic-existential, cognitive, and biological schools of thought have all tried to explain why and have offered corresponding treatments.

The Psychodynamic Perspective
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Sigmund Freud (1933, 1917) believed that all children experience some degree of anxi­ety as part of growing up and that all use ego defense mechanisms to help control such anxiety (see page 38). Children experience realistic anxiety when they face actual danger; neurotic anxiety when they are repeatedly prevented, by parents or by circumstances, from expressing their id impulses; and moral anxiety when they are punished or threatened for expressing their id impulses. According to Freud, some children experience particularly high levels of such anxiety, or their defense mechanisms are particularly inadequate, and these individuals may develop generalized anxiety disorder.

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Psychodynamic Explanations: When Childhood Anxiety Goes Unre‑

solved According to Freud, when a child is overrun by neurotic or moral anxiety, the stage is set for generalized anxiety disorder. Early developmental experiences may pro­duce an unusually high level of anxiety in such a child. Say that a boy is spanked every time he cries for milk as an infant, messes his pants as a 2-year-old, and explores his genitals as a toddler. He may eventually come to believe that his various id impulses are very dangerous, and he may experience overwhelming anxiety whenever he has such impulses.
Alternatively, a child’s ego defense mechanisms may be too weak to cope with even normal levels of anxiety. Overprotected children, shielded by their parents from all frustrations and threats, have little opportunity to develop effective defense mechanisms. When they face the pressures of adult life, their defense mechanisms may be too weak to cope with the resulting anxieties.
Today’s psychodynamic theorists often disagree with specific aspects of Freud’s ex­planation for generalized anxiety disorder. Most continue to believe, however, that the disorder can be traced to inadequacies in the early relationships between children and their parents (Sharf, 2008). Researchers have tested the psychodynamic explanations in various ways. In one strategy; they have tried to show that people with generalized anxiety disorder are particularly likely to use defense mechanisms. For example, one team of investigators examined the early therapy transcripts of patients with this diag­nosis and found that the patients often reacted defensively. When asked by therapists to discuss upsetting experiences, they would quickly forget (repress) what they had just been talking about, change the direction of the discussion, or deny having negative feelings (Luborsky, 1973).
Insecurtiy, Adult Style
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In another line of research, investigators have studied people who as children suf­fered extreme punishment for id impulses. As psychodynamic theorists would predict, these people have higher levels of anxiety later in life (Burijon, 2007; Chiu, 1971). In addition, several studies have supported the psychodynamic position that extreme pro­tectiveness by parents may often lead to high levels of anxiety in their children (Hudson & Rapee, 2004; Jenkins, 1968).
Although these studies are consistent with psychodynamic explanations, some scien­tists question whether they show what they claim to show.When people have difficulty talking about upsetting events early in therapy, for example, they are not necessarily

Anxiety Disorders :1,1 99

repressing those events. They may be focusing purposely on the positive aspects of their lives, or they may be too embarrassed to share personal negative events until they develop trust in the therapist.
Psychodyn t5 lc Ther pies Psychodynamic therapists use the same general tech­niques to treat all psychological problems:free association and the therapist’s interpretations of transference, resistance, and dreams. Freudian psychodynamic therapists use these methods to help clients with generalized anxiety disorder become less afraid of their id impulses and more successful in controlling them. Other psychodynamic therapists, particularly object
relations therapists, use them to help anxious patients identify and settle the childhood re­lationship problems that continue to produce anxiety in adulthood (Lucas, 2006).
Controlled studies have typically found psychodynamic treatments to be of only modest help to persons with generalized anxiety disorder (Goisman et al., 1999). An exception to this trend is short-term psychodynamic therapy (see Chapter 2), which has in some cases significantly reduced the levels of anxiety, worry, and social difficulty of patients with this disorder (Crits-Christoph et al., 2004).
The Humanistic Perspective
GReq.Ky

“Dear Mom and Dad: Thanks for the
happy childhood.You’ve destroyed any
chance I had of becoming a writer.”

Humanistic theorists propose that generalized anxiety disorder, like other psychologi­cal disorders, arises when people stop looking at themselves honestly and acceptingly. Repeated denials of their true thoughts, emotions, and behavior make these people extremely anxious and unable to fulfill their potential as human beings.
The humanistic view of why people develop this disorder is best illustrated by Carl Rogers’s explanation. As you saw in Chapter 2, Rogers believed that children who fail to receive unconditional positive regard from others may become overly critical of them­selves and develop harsh self-standards, what Rogers called conditions of worth. They try to meet these standards by repeatedly distorting and denying their true thoughts and experiences. Despite such efforts, however, threatening self-judgments keep breaking through and causing them intense anxiety. This onslaught of anxiety sets the stage for generalized anxiety disorder or some other form of psychological dysfunctioning.
Practitioners of Rogers’s treatment approach, client-centered therapy, try to show unconditional positive regard for their clients and to empathize with them. The therapists hope that an atmosphere of genuine acceptance and caring will help clients feel. secure enough to recognize their true needs, thoughts, and emotions.When clients eventually are honest and comfortable with themselves, their anxiety or other symptoms will subside. In the following excerpt, Rogers describes the progress made by a client with anxiety and related symptoms:
Therapy was an experiencing of herself, in all its
aspects,
in a safe relationship … the ex­
periencing of self as having a capacity for wholeness . . . a self that cared about others.
This last followed … the realization that the therapist cared, that it really mattered to
him how therapy turned out for her, that he really valued her. . . . She gradually became
aware of the fact that … there was nothing fundamentally bad, but rather, at heart she
was positive and sound.

(Rogers, 1954, pp. 261-264)

°client-centered theraprilie human­istic therapy developed by Carl Rogers in which clinicians try to help clients by being accepting, empathizing accurately, and conveying genuineness.
­In spite of such optimistic case reports, controlled studies have failed to offer strong support for this approach. Although research does suggest that client-centered therapy is usually more helpful to anxious clients than no treatment, the approach is only sometimes superior to placebo therapy (Prochaska & Norcross, 2006, 2003). In addi­tion, researchers have found, at best, only limited support for Rogers’s explanation of generalized anxiety disorder and other forms of abnormal behavior. Nor have other humanistic theories and treatment received much research support.

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Worrying about Worrying:
Items from the Metaworry
Questionnaire

I am going crazy with worry.
My worrying will escalate and cease to function.

I’m making myself ill with worry.
I’m abnormal for worrying.
My mind can’t take the worrying.
I’m losing out in life because of
worrying.
My body can’t take the worrying.
100 ://CHAPTER 4
The Cognitive Perspective
Followers of the cognitive model suggest that psychological problems are often caused by dysfunctional ways of thinking. Given that excessive worry—a cognitive symptom—is a key characteristic of generalized anxiety disorder (see Figure 4-2), it is not surprising that cognitive theorists have had much to say about the causes of and treatments for this particular disorder (Ritter et al., 2010; Holaway, Rodebaugh, & Heimberg, 2006).
Maladaptive Assumptions Initially, cognitive theorists suggested that generalized anxiety disorder is primarily caused by maladaptive assumptions, a notion that continues to be influential.Albert Ellis, for example, proposed that many people are guided by irratio­nal beliefs that lead them to act and react in inappropriate ways (Ellis, 2008, 2002, 1962). Ellis called these basic irrational assumptions, and he claimed that people with gen­eralized anxiety disorder often hold the following ones:
“It is a dire necessity for an adult human being to be loved or approved of by virtually every significant other person in his community.”
“It is awful and catastrophic when things are not the way one would very much like them to be.”
“If something is or may be dangerous or fearsome, one should be terribly con­cerned about it and should keep dwelling oil the possibility of its occurring.”
“One should be thoroughly competent, adequate, and achieving in all possible respects if one is to consider oneself worthwhile.”
(Ellis, 1962)

When people who make these assumptions are faced with a stressful event, such as an exam or a blind date, they are likely to interpret it as dangerous, to overreact, and to experience fear. As they apply the assumptions to more and more events, they may begin to develop generalized anxiety disorder (Warren, 1997).
Similarly, cognitive theorist Aaron Beck argued that people with generalized anxi­ety disorder constantly hold silent assumptions (for example, “A situation or a person is unsafe until proven to be safe” or “It is always best to assume the worst”) that imply they are in imminent danger (Beck & Weishaar, 2008; Beck & Emery, 1985). Since the time of Ellis’s and Beck’s initial proposals, researchers have repeatedly found that people with generalized anxiety disorder do indeed hold maladaptive assumptions, particularly about dangerousness (Riskind & Williams, 2005).
New Wave Cognitive Explanations In recent years, three new explanations for generalized anxiety disorder, sometimes called the new wave cognitive explanations, have emerged (Ritter et al., 2010). Each of them builds on the work of Ellis and Beck and their emphasis on danger.
The metacognitive theory, developed by the researcher Adrian Wells (2009, 2005), suggests that people with generalized anxiety disorder implicitly hold both positive and negative beliefs about worrying. On the positive side, they believe that worrying is a useful way of appraising and coping with threats in life. And so they look for and examine all possible signs of danger—that is, they worry constantly.
At the same time, Wells argues, individuals with generalized anxiety disorder also hold negative beliefs about worrying, and these negative attitudes are the ones that open the door to the disorder. Because society teaches them that worrying is a bad thing, the individuals come to believe that their repeated worrying is in fact harmful (mentally and physically) and uncontrollable. Now they further worry about the fact that they always seem to be worrying (so-called metaworries) (see Table 4-3).The net effect of all this worrying: generalized anxiety disorder.
This explanation has received considerable research support. Studies indicate, for example, that individuals who generally hold both positive and negative beliefs about worrying are particularly prone to developing generalized anxiety disorder (Khawaja &

BeasER II
Anxiety Disorders :1/ 101

Fears, Shmears: The Odds Are Usually on Our Side

loople with anxiety disorders have
‘many unreasonable fears, but millions of other people, too, worry about disaster every day. Most of the catastrophes they fear are not probable. Perhaps the ability to live by laws of probability rather than possibility is what separates the fearless from the fearful. What are the adds, then, that commonly feared events will happen? The range of probability is wide, but the odds are usually heavily in our favor.
A city resident will be a victim of a violent crime … 1 in 60
A suburbanite will be a victim of a violent crime … 1 in 1,000
A small-town resident will be a victim of a violent crime … 1 in 2,000
A child will suffer a high chair injury this year .. . 1 in 6,000
You will develop a tooth cavity .. . 1 in 6
You will contract AIDS from a blood transfusion … 1 in 100,000
You will die in a tsunami . 1 in 500,000
You will be attacked by a shark .. 1 in 4 million
You will be killed on your next automo­bile outing . . . 1 in 4 million
Condom use will eventually fail to pre­vent pregnancy . . . 1 in 10
An IUD will eventually fail to prevent pregnancy . 1 in 10
Coitus interruptus will eventually fail to prevent pregnancy … 1 in 5
You will die as a result of a collision between an asteroid and the earth . . 1 in 500,000
You will die as a result of a lightning strike . . . 1 in 84,000
(ADAPTED FROM BRI1T, 2005)
­­The IRS will audit you this year . 1 in 100
You will be murdered this year . . 1 in 12,000
You will be killed on your next bus ride .. 1 in 500 million
You will be hit by a baseball at a major league game … 1 in 300,000
You will receive a diagnosis of cancer this year . . . 1 in 8,000
A woman will develop breast cancer during her lifetime … 1 in 9
A piano player will eventually develop lower back pain . . . 1 in 3
You will drown in the tub this year .. . 1 in 685,000
Your house will have a fire this year . 1 in 200
Your carton will contain a broken egg . . 1 in 10

Chapman, 2007; Wells, 2005) and that repeated metaworrying is a powerful predictor of developing the disorder (Wells & Carter, 1999).
°basic irrational assumptionsoThe inaccurate and inappropriate beliefs held by people with various psychologi­cal problems, according to Albert Ellis.
­According to another new explanation for generalized anxiety disorder, the intoler­
ance
of uncertainty theory, certain individuals believe that any possibility of a negative event occurring, no matter how slim, means that the event is likely to occur. Given this intolerance of uncertainty, such persons are inclined to worry and are, in turn, more prone to develop generalized anxiety disorder (Dugan, Buhr, & Ladouceur, 2004).Think of when you meet someone you’re attracted to and how you then feel prior to texting or calling call him or her for the first time—or how you feel while you’re waiting for that person to contact you for the first time. The worry that you experience in such

102
.//CHAPTER 4

instances—the sense of sometimes unbearable uncertainty—is, according to this theory, how people with generalized anxiety disorder feel all the time.
According to this theory, people with generalized anxiety disorder keep worrying and worrying in efforts to find “correct” solutions for their various problems and to restore certainty to their situations. However, because they can never really be sure that a given solution is a correct one, they are always left to grapple with intolerable levels of uncertainty, triggering new rounds of wor­rying and new efforts to find correct solutions. Like the metacognitive theory of worry, considerable research supports this theory. Studies have found, for example, that people with generalized anxiety disorder display greater levels of intolerance of uncertainty than people with normal degrees of anxiety (Dugas et al., 2009, 2005, 2002).
Finally, a third new explanation for generalized anxiety disorder, the avoidance
theory, developed by researcher Thomas Borkovec, suggests that people with this disorder have greater bodily arousal (higher heart rate, perspiration, respiration) than other people and that worrying actually serves to reduce this arousal, perhaps by distracting the individuals from their unpleasant physical feelings. In short, the avoidance theory holds that people with generalized anxiety disorder worry repeatedly in order to reduce or avoid uncomfortable states of bodily arousal. When, for example, they find themselves in an uncomfortable job situation or social relationship, they implicitly choose to intellectualize (that is, worry about) losing their job or losing their friend rather than having to stew in a state of intense negative arousal.The worrying serves as a quick, though ultimately maladaptive, way of coping with unpleasant bodily states.

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Borkovec’s explanation has also been supported by numerous studies. Research reveals that people with generalized anxiety disorder experience particularly fast and intense bodily reactions, find such reactions overwhelming and unpleasant, worry more than other people upon becoming aroused, and successfully reduce their arousal whenever they worry (Mennin et al., 2005, 2004, 2002; Roemer et al., 2005; Turk et al., 2005).

p
Cognitive § Tnerapoes Two kinds of cognitive approaches are used in cases of gen‑
eralized anxiety disorder. In one, based on the pioneering work of Ellis and Beck, thera­pists help clients change the maladaptive assumptions that characterize their disorder. In the other, new-wave cognitive therapists help clients to understand the special role that worrying may play in their disorder and to change their views about and reactions to worrying.
CHANGING MALADAPTIVE ASSUMPTIONS In Ellis’s technique of rational-emotive therapy, therapists point out the irrational assumptions held by clients, suggest more appropriate assumptions, and assign homework that gives the individuals practice at challenging old assumptions and applying new ones (Ellis, 2008, 2005, 2002). Studies suggest that this approach and similar cognitive approaches bring at least modest relief to persons suffering from generalized anxiety (Ellis, 2008, 2005; Tafet et al., 2005). Ellis’s approach is illustrated in the following discussion between him and an anxious client who fears failure and disapproval at work, especially over a testing procedure that she has devel­oped for her company:
Client: I’m so distraught these days that I can hardly concentrate on anything for more
than a minute or two at a time. My mind just keeps wandering to that damn test­ing procedure I devised, and that they’ve put so much money into; and whether

°rational-emotive therapy®A cogni­tive therapy developed by Albert Ellis that helps clients identify and change the irrational assumptions and thinking that help cause their psychological disorder.
­it’s going to work well or be just a waste of all that time and money. . .

Ellis: Point one is that you must admit that you are telling yourself something to start
your worrying going, and you must begin to look, and I mean really look, for the specific nonsense with which you keep reindoctrinating yourself . . The false

Anxiety Disorders : it 103

Top-Grossing Fear Movies of the Twenty-first Century
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must have worried yourself to death.”

statement is: “If, because my testing procedure doesn’t work and I am function­
ing inefficiently on my job, my co-workers do not want me or approve of me, then I shall be a worthless person.” .. .

Client: But if I want to do what my firm also wants me to do, and I am useless to them,
aren’t 1 also useless to me?

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unhappy because you are frustrated? And need you deem yourself completely un­
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(Ellis, 1962,
pp.
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FOCUSING ON WORRYING Alternatively, some of today’s new-wave cognitive therapists specifically guide clients with generalized anxiety disorder to recognize and change their dysfunctional use of worrying (Ritter et al., 2010; Beck, 2008).They begin by educating the clients about the role of worrying in their disorder and have them observe their bodily arousal and cognitive responses across various life situations. In turn, the clients come to appreciate the triggers of their worrying, their misconceptions about worrying, and their misguided efforts to control their lives by worrying. As their insights grow, clients are expected to see the world as less threatening (and so less arousing), try out more constructive ways of dealing with arousal, and worry less about the fact that they worry so much. Research has begun to indicate that a concentrated focus on worrying is indeed a helpful addition to the traditional cognitive treatment for generalized anxiety disorder (Ritter et al., 2010; Waters & Craske, 2005).
Treating individuals with generalized anxiety disorder by helping them to recog­nize their inclination to worry is similar to another cognitive approach that has gained popularity in recent years. The approach, mindfidness
–
based cognitive therapy, was devel­oped by psychologist Steven Hayes and his colleagues as part of their broader treatment approach called acceptance and commitment therapy (Hayes et al., 2004; Hayes, 2004, 2002). Here therapists help clients to become aware of their streams of thoughts, including their worries, as they are occurring and to accept such thoughts as mere events of the mind. By accepting their thoughts rather than trying to eliminate them, the clients are expected to be less upset and affected by them. Mindfulness-based cognitive therapy has also been applied to a range of other psychological problems such as depression, post-traumatic stress disorder, personality disorders, and substance abuse, often with promising results (Blackledge et al., 2009; Hayes et al., 2004).

*family pedigree studyeA research design in which investigators determine how many and which relatives of a person with a disorder have the same disorder.
obenzodiazepineseThe most com­mon group of antianxiety drugs, which includes Valium and Xanax.
eGABAoThe neurotransmitter gamma­aminobuiyric acid, whose low activity has been linked to generalized anxiety disorder.
*sedative-hypnotic drugseDrugs that calm people at lower doses and help them to Fall asleep at higher doses.
*relaxation training0A treatment pro­cedure that teaches clients to relax at will so they can calm themselves in stressful situations.
obiofeedbackeA technique in which a client is given information about physi­ological reactions as they occur and learns to control the reactions voluntarily.
,.electrornyograph (EMG)*A device that provides Feedback about the level of muscular tension in the body.
­­­­104
://CHAPTER 4
The Biological Perspective

Biological theorists believe that generalized anxiety disorder is caused chiefly by bio­logical factors. For years this claim was supported primarily by family pedigree studies, in which researchers determine how many and which relatives of a person with a disorder have the same disorder. If biological tendencies toward generalized anxiety disorder are inherited, people who are biologically related should have similar prob­abilities of developing this disorder. Studies have in fact found that biological relatives of persons with generalized anxiety disorder are more likely than nonrelatives to have the disorder also (Wetherell et al., 2006; Hettema et al., 2005, 2003). Approximately 15 percent of the relatives of people with the disorder display it themselves—much more than the prevalence rate found in the general population. And the closer the rela­tive (an identical twin, for example), the greater the likelihood that he or she will also have the disorder (APA, 2000).
Biological Explanations: GABA inactivi In recent decades important dis­coveries by brain researchers have offered clearer evidence that generalized anxiety disorder is related to biological factors. One of the first such discoveries occurred in the 1950s, when researchers determined that benzodiazepines, the family of drugs that includes aiprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium), provide relief from anxiety. At first, no one understood why benzodiazepines reduce anxiety. Eventu­ally, however, the development of radioactive techniques enabled researchers to pinpoint the exact sites in the brain that are affected by benzodiazepines (Mohler & Okada, 1977). Apparently certain neurons have receptors that receive the benzodiazepines, just as a lock receives a key.
Investigators soon discovered that these benzodiazepine receptors ordinarily receive gamma-aminobutyric acid (GABA), a common neurotransmitter in the brain. As you read in Chapter 2, neurotransmitters are chemicals that carry messages from one neuron to another. GABA carries inhibitory messages:When GABA is received at a re­ceptor, it causes the neuron to stop firing.

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On the basis of such findings, biological researchers eventually pieced together several scenarios of how fear reactions may occur. A leading one began with the no­tion that in normal fear reactions, key neurons throughout the brain fire more rapidly, triggering the firing of still more neurons and creating a general state of excitability throughout the brain and body. Perspiration, breathing, and muscle tension increase.This state is experienced as fear or anxiety. Continuous firing of neurons eventually triggers a feedback system—that is, brain and body activities that reduce the level of excitability. Some neurons throughout the brain release the neurotransmitter GABA, which then binds to GABA receptors on certain neurons and instructs those neurons to stop firing. The state of excitability ceases, and the experience of fear or anxiety subsides (Ator, 2005; Costa, 1985, 1983).
Some researchers have concluded that a malfunction in this feedback system can cause fear or anxiety to go unchecked (Roy-Byrne, 2005). In fact, when investigators reduced GABA’s ability to bind to GABA receptors, they found that animal subjects reacted with a rise in anxiety (Costa, 1985; Mohler et al., 1981). This finding suggested that people with generalized anxiety disorder might have ongo­ing problems in their anxiety feedback system. Perhaps they have too few GABA receptors, or perhaps their GABA receptors do not readily capture the neurotransmitter.
This explanation continues to have many supporters, but it is also prob­lematic. First, according to recent biological discoveries, other neurotransmit­ters may also play important roles in anxiety and generalized anxiety disorder, either acting alone or in conjunction with GABA (Garrett, 2009; Burijon, 2007). Second, biological theorists are faced with the problem of establishing a causal relationship.The abnormal GABA responses of anxious persons may be the result, rather than the cause, of their anxiety disorders. Perhaps long-term anxiety eventually leads to poorer GABA reception, for example.

Anxiety Disorders 105

table:
Bidogica Treatments The leading biological treatment for generalized anxiety disorder is drug therapy (see Table 4-4). Other biological interventions are relaxation train­
ing and biofeedback.

Drugs That Reduce Anxiety

Generic Name
Benzodiazepines

A[prazolam Chlorazepate Chlordiazepoxide CIonazepam Diazepam Estazolam Halazepam Lorazepam Midazolam Oxazepam Prazepam Temazepam

Trade Name

Xanax
Tranxene Librium
Klonopin Valium
ProSom Paxipam Ativan
Versed
Serax
Centrax Rostoril
BuSpar
Inderal
Tenorm in

ANTIANXIETY DRUG THERAPY In the late 1950s benzodiazepines were originally marketed as sedative—hypnotic drugs—drugs that calm people in low doses and help them fall asleep in higher doses. These new antianxiety drugs seemed less addictive than previ­ous sedative-hypnotic medications, such as barbiturates, and they appeared to produce less tiredness (Meyer & Quenzer, 2005). Thus, they were quickly embraced by both doctors and patients.
Only years later did investigators come to understand the reasons for the effective­ness of benzodiazepines. As you have read, researchers eventually learned that there are specific neuron sites in the brain that receive benzodiazepines and that these same receptor sites ordinarily receive the neurotransmitter GABA. Apparently, when benzo­diazepines bind to these neuron receptor sites, particularly those receptors known as GABA-A receptors, they increase the ability of GABA to bind to them as well, and so im­prove GABA’s ability to stop neuron firing and reduce anxiety (Dawson et al., 2005).
Others

Buspirone Propranolol Atenolol
Studies indicate that benzodiazepines often provide temporary relief for people with generalized anxiety disorder (Burijon, 2007). However, clinicians have come to realize the potential dangers of these drugs. First, when the medications are stopped, many persons’ anxieties return as strong as ever. Second, we now know that people who take benzodiazepines in large doses for an extended time can become physically dependent on them. Third, the drugs can produce undesirable effects such as drowsiness, lack of coordination, memory loss, depression, and aggressive behavior. Finally, the drugs mix badly with certain other drugs or substances, such as alcohol.
In recent decades, still other kinds of drugs have become available for people with generalized anxiety disorder ( Julien, 2008). In particular, it has been discovered that a number of antidepressant medications, drugs that are usually used to lift the moods of depressed persons, are also helpful to many people with generalized anxiety disorder. In fact, a number of today’s clinicians are more inclined to prescribe such antidepressants to treat generalized anxiety disorder than the GABA-enhancing benzodiazepines (Burijon, 2007; Liebowitz et al., 2005).
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RELAXATION TRAINING A nonchemical biological technique commonly used to treat gen­eralized anxiety disorder is relaxation training. The notion behind this approach is that physical relaxation will lead to a state of psychological relaxation. In one version, therapists teach clients to identify individual muscle groups, tense them, release the ten­sion, and ultimately relax the whole body. With continued practice, they can bring on a state of deep muscle relaxation at will, reducing their state of anxiety.

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Research indicates that relaxation training is more effective than no treatment or placebo treatment in cases of generalized anxiety disorder. The improvement it produces, however, tends to be modest (Leahy, 2004), and other techniques that are known to relax people, such as meditation, often seem to be equally effective (Bourne et al., 2004). Relaxation training is of greatest help to people with generalized anxiety disorder when it is combined with cognitive therapy or with biofeedback (Lang, 2004).
BIOFEEDBACK In biofeedback, therapists use electrical signals from the body to train people to control physiological processes such as heart rate or muscle tension. Clients are connected to a monitor that gives them continuous information about their bodily activities. By attending to the signals from the monitor, they may gradually learn to control even seemingly involuntary physiological processes.
The most widely applied method of biofeedback for the treat­ment of anxiety uses a device called an electromyograph (EMG), which provides feedback about the level of muscular tension in the

106 :1/cHAPTER 4

body. Electrodes are attached to the client’s muscles—usually the forehead muscles—where they detect the minute electri­cal activity that accompanies muscle tension (see Figure 4-3). The device then converts electric potentials coming from the muscles into an image, such as lines on a screen, or into a tone whose pitch changes along with changes in muscle tension. Thus clients “see” or “hear” when their muscles are becoming more or less tense. Through repeated trial and error, the individuals become skilled at voluntarily reducing muscle tension and, theoretically, at reducing tension and anxiety in everyday stressful situations.
next
Research finds that, in most cases, EMG biofeedback, like relaxation training, has only a modest effect on a per­son’s anxiety level (Brambrink, 2004).As you will see in the chapter, biofeedback has had its greatest impact when it plays adjunct roles in the treatment of certain medical problems, including headaches and back pain (Astin, 2004; Engel et al., 2004).
Generalized An:,.ie:y Disorder
People with generalized anxiety disorder experience excessive anxiety and worry about a wide range of events and activities. Most explanations and treatments for this disorder have received only limited research support, although recent cognitive and biological approaches are promising.
According to the sociocultural view, societal dangers, economic stress, or re­lated racial and cultural pressures create a threatening climate in which cases of generalized anxiety disorder are more likely to develop.
In the original psychodynamic explanation, Freud said that this disorder may develop when anxiety is excessive and defense mechanisms break down. Psycho-dynamic therapists use free association, interpretation, and related psychodynamic techniques to help people overcome this problem.
Carl Rogers, the leading humanistic theorist, believed that people with general­ized anxiety disorder fail to receive unconditional positive regard from significant others during their childhood and so become overly critical of themselves. He treated such individuals with client-centered therapy.
Cognitive theorists believe that generalized anxiety disorder is caused by mal­adaptive assumptions that lead people to view most life situations as dangerous. Many cognitive theorists also propose that implicit beliefs about the power and value of worrying further contribute to this disorder. Cognitive therapists help clients change such thinking and find more effective ways of coping during stressful situations.
Biological theorists hold that generalized anxiety disorder results from low ac­tivity of the neurotransmitter GABA. Common biological treatments are antianxiely drugs, particularly benzodiazepines, and certain antidepressant drugs. Relaxation training and biofeedback are also applied in many cases.
-rPhobias

ophobia•A persistent and unreasonable fear of a particular object, activity, or situation.
°specific phobia°A severe and persis­tent fear of a specific object or situation (other than agoraphobia and social phobia).
­A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear of a particular object, activity; or situation. People with a phobia become fearful if they even think about the object or situation they dread, but they usually remain comfortable as long as they avoid it or thoughts about it.
We all have our areas of special fear, and it is normal for some things to upset us more than other things. How do such common fears differ from phobias? DSM-IV-TR

Anxiety Disorders
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indicates that a phobia is more intense and persistent and the desire to avoid the object or situation is greater (APA, 2000). People with phobias often feel so much distress that their fears may interfere dramatically with their lives.
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Most phobias technically fall under the category of specific phobias, DSM-IV-TR’s label for an intense and persistent fear of a specific object or situation. In addition, there are two broader kinds of phobias: social phobia, a fear of social or performance situations in which embarrassment may occur, and agoraphobia, a fear of venturing into public places, especially when one is alone. Because agoraphobia is usually, perhaps always, experienced in conjunction with panic attacks, unpredictable attacks of terror, we shall examine that phobia later within our discussion of panic disorders.
Specific Phobias

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A specific phobia is a persistent fear of a specific object or situation (see Table 4-5). When sufferers are exposed to the object or situation, they typically experience im­mediate fear. Common specific phobias are intense fears of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood. Here Andrew talks about his phobic fear of flying:

We got on board, and then there was the take-off There it was again, that horrible feel­
ing as we gathered speed. It was creeping over me again, that old feeling of panic. I kept seeing everyone as puppets, all strapped to their seats with no control over their destinies, me included. Every time the plane did a variation of speed or route, my heart would leap and I would hurriedly ask what was happening. When the plane started to lose height, I
was terrified that we were about to crash.

(Melville, 1978, p. 59)

Each year close to 9 percent of all people in the United States have the symptoms of a specific phobia (Kessler et al., 2009, 2005). More than 12 percent of individuals develop such phobias at some point during their lives, and many people have more than one at a time. Women with the disorder outnumber men by at least 2 to 1. For reasons that are not clear, the prevalence of specific phobias also differs among racial and ethnic minority groups. In some studies, African Americans and Hispanic Americans report having at least 50 percent more specific phobias than do white Americans, even when economic factors, education, and age are held steady across the groups (Hopko et al., 2008; Breslau et al., 2006). It is worth noting, however, that these heightened rates are at work only among African and Hispanic Americans who were born in the United States, not those who emigrated to the United States at some point during their lives (Hopko et al., 2008).

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The impact of a specific phobia on a person’s life depends on what arouses the fear (Scher et al., 2006). People whose phobias center on dogs, insects, or water will keep encountering the objects they dread. Their efforts to avoid them must be elaborate and may greatly restrict their activities. Urban residents with snake phobias have a much easier time. The vast majority of people with a specific phobia do not seek treatment. They try instead to avoid the objects they fear (Roth & Fonagy, 2005).
Social Phobias

Many people worry about interacting with others or about talking or performing in front of others. A number of entertainers, from singer Barbra Streisand to actor Sir Laurence Olivier, have described major bouts of anxiety before performing. Social fears of this kind are unpleasant and inconvenient, but usually the people who have them manage to function adequately, some at a very high level.

108 //CHAPTER 4

People with a social phobia, by contrast, have severe, per­sistent, and irrational fears of social or performance situations in which embarrassment may occur (see Table 4-6). A social phobia may be narrow, such as a fear of talking in public or writing in front of others, or it may be broad, such as a general fear of functioning poorly in front of others. In both forms, people repeatedly judge themselves as performing less adequately than they actually do.
A social phobia can interfere greatly with one’s life (Koury & Rapaport, 2007).A person who is unable to interact with others or speak in public may fail to perform important responsibilities. One who cannot eat in public may reject dinner invitations and other social opportunities. Since most people with this phobia keep their fears secret, their social reluctance is often misinterpreted as snob­bery, lack of interest, or hostility.
Surveys indicate that 7.1 percent of people in the United States and other Western countries—around three women for every two men—experience a social phobia in any given year (see Table 4-7). Around 12 percent develop this problem at some point in their lives (Ruscio et al., 2008). It often begins in late childhood or adolescence and may continue into adulthood (APA, 2000).

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In several studies African and Asian American participants have scored higher than white Americans on surveys of social anxiety (Schultz et al., 2008, 2006; Okazaki et al., 2002,APA, 2000). In addition, a culture-bound disorder called taf in kyofusho seems to be particularly common in Asian countries such as Japan and Korea. Although this disorder is traditionally defined as a fear of making other people feel uncomfortable, a number of clinicians now suspect that its sufferers primarily fear being evaluated negatively by other people, a key feature of social phobias.
What Causes Phobias?

Each of the models offers explanations for phobias. Evidence tends to support the be­havioral explanations. Behaviorists believe that people with phobias first learn to fear certain objects, situations, or events through conditioning (Wolfe, 2005). Once the fears are acquired, the individuals avoid the dreaded object or situation, permitting the fears to become all the more entrenched.
Behavioral Explanations: How Are Fears Learned? Behaviorists propose classical conditioning as a common way of acquiring phobic reactions. Here, two events that occur close together in time become closely associated in a person’s mind, and, as you saw in Chapter 2, the person then reacts similarly to both of them. If one event triggers a fear response, the other may also.
In the 1920s a clinician described the case of a young woman who apparently ac­quired a phobia of running water through classical conditioning (Bagby, 1922). When she was 7 years old she went on a picnic with her mother and aunt and ran off by herself into the woods after lunch. While she was climbing over some large rocks, her feet were caught between two of them. The harder she tried to free herself, the more trapped she became. No one heard her screams, and she grew more and more terrified. In the language of behaviorists, the entrapment was eliciting a fear response.
Entrapment r Fear response
As she struggled to free her feet, the girl heard a waterfall nearby. The sound of the running water became linked in her mind to her terrifying battle with the rocks, and she developed a fear of running water as well.
Running water Fear response
Eventually the aunt found the screaming child, freed her from the rocks, and com­forted her, but the psychological damage had been done. From that day forward, the

Anxiety Disorders
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Percentage

Prevalence

Currently

Female

Typical

among

Receiving

One-Year

to Male

Age at

Close

Clinical

Prevalence

Ratio

Onset

Relatives

Treatment

3.0%
2:1
0-20 years
Elevated
25.5%
8.7%
2:1
Variable
Elevated
19.0%
7.1%
3:2
10-20 years
Elevated
24.7%
2.8%
5:2
15-35 years
Elevated
34.7%
1.0%
1:1
4-25 years
Elevated
41.3%

Source: Ruscio et al., 2007; Kessler et al., 2005, 1999, 1994; Wang et al., 2005; Regier et at., 1993.
Anxiety Disorders Profile
Social phobia

Panic disorder Obsessive-compulsive disordergirl was terrified of running water. For years family members had to hold her down to bathe her.When she traveled on a train, friends had to cover the windows so that she would not have to look at any streams. The young woman had apparently acquired a phobia through classical conditioning.In conditioning terms, the entrapment was an that under­standably elicited an (UR) of fear.The running water represented a a formerly neutral stimulus that became associated with en­trapment in the child’s mind and came also to elicit a fear reaction.The newly acquired fear was a
unconditioned stimulus (US) unconditioned response conditioned stimulus (CS), conditioned response (CR).
US: Entrapment -,- UR: Fear
CS: Running water -> CR: Fear

Another way of acquiring a fear reaction is through that is, through observation and imitation (Bandura Rosenthal, 1%6). A person may observe that others are afraid of certain objects or events and develop fears of the same things. Consider a young boy whose mother is afraid of illnesses, doctors, and hospitals. If she frequently expresses those fears, before long the boy himself may fear illnesses, doctors, and hospitals.modeling, & Why should one or a few upsetting experiences or observations develop into a long­term phobia? Shouldn’t the trapped girl see later that running water will bring her no harm? Shouldn’t the boy see later that illnesses are temporary and doctors and hospitals helpful? Behaviorists believe that after acquiring a fear response, people try to what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.avoid
severe and persistent fear of social or performance situations in which embarrassment may occur.°social phobiaoA
process of learning in which two events that repeat­edly occur close together in time become tied together in a person’s mind and so produce the same response.*classical conditioningoA
process of learning in which a person observes and then imi­tates others. Also, a therapy approach based on the same principfe,omodelingeA
phenom­enon in which responses to one stimulus are also produced by similar stimuli.•stimulus generalizationeA
­­­Behaviorists also propose that specific learned fears will blossom into a generalized anxiety disorder when a person acquires a large number of them. This development is presumed to come about through Responses to one stimu­lus are also elicited by similar stimuli. The fear of running water acquired by the girl in the rocks could have generalized to such similar stimuli as milk being poured into a glass or even the sound of bubbly music. Perhaps a person experiences a series of upsetting events, each event produces one or more feared stimuli, and the person’s reactions to each of these stimuli generalize to yet other stimuli. That person may then build up a large number of fears and eventually develop generalized anxiety disorder.stimulus generalization:

How Have Behavioral Explanations Fared in Research? Some labora‑tory studies have found that animals and humans can indeed be taught to fear objects
1 1 0
://CHAPTER 4

through classical conditioning (Miller, 1948; Mowrer, 1947, 1939). In one famous report, psychologists John B.Watson and Rosalie Rayner (1920) described how they taught a baby boy called Little Albert to fear white rats. For weeks Albert was allowed to play with a white rat and appeared to enjoy doing so. One time when Albert reached for the rat, however, the experimenter struck a steel bar with a hammer, making a very loud noise that frightened Albert. The next several times that Albert reached for the rat, the experimenter again made the loud noise. Albert acquired a fear and avoidance response to the rat.9

a

Research has also supported the behavioral position that fears can be acquired through modeling. Psychologists Albert Bandura and Theodore Rosenthal (1966), for example, had human research participants observe a person apparently being shocked by electricity whenever a buzzer sounded.The victim was actually the experimenter’s accomplice—in research ter­minology, a pretended to experience pain bycoqfederate—who
twitching and yelling whenever the buzzer went on. After the unsuspecting participants had observed several such episodes, they themselves experi­enced a fear reaction whenever they heard the buzzer.
· .tm anzeeln l~_) ans may acquire4offSpring. Altho 0bias by either modeling, resew es atom rpore likelI HIlliliF4F0.11f,Lt:_tc,Although these studies support behaviorists’ explanations of phobias, other research has called those explanations into question (Ressler & Davis, 2003). Several laboratory studies with children and adults have failed to condition fear reactions. In addition, although most case studies trace phobias to incidents of classical conditioning or mod­eling, quite a few fail to do so. So, although it appears that a phobia be acquired by classical conditioning or modeling, researchers have not established that the disorder is acquired in this way.can ordinarily A Behavioral-Evolutionary Explanation Some phobias are much more com­mon than others. Phobic reactions to animals, heights, and darkness are more common than phobic reactions to meat, grass, and houses. Theorists often account for these dif­ferences by proposing that human beings, as a species, have a predisposition to develop certain fears (Scher et al., 2006; Seligman, 1971).This idea is referred to as preparedness because human beings, theoretically, are “prepared” to acquire some phobias and not others.The following case makes the point:
the she
the door the the results were severe sev­eral Before snakes,
experience, developed, not of The treatment
A four-year-old girl was playing in park. Thinking that she saw a snake, ran to her parents’ car and jumped inside, slamming behind her. Unfortunately, the girl’s hand was caught by closing car door, of which pain and visits to the doctor. this, she may have been afraid of but not phobic. After this a phobia cars or car doors, but of snakes. snake phobia persisted into adulthood, at which time she sought from me.

(Marks, 1977, p. 192)
· preparedness0A predisposition to develop certain fears.

In a series of studies on preparedness, psychologist Arne Ohman and his colleagues conditioned different kinds of fears in human participants (Lundqvist & Ohman, 2005; Ohman et al., 1975). In one study they showed all participants slides of faces, houses, snakes, and spiders. One group received electric shocks whenever they observed the slides of faces and houses, while the other group received shocks when they looked at snakes and spiders.Were participants more prepared to fear snakes and spiders? Using skin reactions, or as a measure of fear, the experimentersgalvanic skin responses (GSRs),
Anxiety
Disorders :// 1 1 1

Night—nyctophobiaNoise or loud talking —phonophobiaOdors — osmophobia Pleasure— hedonophobia Poison —toxi phobia Poverty— peniaphobia Pregnancy— maieusiophobiaRailways—siderodromophobiaRain —ombrophobia Rivers— potamophobia Robbers— harpaxophobia Satan —SatanophobiaSexual intercourse— coitophobia,cypridophobiaShadows sciophobia Sleep— hypnophobia Snakes —ophidiophobia Snow—chionophobia Speed —tachophobia Spiders — arachnophobia Stings—cnidophobia Strangers—xenophobia Sun— Fel iophobiaSurgery—ergasiophobia Teeth —odontophobia Travel— hodophobia Trees — dendrophobia Wasps spheksophobia Water—hydrophobia Wind —anemophobiaWorms— helm inthophobia Wounds, injury—traumatophobia(VAN WAGNER, 2007; MELVILLE, 1978)
;1111,11-3 1nt(-11)Girl 0 10.1111;,iQI.1,..P ::111.)(91,1’111,.W;11′
Animals— zoophobia Beards —pogonophobia Being afraid— phobophobiaPhobias, Familiar and Not So Familiar
Blood —hematophobia Books—bibliophobia Church es —ecclesiaphobia Corpses— necrophobiaCrossing a bridge—gephyrophobia Crowd s —ochlophobiaDarkness— achluophobia, nyctophobia Demons or devils —demonophobia Dogs— cynophobiaDolls— pediophobia Drugs — pharmacophobiaEnclosed spaces—claustrophobia Eyes— ommatophobiaFeces —coprophobia Fire— pyrophobiaFlood —antlophobia Flowers —a nthophobia Flying —aerophobia Fog— horn ichlophobia Fur doraphobiaGerms —spermophobia Ghosts —phasmophobia God —theophobiaMachinery— mechanophobia Marriage—gamophobiaMeat— carnophobiaMice— musophobia Mirrors—eisoptrophobia Money —chrometrophobiaGraves —taphophobia Heat— thermophobio Heights—acrophobia Homosexuality— homophobiaHorses —hippophobia Ice, frost —cryophobia Insects —entomophobia
******************************************************************************** .11,71,•!.11,11,..••11111••…11.••••••••••••••••••••••••••••••••••,..found that both groups learned to fear the intended objects after repeated shock pairings. But then they noted an interesting difference:After a short shock-free period, the persons who had learned to fear faces and houses stopped registering high GSRs in the presence of those objects, while the persons who had learned to fear snakes and spiders continued to show high GSRs in response to them for a long while. One interpretation is that animals and insects are stronger candidates for human phobias than faces or houses.
112 :41/CHAPTER 4

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Where might such predispositions to fear come from? According to some theo­rists, the predispositions have been transmitted genetically through an evolutionary process. Among our ancestors, the ones who more readily acquired fears of animals, darkness, heights, and the like were more likely to survive long enough to reproduce and to pass on their fear inclinations to their offspring (Ohman & Mineka, 2003; Mineka Ohman, 2002).&

How Are Phobias Treated?Surveys reveal that 19 percent of individuals with specific phobias and almost 25 per­cent of those with social phobia are currently in treatment (Wang et al., 2005). Every theoretical model has its own approach to treating phobias, but behavioral techniques are more widely used than the rest, particularly for specific phobias. Research has shown such techniques to be highly effective and to fare better than other approaches in most head-to-head comparisons. Thus we shall focus primarily on the behavioral interventions.Treatments for Specific Phobias Specific phobias were among the first anxiety disorders to be treated successfully in clinical practice. The major behavioral approaches to treating them are and Together, these approaches are called exposure treatments because in all of them individuals are exposed to the ob­jects or situations they dread.desensitization,flooding, modeling. 1111.111, 1, IIII!i!11111 1Il=:li iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii
‘..1%1DIF.*;….1 1! V010..:1 1 • Arfl. 4.i i .1011/111 ,,,i1111111.1People treated by systematic desensitization, a technique developed by Joseph Wolpe (1997,1987, 1969), learn to relax while gradually facing the objects or situations they fear. Since relaxation and fear are incompatible, the new relaxation response is thought to substitute for the fear response. Desensitization therapists first offer
to clients, teaching them how to bring on a state of deep muscle relaxation at will. In addition, the therapists help clients create a a list of feared objects or situations, ordered from mildly to extremely upsetting.relaxation training fear hierarchy,
Then clients learn how to pair relaxation with the objects or situations they fear. While the client is in a state of relaxation, the therapist has the client face the event at the bottom of his or her hierarchy. This may be an actual confrontation, a process called A person who fears heights, for example, may stand on a chair or climb a stepladder. Or the confrontation may be imagined, a process called In this case, the person imagines the frightening event while the therapist describes it.The client moves through the entire list, pairing his or her relax‑in vivo desensitization. covert desensitization.

13Anxiety Disorders 1
°exposure treatments0Behavioral treatments in which persons are exposed to the objects or situations they dread.osystematic desensitizationoA behavioral treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.ofloodingeA treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.ation responses with each feared item. Because the first item is only mildly frightening, it is usually only a short while before the person is able to relax totally in its presence. Over the course of several sessions, clients move up the ladder of their fears until they reach and overcome the one that frightens them most of all.Another behavioral treatment for specific phobias is flooding. Flooding therapists believe that people will stop fearing things when they are exposed to them repeatedly and made to see that they are actually quite harmless. Clients are forced to face their feared objects or situations without relaxation training and without a gradual buildup. The flooding procedure, like desensitization, can be either in vivo or covert.When flooding therapists guide clients in imagining feared objects or situations, they often exaggerate the description so that the clients experience intense emotional arousal. In the case of a woman with a snake phobia, the therapist had her imagine the following scene, among others:•Close your eyes
its
it. it. Squeeze it feel Feel it start
it. there, feel
again. Picture the snake out in front of you, now make yourself pick it up. Reach down, pick it up, put it in your lap, feel it wiggling around in your lap, leave your hand on it put your hand out and feel it wiggling around. Kind of explore body with your fingers and hand. You don’t like to do it, make yourself do Make yourself do Really grab onto the snake. a little bit, it. kind of to wind around your hand. Let Leave your hand it touching your hand and winding around it curling around your wrist.

(Hogan, 1968, p. 423)

In it is the therapist who confronts the feared object or situation while the fearful person observes (Bandura, 2004, 1977, 1971; Bandura et al., 1977). The behavioral therapist acts as a model to dem­onstrate that the person’s fear is groundless. After several sessions many clients are able to approach the objects or situations calmly. In one ver­sion of modeling, the client is actively encouraged to join in with the therapist.modeling participant modeling, Clinical researchers have repeatedly found that each of the exposure treatments helps people with specific phobias (Farmer & Chapman, 2008; Pull, 2005).The key to success in all of these therapies appears to be contact with the feared object or situation. In vivo desensitiza­tion is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling. In addition, a growing number of therapists are using computer graphics that simulate real-world objects and situations—as a useful exposure tool (Winerman, 2005).actual virtual reality-3D Trea mer ts for Social Phobias Only in recent years have clinicians been able to treat social phobias successfully (Rosenberg, Ledley, & Heimberg, 2010; Ruscio et al., 2008).Their newfound success is due in part to the growing recognition that so­cial phobias have two distinct features that may feed upon each other: (1) People with such phobias may have overwhelming social fears, and (2) they may lack skill at starting conversations, communicating their needs, or meeting the needs of others. Armed with this insight, clinicians now treat social phobias by trying to reduce social fears, by pro­viding training in social skills, or both.HOW CAN SOCIAL FEARS BE REDUCED? Unlike specific phobias, which do not typically re­spond to psychotropic drugs, social fears are often reduced through medication (Julien, 2008). Son-Lewhat surprisingly, it is that seem to be the drugs of most help t-or this disorder, often more helpful than benzodiazepines or other kinds of antianxiety medications (Burijon, 2007).antidepressant medications

1 14 ://CHAPTER 4e rize winner in iterature
d o accept this prestigi7Dus honor’ and present her_Nobel lectu y video trans, :mission because she harsea social phobia that prevented her from oitending the ha
igestivities in Stokholrn in peeson.

At the same time, several types of psychotherapy have proved to be at least as effective as medication at reducing social fears, and people helped by such psychological treat­ments appear less likely to relapse than those treated with medications alone (Rodebaugh, Holaway, & Heitnberg, 2004). This finding suggests to some clinicians that the psycho­logical approaches should always be included in the treatment of social fears.One psychological approach is the behavioral intervention so ef­fective with specific phobias. Exposure therapists encourage clients with social fears to expose themselves to the dreaded social situations and to remain until their fears subside. Usually the exposure is gradual, and it often includes homework assignments that are carried out in the social situations. In addition, group therapy offers an ideal setting for exposure treatments by allowing people to face social situations in an atmosphere of support and caring (McEvoy, 2007). In one group, for example, a man who was afraid that his hands would tremble in the presence of other people had to write on a black­board in front of the group and serve tea to the other members (Emmelkamp, 1982).exposure therapy,
have also been widely used to treat social fears, often in combina­tion with behavioral techniques (Rosenberg et al., 2010; McEvoy, 2007). In the fol­lowing discussion, Albert Ellis uses rational-emotive therapy to help a man who fears he will be rejected if he speaks up at gatherings. The discussion took place after the man had done a homework assignment in which he was to identify his negative social expectations and force himself to say anything he had on his mind in social situations, no matter how stupid it might seem to him:Cognitive therapies

After two weeks session
“I me to do…. [Every] see it, there be sentences. are they?’ And I there were
the same
of this assignment, the patient came into his next of therapy and reported: did what you told time, just as you said, I found myself retreating from people, I said to myself ‘Now, even though you can’t must some What finally found them. And many of them! And they all seemed to say thing.”

“What thing?”

to be rejected…. related to them I was going to be re­jected. be perfectly be rejected. there to be rejected that
“That I, uh, was going [10 I And wouldn’t that awful if I was to And was no rea­son for me, uh, take that, uh, sort of thing, and in awful manner.” ..

1 15Anxiety Disorders :1,1
°social skills trainingoA therapy approach that helps people learn or improve social skills and assertiveness through role playing and rehearsing of desirable behaviors.

“And did you do the second part of the homework assignment?” “The forcing myself to speak up and express myself?”

“Yes, that part.”

“That was worse. That was really hard. Much harder than 1 thought it would be. But I did it.”

`And?”

spoke up several times; I’ve ever people were spoke ..”Oh, not bad at all. I more than done before. Some very surprised. Phyllis was very surprised, too. But I up.”

yourself like
`And how did you feel after expressing that?”

felt really something to times week I
“Remarkable! I don’t remember when I last this way. I felt, uh, just remarkable—good, that is. It was feel! But it was so hard. I almost didn’t make it. And a couple of other during the had to force myself again. Butt did. And was glad!”

(Ellis, 1962, pp. 202-203)
Studies show that rational-emotive therapy and other cognitive approaches do in­deed help reduce social fears (Rosenberg et al., 2010; Hollon et al., 2006). And these reductions typically persist for years. On the other hand, research also suggests that while cognitive therapy often reduces social fears, it does not consistently help people perform effectively in social settings.This is where social skills training has come to the forefront.

In social skills training, therapists combine several behavioral techniques in order to help people improve their social skills. They usually appropriate social behaviors for clients and encourage the individuals to try them out. The clients then with the therapists, their new behaviors until they become more effective. Throughout the process, therapists provide and (praise) the clients for effective performances.HOW CAN SOCIAL SKILLS BE IMPROVED? model role-play rehearsing frank feedback rein force

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–onfetence on Humiri Factors in

,0:-nputing Systems, 7,005; ZONFT, 2005)PhobiasA phobia is a severe, persistent, and unreasonable fear of a particular object, activity, or situation. There are three main categories of phobias: specific phobias, social phobias, and agoraphobia. Behavioral explanations of phobias, particularly specific phobias, are the most influential. Behaviorists believe that phobias are learned through classical conditioning or modeling, and then are maintained by avoidance behaviors.Specific phobias have been treated most successfully with behavioral exposure techniques. The exposure may be gradual and relaxed (desensitization), intense (flooding), or vicarious (modeling).Therapists who treat social phobias typically separate two features of this dis­order: social fears and poor social skills. They try to reduce clients’ social fears by drug, exposure, group, or cognitive therapy—or a combination of these interven­tions. They may try to improve social skills by social skills training.­­Reinforcement from other people with similar social difficulties is often more powerful than reinforcement from a therapist alone. In and
members try out and rehearse new social behaviors with other group members. The group can also provide guidance on what is socially appropriate. According to research, social skills training, both individual and group formats, has helped many people perform better in social situations (Fisher et al., 2004).social skills training groups as­sertiveness training groups,

116 ://CHAPTER 4

OPanic Disorder

Sometimes an anxiety reaction takes the form of a smothering, nightmarish panic in which people lose control of their behavior and, in fact, are practically unaware of what they are doing.Anyone can react with panic when a real threat looms up suddenly. Some people, however, experience panic attacks—periodic, short bouts of panic that occur suddenly, reach a peak within 10 minutes, and gradually pass.

The attacks feature at least four of the following symptoms of panic: palpitations of the heart, tingling in the hands or feet, shortness of breath, sweating, hot and cold flashes, trembling, chest pains, choking sensations, faintness, dizziness, and a feeling of unreality. Small wonder that during a panic attack many people fear they will die, go crazy, or lose control.

very
like It got wet seemed to felt
to collapse; it if I
were move. been token over people me—just faces,
to stop. 1 see people but
get escape the
I was inside a busy shopping precinct and all of a sudden it happened: in a matter of seconds I was a mad woman. was like a nightmare, only I was awake; everything went black and sweat poured out of me—my body, my hands and even my hair through. All the blood drain out of me; 1 went as white as a ghost. I as if I were going was as had no control over my limbs; my back and legs were very weak and I felt as though it impossible to It was as if I had by some stronger force. I saw all the looking at no bodies, all merged into one. My heart started pounding in my head and in my ears; I thought my heart was going could black and yellow lights. I could hear the voices of the from a long way off I could not think of anything except the way I was feeling and that now I had to out and run quickly or I would die. I must and get into fresh air.

(Hawkrigg, 1975)

attacksoPeriodic, short bouts of panic that occur suddenly, reach a peak within minutes, and gradually pass.•panic

panic disordereAn anxiety disorder marked by recurrent and unpredictable panic attacks.
anxiety disorder in which a person is afraid to be in places or situations from which escape might be difficult (or embarrassing) or help unavailable if panic-like symptoms were to occur.ocagoraphobiaoAn More than one-quarter of all people have one or more panic attacks at some point in their lives (Kessler et al., 2006). Some people, however, have panic attacks repeatedly and unexpectedly and without apparent reason. They may be suffering from panic disorder. In addition to the panic attacks, people who are diagnosed with panic disor­der experience dysfunctional changes in their thinking or behavior as a result of the at­tacks (see Table 4-8).They may, for example, worry persistently about having additional attacks, have concerns about what such attacks mean (“Am I losing my mind?”), or plan their lives around the possibility of future attacks.Panic disorder is often accompanied by agoraphobia, one of the three categories of phobia mentioned earlier. People with agoraphobia are afraid to leave the house and travel to public places or other locations where escape might be difficult or help unavail­able should panic symptoms develop. In severe cases, people become virtual prisoners in their own homes. Their social life dwindles, and they cannot hold a job.Until recently, clinicians failed to recognize the close link between agoraphobia and panic attacks.They now realize that panic attacks, or at least some panic-like symptoms, typically set the stage for agoraphobia: After experiencing one or more unpredictable attacks, certain individuals become fearful of having new attacks in public places where help or escape might be difficult.Not everyone with panic disorder develops agoraphobia, but many such persons do. Thus DSM-IV-TR_ distinguishes from
Around 2.8 percent of all people in the United States suffer from one or the other of these patterns in a given year; close to 5 percent develop one of the pat­terns at some point in their lives (Kessler et al., 2009, 2006, 2005). Both kinds of panic disorder tend to develop in late adolescence or early adulthood and are at least twice as common among women as among men (APA, 2000).The prevalence of panic disor­der is the same across various cultural and racial groups in the United States. Similarly,panic disorder without agoraphobia panic disorder with agoraphobia.

1 17Anxiety Disorders ://
enorepinephrineeA neurotransmitter whose abnormal activity is linked to panic disorder and depression.°locus ceruleusoA small area of the brain that seems to be active in the regu­lation of emotions. Many of its neurons use norepinephrine.oomygdolaoA small, almond-shaped structure in the brain that processes emotional information.­the disorder seems to occur in equal numbers in cultures across the world, although its specific context differs from country to country (Nazarian & Craske, 2008). Surveys indicate that around 35 percent of individuals with panic disorder in the United States are currently in treatment (Wang et al., 2005).
The Biological Perspective

In the 1960s, clinicians made the surprising discovery that panic disorder was helped more by certain drugs that are usually used to reduce the symptoms of depression, than by most of the benzodiazepine drugs, the drugs useful in treating generalized anxiety disorder (Klein, 1964; Klein & Fink, 1962).This observation led to the first biological explanations and treatments for panic disorder.antidepressant drugs, What Biological Factors Contribute to Panic Disorder? To understand thebiology of panic disorder, researchers worked backward from their understanding of the antidepressant drugs that seemed to control it.They knew that these particular antidepres­sant drugs operate in the brain primarily by changing the activity of norepinephrine, yet another one of the neurotransmitters that carry messages between neurons. Given that the drugs were so helpful in eliminating panic attacks, researchers began to suspect that panic disorder might be caused in the first place by abnormal norepinephrine activity.Several studies produced evidence that norepinephrine activity is indeed irregular in people who suffer from panic attacks. For example, the locus ceruleus is a brain area rich in neurons that use norepinephrine.When this area is electrically stimulated in monkeys, the monkeys have a panic-like reaction, suggesting that panic reactions may be related to changes in norepinephrine activity in the locus ceruleus (Redmond, 1981, 1979, 1977). Similarly, in another line of research, scientists were able to produce panic attacks in human beings by injecting them with chemicals known to affect the activity of norepinephrine (Bourin et al., 1995; Charney et al., 1990, 1987).Ventromedialnutieus of thehypothalamusThese findings strongly tied norepinephrine and the locus ceruleus to panic attacks. However, research conducted in recent years indicates that the root of panic attacks is probably more complicated than a single neurotransmitter or single brain area. Re­searchers have determined, for example, that emotional reactions of various kinds are tied to brain
of brain structures that work together, triggering each other into action and producing a particular kind of emotional reaction. It turns out that the circuit that produces panic reactions includes brain areas such as the
and (Ninan & Dunlop, 2005) (see Figure 4-4).When a person confronts a frightening ob­ject or situation, the amygdala, a small almond-shaped structure that processes emotional information, is stimulated. In turn, the amygdala stimulates the other brain areas in the circuit, temporar­ily setting into motion an “alarm-and-escape” response (increased heart rate, respiration, blood pressure, and the like) that is very similar to a panic reaction (Gray & McNaughton, 1996). Most of today’s researchers believe that this brain circuit—including the neu­rotransmitters at work throughout the circuit—probably functions improperly in people who experience panic disorder (Burijon, 2007; Bailey et al., 2003).circuits—networks ainygdala, ventromedial nucleus of the hypothalamus, central gray matter; locus ceruleus It is worth noting that the brain circuit responsible for panic reactions appears to be different from the circuit responsible for reactions (reactions that are more diffuse, ongoing, and worry-dominated than panic reactions) (see Figure 4-5 on the next page).The anxiety brain circuit, which functions improperly in people with generalized anxiety disorder, includes the
and (McClure et al., 2007).anxiety amygdala, prefrontal cortex, anterior cingulate cortex
1 20 ://CHAPTER 4

*anxiety sensitivity®A tendency to focus on one’s bodily sensations, assess them illogically, and interpret them as harmful.oobsessionoA persistent thought, idea, impulse, or image that is experienced repeatedly, feels intrusive, and causes anxiety.ocompulsion®A repetitive and rigid behavior or mental act that a person feels driven to perform in order to pre­vent or reduce anxiety.°obsessive-compulsive disorder®A disorder in which a person has recurrent and unwanted thoughts, a need to per­form repetitive and rigid actions, or both.­­Why might some people be prone to such misinterpretations? One possibility is that panic-prone individuals generally experience, through no fault of their own, more frequent or more intense bodily sensations than other people do (Nardi et al., 2001). In fact, the kinds of sensations that are most often misinterpreted in panic disorders seem to be carbon dioxide increases in the blood, shifts in blood pressure, and rises in heart rate—bodily events that are controlled in part by the locus ceruleus and other regions of the panic brain circuit.Whatever the precise causes of such misinterpretations may be, research suggests that panic-prone individuals generally have a high degree ofwhat is called anxiety sensitivity; that is, they focus on their bodily sensations much of the time, are unable to assess them logically, and interpret them as potentially harmful (Wilson Hayward, 2005). One study found that people who scored high on an anxiety sensitivity survey were five times more likely than other people to develop panic disorder (Mailer & Reiss, 1992). Other studies have found that individuals with panic disorder typically earn higher anxiety sensitivity scores than other persons do (Dattilio, 2001; McNally, 2001).Sc Cognitive Therapy Cognitive therapists try to correct people’s misinterpretations of their body sensations (McCabe & Antony, 2005). The first step is to educate clients about the general nature of panic attacks, the actual causes of bodily sensations, and the tendency of clients to misinterpret their sensations. The next step is to teach clients to apply more accurate interpretations during stressful situations, thus short-circuiting the panic sequence at an early point. Therapists may also teach clients to cope better with anxiety—for example, by applying relaxation and breathing techniques—and to distract themselves from their sensations, perhaps by striking up a conversation with someone.In addition, cognitive therapists may use biological challenge procedures to induce panic sensations, so that clients can apply their new skills under watchful supervision (Meuret et al., 2005). Individuals whose attacks typically are triggered by a rapid heart rate, for example, may be told to jump up and down for several minutes or to run up a flight of stairs.They can then practice interpreting the resulting sensations appropriately, without dwelling on them.According to research, cognitive treatments often help people with panic disorder (Marchand et al., 2009; Otto & Deveney, 2005). In a number of international studies, 85 percent of participants given these treatments have been found to be free of panic for two years or more, compared to only 13 percent of control participants. Such cognitive

0 The Hew Yaker .0It1

son I didn’t hear what you said. I was listening to my body.”

1 21Anxiety Disorders :11

_’,’L::::.,1
1 .4-i…,4-4-,i 1-,,:ilif,-…, Ijiri-, ”i,s”’,1 ll.=t-.:1,,y,-Fiti’;’,I…T..,lifir.)1711tiii’.%-f-lit°–qijif,(141c,-J-W1IITI-X1 l’)/,,L Y 1,J,•=11V•50,:i,111“:”.ra.-S1,(4e.treatments also are helpful for many persons whose panic disorders are accompanied by agoraphobia. For some individuals with the agoraphobic pattern, therapists further add exposure techniques to the cognitive treatment program—an addition that has produced p articularly high success rates.Cognitive therapy has proved to be at least as helpful as antidepressant drugs or alprazolam in the treatment of panic disorder, sometimes even more so (McCabe Antony, 2005). In view of the effectiveness of both cognitive and drug treatments, many clinicians have tried combining them (Julien, 2008; Baskin, 2007). It is not yet clear, however, whether this strategy is more effective than cognitive therapy alone.&
Panic DisorderPanic attacks are periodic, short bouts of panic that occur suddenly. Sufferers of panic disorder experience such attacks repeatedly and unexpectedly and without apparent reason. When panic disorder leads to agoraphobia, it is termed panic disorder with agoraphobia.Some biological theorists believe that abnormal norepinephrine activity in the brain’s locus ceruleus is the key to panic disorder. Others believe that related neurotransmitters and structures in the panic brain circuit also play key roles. Biological therapists use certain antidepressant drugs or powerful benzodiazepines to treat people with this disorder.Cognitive theorists suggest that panic-prone people are very sensitive to their bodily sensations and misinterpret them as signs of medical catastrophe. Such per­sons have a high degree of anxiety sensitivity and also experience greater anxiety during biological challenge tests. Cognitive therapists teach patients to interpret their physical sensations more accurately and to cope better with anxiety.
Obsessive-Corn puisive Disorder
Obsessions are persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness. Compulsions are repetitive and rigid behaviors or mental acts that people feel they must perform in order to prevent or reduce anxiety. As Figure 4-6 on the next page indicates, minor obsessions and compulsions are familiar to almost everyone.You may find yourself filled with thoughts about an upcoming performance or exam or keep wondering whether you forgot to turn off the stove or lock the door. You may feel better when you avoid stepping on cracks, turn away from black cats, or arrange your closet in a particular manner.

Minor obsessions and compulsions can play a helpful role in life. Little rituals often calm us during times of stress. A person who repeatedly hums a tune or taps his or her fingers during a test may be releasing tension and thus improving performance. Many people find it comforting to repeat religious or cultural rituals, such as touching a mezuzah, sprinkling holy water, or fingering rosary beads.According to DSM-IV-TR, a diagnosis of obsessive-compulsive disorder is called for when obsessions or compulsions feel excessive or unreasonable, cause great distress, take up much time, or interfere with daily functions (see Table 4-9).The disor­der is classified as an anxiety disorder because the obsessions cause intense anxiety, while the compulsions are aimed at preventing or reducing anxiety. In addition, anxiety rises if individuals try to resist their obsessions or compulsions.A woman with this disorder observed: “I can’t get to sleep unless I am sure everything in the house is in its proper place so that when I get up in the morning, the house is organized. I work like mad to set everything straight before I go to bed, but, when I get up in the morning, I can think of a thousand things that I ought to do…. I can’t stand to know something needs doing and I haven’t done it” (McNeil, 1967, pp. 26-28).
122 ://CHAPTER 4
– I ( I,– I ,ThEil – l 0 1 .’Jails ‘1, n i 11112 I H. I1c II a dll”irl : , ,,of r) ,I f 1,,1111, il-n 1, 1 -‘ ‘—r. 1’1’1,,i’l.r— 1 1, r, I+,Irroiji I’l Il ,,_-,1?{Ilnr, ‘, 1,111-5’ .Brush teeth up and down Change towels ‘1 daily or after every showera)
4.z
Crack knuckles
ce
Sleep on left side

Sleep on right sideSleep on stomachSleep on backPercentage of Population Who Follow Routine50%50%Between 1 and 2 percent of the people in the United States and other countries throughout the world suffer from obsessive-compulsive disorder in any given year (Bjorgvinsson & Hart, 2008; Wetherell et al., 2006). As many as 3 percent develop the disorder at some point during their lives. It is equally common in men and women and among people of different races and ethnic groups.The disorder usually begins by young adulthood and typically persists for many years, although its symptoms and their severity may fluctuate over time (Angst et al., 2004). It is estimated that more than 40 percent of people with obsessive-compulsive disorder seek treatment (Kessler et al., 1999, 1994).4 id
What Are the Features of Obsessions and Compulsions?Obsessive thoughts feel both intrusive and foreign to the people who experience them. Attempts to ignore or resist these thoughts may arouse even more anxiety, and before long they come back more strongly than ever. Like the woman quoted at the bottom of page 121, people with obsessions are quite aware that their thoughts are excessive.Obsessions often take the form of obsessive (for example, repeated wishes that one’s spouse would die), (repeated urges to yell out obscenities at work or in church), (fleeting visions of forbidden sexual scenes), (notions that germs are lurking everywhere), or (concerns that one has made or will make a wrong decision). In the following excerpt, a clinician describes a 20-year-old college junior who was plagued by obsessive doubts.wishes impulses images ideas doubts . .::;:11111.••:.•: I f;;.)’-F1:!rj.i;’ ‘; r I 1. :”.:1q.ri.!1.1carinur, ‘1995)He now the events,
teachers,
process to videotape of over

orspent hours each night “rehashing” day’s especially interactions with friends and endlessly making “right” in his mind any and all regrets. He likened the playing a each event and over again in his mind, ask­ing himself if he had behaved properly and telling himself that he had done his best,

123Anxiety Disorders :1/
0Avili41-4i,!FcrAn Obsession That Changed the World
this while sitting desk, to the
note that, to three elapsed.had said the right thing every step of the way. He would do at his supposedly studying; and it was not unusual for him look at clock after such a period of rumination and his surprise, two or hours had
(Spitzer et al., 1981, pp. 20-21)

•
4.

1.1? `: (“:”97,

•ITI ICertain basic themes run through the thoughts of most people troubled by obsessive thinking (Abramowitz, McKay, & Taylor, 2008). The most common theme appears to be dirt or contamination (Tolin & Meunier, 2008). Other common ones are violence and aggression, orderliness, religion, and sexuality. The prevalence of such themes may vary from culture to culture. Religious obsessions, for example, seem to be more com­mon in cultures or countries with strict moral codes and religious values (Bjorgvinsson & Hart, 2008).Compulsions are similar to obsessions in many ways. For example, although compul­sive behaviors are technically under voluntary control, the people who feel they must do them have little sense of choice in the matter. Most of these individuals recognize that their behavior is unreasonable, but they believe at the same time something terrible will happen if they don’t perform the compulsions. After performing a compulsive act, they usually feel less anxious for a short while. For some people the compulsive acts develop into detailed They must go through the ritual in exactly the same way every time, according to certain rules.rituals. Like obsessions, compulsions take various forms. are very common. Like the woman we heard from earlier, people with these compulsions feel compelled to keep cleaning themselves, their clothing, or their homes. The cleaning may follow ritualistic rules and be repeated dozens or hundreds of times a day. People with check the same items over and over—door locks, gas taps, important papers—to make sure that all is as it should be (Radomsky et al., 2008). Another common compulsion is the constant effort to seek or (Coles & Pietrefesa, 2008). People with this com­pulsion keep placing certain items (clothing, books, foods) in perfect order in accordance with strict rules.
and compulsions are also common.Cleaning compulsions checking compulsions order balance Touching, verbal, counting Although some people with obsessive-compulsive dis­order experience obsessions only or compulsions only, most of them experience both (Clark & Guyitt, 2008). In fact, compulsive acts are often a response to obsessive thoughts. One study found that in most cases, compulsions seemed to represent a to obsessive doubts, ideas, or urges (Akhtar et al., 1975).A woman who keeps doubting that her house is secure may yield to that obsessive doubt by repeatedly checking locks and gas jets. Or a man who obsessively fears contamination may yield to that fear by performing cleaning rituals.yielding pulsioni, In eed rituals often give ni to their practitioners. Here, Buddhist monks splash Water oyer themselve: during their annualwinter prayers at temple in Tokyo This -cleansing riival erformecl. o pro r good luck Isor cry , ir% ea in com•uisionsMany people with obsessive-compulsive disorder worry that they will act out their obsessions. A man with obsessive images of wounded loved ones may worry that he is but a step away from committing murder, or a woman with obsessive urges to yell out in church may worry that she will one day give in to them and embarrass herself. Most such concerns are unfounded. Although many obsessions lead to compulsive acts—particularly to cleaning and checking compulsions—they usually do not lead to violence or immoral conduct.
Obsessive-compulsive disorder was once among the least understood of the psy­chological disorders. In recent decades, however, researchers have begun to learn more about it. The most influential explanations and treatments conic from the psychody­namic, behavioral, cognitive, and biological models.
124 ://CHAPTER 4

The Psychodynamic Perspective
As you have seen, psychodynamic theorists believe that an anxiety disorder develops when children come to fear their own id impulses and use ego defense mechanisms to lessen the resulting anxiety. What distinguishes obsessive-compulsive disorder from other anxiety disorders, in their view, is that here the battle between anxiety-provoking id impulses and anxiety-reducing defense mechanisms is not buried in the unconscious but is played out in overt thoughts and actions. The id impulses usually take the form of obsessive thoughts, and the ego defenses appear as counterthoughts or compulsive

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Dining Out: The Obsessive-Compulsive Experience
INew York Times an this February 2008 article, Jeff Bell,

a
radio news anchor, describes the ordeal that he and other people with similar obsessive-compulsive disorders confront whenever they go to a restaurant for “pleasurable” night out.
[R]estaurants are designed to be calming and relaxing. That is one of the main reasons people like to eat out. To many of us with obsessive-compulsive disorder, those pleasures are invis­ible. We walk into a calm and civilized dining room and see things we won’t be able to control. . . .

Personally, lam fine with just about any table, although the wobbly onescan spell big trouble. I have harm obses­sions, which means I am plagued by the fear that other people will be hurt by something I do, or don’t do. Seated ata less-than-sturdy table, I conjure images of fellow diners being crushed or other­wise injured should I fail to notify the restaurant’s management. This is called a reporting compulsion in the vernacular of the disorder, and before I learned to fight these urges, many a manager heard from me.Forget the tabletop, my friend Matt S. tells me; it’s what’s on top of the table,and precisely where, that really matters. Mr. S. is a 39-year-old lawyer in Fort Worth with order compulsions. To enjoy a meal he needs to separate the salt and pepper shakers, and, ide­ally, place a napkin holder or other divider midway between them.. . .Some of our other concerns may seem familiar. I imagine most diners, for example, have noticed and perhaps even struggled to remove white detergent spots that can sometimes be seen on silverware. But few, I suspect, have gone to the lengths Jared K. has to get rid of them. Mr. is a 24-year-old research assistant living outside of Boston who has obsessive fears of con­tamination. . . . Last year he visited a Chinese restaurant with K.
several friends, one of whom pointed out that their silverware was spotted and seemed dirty. Mr. K. collected all the utensils at the table and attempted to sterilize them by holding them above a small flame at the center of a pu-pu platter, quickly attracting the attention of their waiter. .
As part of my harm obsession, one of my concerns is that germs from my mouth will hurt others. Although I try to keep my fingers away from my lips and their germs while I’m eat­ing, I’m rarely successful fit’s not as easy as it sounds]. By the 4 end of the meal I believe that my hands
are contaminated. The problem is that I need them to scribble my signature on the check. If I’m lucky, I will have re­membered to bring my own pen; if not, I may feel compelled to “table-wash” my hands, a little trick I developed over the years: I use the condensation on theoutside of a cold water glass to rinse off the germs. . . .Once the check is signed, I must be sure that it is really signed. At my worst, I have opened and closed the vinyl check holder again and again, seeing my signature each time, yet unable to feel certain. I’ve left the table, only to re­turn to check again. And again. . . .
therapy][Postscript: After exposure and response prevention Today I travel extensively, sharing my recovery story and working with groups like the Obsessive Compulsive Foundation to raise awareness. . . . I wind up eating in a lot of restaurants. I can honestly say I’m starting to enjoy it. In fact, while I still like ice water with my meal, I often find myself drinking from the glass, not washing with it.Now when I say check, please, I’m simply asking for my bill.Jeff Bell, “When Anxiety Is at the Table,” Neu,February 6, 2008. York Times, Copyright © 2008 New York Times Company. Reprinted by permission of PARS International, Inc. All rights reserved.

1 25Anxiety Disorders :11

IffiA

“Is the Its), Bits), Spider obsessive-compulsive?”

Ronald1. Corner

Princeton University

Worth Publishers
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Credits for miscellaneous text excerpts: p. 228, Dennis Yusko, “At Home, but Locked in War,” Times
Union (Albany) Online. Copyright 0 2008 by Times Union/Albany. Reproduced with permission
via Copyright Clearance Center; pp. 396-397, case study excerpt from Bernstein et a1., Personality
Disorders. Copyright 0 2007 by Sage Publications Inc. Books. Reproduced with permission via
Copyright Clearance Center; p. 411, case study excerpts from Meyer and Osborne, Case Studies in
Abnormal Behavior, 2″d edition. Copyright 2002. Reprinted with permission of Pearson Education,
Inc.; pp. 418-419, case study excerpt reprinted with permission from the DSM-IV-TR Casebook.
Copyright © 2002 American Psychiatric Association.

Library of Congress Control Number: 2009942297

ISBN-13: 978-1-4292-1633-3
ISBN-10: 1-4292-1633-6

C 2011, 2008, 2005 by Worth Publishers

All rights reserved

Printed in the United States of America

Fourth printing

Worth Publishers
41 Madison Avenue
New York, NY 100

10

www.vvorthpublishers.com

To Marlene
whose grace, generosity,

and love fill my life

ABOUT THE AUTHOR

Ronald J. Corner has been a professor in Princeton University’s Department of
Psychology for the past 35 years and has served as Director of Clinical Psychology
Studies for most of that time. His courses—Abnormal Psychology, Theories of
Psychotherapy, Childhood Psychopathology, Experimental Psychopathology, and
Controversies in Clinical Psychology—have been among the university’s most popular
offerings.

Professor Corner has received the President’s Award for Distinguished Teaching at the
university. He is also a practicing clinical psychologist and serves as a consultant to the
Eden Institute for Persons with Autism and to hospitals and family practice residency
programs throughout New Jersey.

In addition to writing Fundamentals of Abnormal Psycnology, Professor Corner is the
author of the textbook Abnormal Psychology, now in its seventh edition, co-author

of the

introductory psychology textbook Psychology Around Us, and co-author of Case Studies

in Abnormal Psychology, He is the producer of various educational videos, including The
Higher Education Video Library Series, Video Segments in Abnormal Psychology, Video Segments
in Neuroscience, Introduction to Psychology
Video Clipboard, and Developmental
Psychology Video Clipboard. He also has
published numerous journal articles in
clinical psychology, social psychology,
and family medicine.

Professor Corner completed his
undergraduate studies at the University
of Pennsylvania and his graduate
work at Clark University. He lives in
Lawrenceville, New Jersey, with his
wife, Marlene. From there he can keep
an eye on the Philadelphia sports teams
with which he grew up. After years of
frustration, he was shaken to the core
by the 2008 World Series success (and
2009 near-success) of the Philadelphia
Phillies and currently is trying his best
to adjust to the new world order.

viii :11

CONTENTS IN BRIEF

Abnormal Psychology in Science and Clinical Practice

1 Abnormal Psychology: Past and Present

2 Models of Abnormality 3

1

3 Clinical Assessment, Diagnosis, and Treatment

67

Problems of Anxiety and Mood

4 Anxiety Disorders 95

5 Stress Disorders

133

6 Somatoform and Dissociative Disorders

163

7 Mood Disorders

193

8 Suicide 2

29

Problems of the Mind and Body

9 Eating Disorders

257

10 Substance-Related Disorders 2C5

11 Sexual Disorders and Gender Identity Disorder 321

Problems of Psychosis and the Cognitive Function

12 Schizophrenia

357

Life-Span Problems

13 Personality Disorders 393

14 Disorders of Childhood and Adolescence 429

15 Disorders of Aging and Cognition 467

Conclusion

16 Law, Society, and the Mental Health Profession 491

CONTENTS

Preface

CHAPTER

Abnormal Psychology:

xvii

Past and Present 1

What Is Psychological Abnormality? 2

Deviance 2

Distress 3

Dysfunction 3

Danger 3

The Elusive Nature of Abnormality 3

What Is Treatment? 4

How Was Abnormality Viewed and
Treated in the Past? 6

Ancient Views and Treatments 7

Greek and Roman Views and Treatments 7

Europe in the Middle Ages: Demonology Returns 7

The Renaissance and the Rise of Asylums 8

The Nineteenth Century: Reform and Moral

Treatment 9

The Early Twentieth Century: The Somatogenic

and Psychogenic Perspectives 10

Current Trends 13

How Are People with Severe Disturbances

Cared For? 13

How Are People with Less Severe Disturbances

Treated? 14
A Growing Emphasis on Preventing Disorders

and Promoting Mental Health 16

Mu lticultural Psychology 17

The Growing Influence of Insurance Coverage 17

What Are Today’s Leading Theories and Professions? 18

What Do Clinical Researchers Do? 19
The Case Study 20

The Correlational Method 20

The Experimental Method 23

What Are the Limits of Clinical Investigations? 27

PUTTING IT TOGETHER A WORK IN PROGRESS 27

CRITICAL THOUGHTS

28

KEY TERMS

28

QUICK QUIZ

29

CYBERSTUDY

29

A CLOSER LOOK Marching to a
Different Drummer: Eccentrics 5

PSYCH WATCH Verbal Debuts 12

PSYCH WATCH Modern Pressures:
Modern Problems

15

PSYCH WATCH Positive Psychology:
Happiness Is All Around Us 16

THE MEDIA SPEAKS On Facebook, Scholars Link Up
with Data 23

CHAPTER

Models of Abnormality

The Biological Model

How Do Biological Theorists Explain

31
33

Abnormal Behavior? 33

Biological Treatments 35

Assessing the Biological Model 36

The Psychodynamic Model 37
How Did Freud Explain Normal and

Abnormal Functioning? 37

How Do Other Psychodynamic Explanations

Differ from Freud’s? 39
Psychodynamic Therapies 40

Assessing the Psychodynamic Model 43

The Behavioral Model 43
How Do Behaviorists Explain Abnormal

Functioning? 44

Behavioral Therapies 45

Assessing the Behavioral Model 46

The Cognitive Model 47
How Do Cognitive Theorists Explain

Abnormal Functioning? 47

Cognitive Therapies 47

Assessing the Cognitive Model 49

The Humanistic-Existential Model

50
Rogers’s Humanistic Theory and Therapy

51

Gestalt Theory and Therapy

52

Spiritual Views and Interventions

53

Existential Theories and Therapy

53

Assessing the Humanistic-Existential Model

54

The Sociocultural Model: Family-Social and
Multicultural Perspectives

How Do Family-Social Theorists Explain Abnormal

55

Functioning? 55

Family-Social Treatments 57

How Do Multicultural Theorists Explain Abnormal

Functioning? 60

Multicultural Treatments 61

Assessing the Sociocultural Model 62

PUTTING IT TOGETHER INTEGRATION OF
THE MODELS 63

CRITICAL THOUGHTS 64
KEY TERMS 64

QUICK QUIZ 65

CYBERSTUDY 65

PSYCH WATCH Maternal Instincts 42

PSYCH WATCH Surfing for Help 48

PSYCH WATCH Self- Help Groups: Too Much
of a Good Thing? 59

CHAPTER

Clinical Assessment, Diagnosis,
and Treatment

Clinical Assessment: How and Why Does the

67

Client Behave Abnormally? 67
Characteristics of Assessment Tools 68

Clinical Interviews 69
Clinical Tests 71

Clinical Observations 80

Diagnosis: Does the Client’s Syndrome Match a
Known Disorder? 81

Classification Systems 82

DSM-IV-TR 83

Is DSM-IV-TR an Effective Classification System? 84

Can Diagnosis and Labeling Cause Harm? 86

Treatment: How Might the Client Be Helped? 87
Treatment Decisions 87

The Effectiveness of Treatment 89

Contents

PUTTING IT TOGETHER RENEWED RESPECT COLLIDES WITH
ECONOMIC PRESSURE 91

CRITICAL THOUGHTS 92
KEY TERMS 92
QUICK QUIZ 93
CYBERSTUDY 93

A CLOSER LOOK The Truth, the Whole Truth, and
Nothing but the Truth 77

THE MEOLA SPEI-Vel.S Tests, eBay, and the Public Good 79

PSYCH WATCH Dark Sites 85

E.7E ON MLR! E Culture-Bound Abnormality 88

CHAPTER

a Anxiety Disorders 95
Generalized Anxiety Disorder 96

The Sociocultural Perspective: Societal and

Multicultural Factors 97

The Psychodynamic Perspective 98

The Humanistic Perspective 99

The Cognitive Perspective 100

The Biological Perspective 104

Phobias 106
Specific Phobias 107

Social Phobias 107

What Causes Phobias? 108

How Are Phobias Treated? 112

Panic Disorder 116
The Biological Perspective 117

The Cognitive Perspective 118

Obsessive-Compulsive Disorder 121
What Are the Features of Obsessions and

Compulsions? 122

The Psychodynamic Perspective 124

The Behavioral Perspective 125

The Cognitive Perspective 127

The Biological Perspective 127

PUTTING IT TOGETHER DIATHESIS-STRESS IN ACTION 129
CRITICAL THOUGHTS 130
KEY TERMS 130
QUICK QUIZ 131
CYBERSTUDY 131

A CLOSER LOOK Fears, Shmears: The Odds Are
Usually on Our Side 101

A CLOSER LOOK Phobias, Familiar and Not So Familiar 111

PSYCH WATCH Panic: Everyone Is Vulnerable

119

THE MEDIA SPEi-kKS Dining Out: The
Obsessive-Compulsive Experience

124

CHAPTER

0 Stress Disorders

133

Stress and Arousal: The Fight-or-Flight Response 134

The Psychological Stress Disorders: Acute and
Post-traurnatic Stress Disorders 136

What Triggers a Psychological Stress Disorder? 137

Why Do People Develop a Psychological

Stress Disorder? 142

How Do Clinicians Treat the Psychological

Stress Disorders? 144

The Physical Stress Disorders: Psychophysiological
Disorders

148

Traditional Psychophysiological Disorders

148

New Psychophysiological Disorders

152

Psychological Treatments for Physical Disorders

156

PUTTING IT TOGETHER EXPANDING THE BOUNDARIES OF
159 ABNORMAL PSYCHOLOGY
160 CRITICAL THOUGHTS
160 KEY TERMS
161 QUICK QUIZ
161 CYBERSTUDY

PSYCH WATCH September 11, 2001:
The Psychological Aftermath

141

THE MEDIA SPEAKS Combat Trauma Takes the Stand

145

THE MEDIA SPEAKS Empathy Goes a Long Way

159

CHAPTER

* Somatoform and Dissociative
Disorders

163

Somatoform Disorders

164
What Are Hysterical Somatoform Disorders?

164

What Are Preoccupation Somatoform

Disorders?

169

What Causes Somatoform Disorders?

170

How Are Somatoform Disorders Treated?

174

Dissociative Disorders

176

Dissociative Amnesia

177

Dissociative Fugue

180

Dissociative Identity Disorder

(Multiple Personality Disorder)

18

1

How Do Theorists Explain Dissociative

Disorders?

184

How Are Dissociative Disorders Treated?

187

PUTTING IT TOGETHER DISORDERS
REDISCOVERED

189
CRITICAL THOUGHTS

190

KEY TERMS

190
QUICK QUIZ

191

CYBERSTUDY

191

A CLOSER LOOK Munchausen Syndrome by Proxy 168

EYE OrcuLTLI PE. Beauty Is in the Eye of
the Beholder 171

A CLOSER LOOK Repressed Childhood Memories or
False Memory Syndrome? 178

THE MEDIA SPEAKS Homeward Hound: A Case
of Dog Fugue?

181

A CLOSER LOOK Peculiarities of Memory

185

CHAPTER

0 Mood Disorders

193

Unipolar Depression

194

How Common Is Unipolar Depression?

194

What Are the Symptoms of Depression?

194

Diagnosing Unipolar Depression

197

Stress and Unipolar Depression

197

The Biological Model of Unipolar Depression

198

Psychological Models of Unipolar Depression

205

The Sociocultural Model of Unipolar Depression

213

Bipolar Disorders

218

What Are the Symptoms of Mania?

219

Diagnosing Bipolar Disorders

219

What Causes Bipolar Disorders?

220

What Are the Treatments for Bipolar Disorders?

222

PUTTING IT TOGETHER MAKING SENSE OF

ALL THAT IS KNOWN

225
CRITICAL THOUGHTS

226
KEY TERMS

226
QUICK QUIZ

227

CYBERSTUDY

227

PSYCH WATCH Sadness at the Happiest of Times 196

EYE ON CLJLTLIF– – First Dibs on Antidepressant Drugs? 202

THE MEDIA SPEAKS How Well Do Colleges
Treat Depression? 207

PSYCH WATCH ABNORMALITY AND THE ARTS Abnormality
and Creativity: A Delicate Balance 223

Contents :// xiii

CHAPTER

Suicide

What Is Suicide?

How Is Suicide Studied?

Patterns and Statistics

229

231

233

234

What Triggers a Suicide?

Stressful Events and Situations

Mood and Thought Changes

Alcohol and Other Drug Use

Mental Disorders

Modeling: The Contagion of Suicide

What Are the Underlying Causes of Suicide?

The Psychodynamic View

Durkheim’s Sociocultural View

The Biological View

Is Suicide Linked to Age?

Children

Adolescents

The Elderly

Treatment and Suicide

What Treatments Are Used after Suicide

Attempts?

What Is Suicide Prevention?

Do Suicide Prevention Programs Work?

PUTTING IT TOGETHER PSYCHOLOGICAL AND BIOLOGICAL
INSIGHTS LAG BEHIND

CRITICAL THOUGHTS

KEY TERMS
QUICK QUIZ
CYBERSTUDY

Bulimia Nervosa

Binges

Compensatory Behaviors

Bulimia Nervosa versus

Anorexia Nervosa

260

262

263

264

What Causes Eating Disorders? 265
Psychodynamic Factors: Ego Deficiencies 265

Cognitive Factors 267

Mood Disorders 267

Biological Factors 267

Societal Pressures 270

Family Environment 271

Multicultural Factors: Racial and Ethnic

Differences 272

Multicultural Factors: Gender Differences 274

236
236

237

237
237

238

241
241

242

243

244
244

245

248

250

250

251

253

254
254

255
255
255

How Are Eating Disorders Treated? 275
Treatments for Anorexia Nervosa 275

Treatments for Bulimia Nervosa 279

PUTTING IT TOGETHER A STANDARD FOR INTEGRATING
PERSPECTIVES 282

CRITICAL THOUGHTS 282
KEY TERMS 282
QUICK QUIZ 283

CYBERSTUDY 283

PSYCH WATCH ABNORMALITY AND THE ARTS We’ve
Only Just Begun 259

A CLOSER LOOK Obesity: To Lose or Not to Lose 268

CLILTOME: Eating Disorders acro

ss

the World 273

PSYCH WATCH And She Lived Happily Ever After? 279

PSYCH WATCH ABNORMALITY AND THE ARTS Suicide in
the Family

PSYCH WATCH ABNORMALITY AND THE ARTS Can Music
Inspire Suicide?

A CLOSER LOOK The Black Box Controversy:
Do Antidepressants Cause Suicide?

PSYCH WATCH The Right to Commit Suicide

233

239

246

249

CHAPTER

0 Eating Disorders

Anorexia Nervosa

The Clinical Picture

Medical Problems

CHAPTER

0 Substance-Related Disorders 285

Depressants 287

Alcohol 287

Sedative-Hypnotic Drugs 292

Opioids 293

Stimulants 295
Cocaine 295

Amphetamines 298

Hallucinogens, Cannabis, and Combinations
of Substances 299

Hallucinogens 299

Cannabis 301

Combinations of Substances 304

257

258
258

260

xiv :1/Contents

What Causes Substance-Related Disorders? 305
Sociocultural Views 305

Psychodynamic Views 306

Cognitive-Behavioral Views 306

Biological Views 307

How Are Substance -Related Disorders Treated? 310
Psychodynamic Therapies 310

Behavioral Therapies 310

Cognitive-Behavioral Therapies 312

Biological Treatments 312

Sociocultural Therapies 314

PUTTING IT TOGETHER NEW WRINKLES TO
A FAMILIAR STORY 317

CRITICAL THOUGHTS 318
KEY TERMS 318

QUICK QUIZ 318

CYBERSTUDY 319

PSYCH WATCH College Binge Drinking:
An Extracurricular Crisis 290

A CLOSER LOOK Tobacco, Nicotine, and Addiction 297

PSYCH WATCH Club Drugs: X Marks the {Wrong) Spot 300

THE MEDIA SPEAKS In Real Time, Amy Winehouse’s
Deeper Descent 313

CHAPTER

Sexual Disorders and Gender
Identity Disorder 321

Sexual Dysfunctions 322
Disorders of Desire 322

Disorders of Excitement 325

Disorders of Orgasm 328

Disorders of Sexual Pain 332

Treatments for Sexual Dysfunctions 333
What Are the General Features of Sex Therapy? 334

What Techniques Are Applied to Particular

Dysfunctions? 336

What Are the Current Trends in Sex Therapy? 338

Paraphilias 339
Fetishism 340

Transvestic Fetishism 341

Exhibitionism 342

Voyeurism 342

Frotteurism 343

Pedophilia 343

Sexual Masochism 345

Sexual Sadism 346

A Word of Caution 347

Gender Identity Disorder 348
Explanations of Gender Identity Disorder 349

Treatments for Gender Identity Disorder 349

PUTTING IT TOGETHER A PRIVATE TOPIC DRAWS
PUBLIC ATTENTION 353

CRITICAL THOUGHTS 354
KEY TERMS 354
QUICK QUIZ 354
CYBERSTUDY 355

PSYCH WATCH Lifetime Patterns of Sexual Behavior 324

PSYCH WATCH Serving the Public Good 344

`Y`? ON CLILTJJE
.

Homosexuality and Society 347

THE MEDIA SPEAKS Battling a Culture of Shame 351

CHAPTER

* Schizophrenia 357

The Clinical Picture of Schizophrenia 358
What Are the Symptoms of Schizophrenia? 360

What Is the Course of Schizophrenia? 363

Diagnosing Schizophrenia 363

How Do Theorists Explain Schizophrenia? 364
Biological Views 364

Psychological Views 370

Sociocultural Views 371

How Are Schizophrenia and Other Severe
Mental Disorders Treated? 373

Institutional Care in the Past 375
Institutional Care Takes a Turn for the Better 375

Antipsychotic Drugs 377

Psychotherapy

380

The Community Approach 383

PUTTING IT TOGETHER AN IMPORTANT
LESSON 389

CRITICAL THOUGHTS 390
KEY TERMS 390
QUICK QUIZ 391
CYBERSTUDY 391

A CLOSER LOOK Postpartum Psychosis: The Case
of Andrea Yates 367

PSYCH WATCH Howling for Attention 368

A CLOSER LOOK Lobotomy: How Could It Happen? 374

ON First Dibs on Atypical
Antipsychotic Drugs?

378

THE MEDIA SPEAK’S Can You Live with the Voices
in Your Head?

380
CHAPTER

Personality Disorders

393
“Odd” Personality Disorders

396

Paranoid Personality Disorder 396

Schizoid Personality Disorder

398
Schizotypal Personality Disorder

399

“Dramatic” Personality Disorders

402
Antisocial Personality Disorder

402

Borderline Personality Disorder

406
Histrionic Personality Disorder

411

Narcissistic Personality Disorder

413

“Anxious” Personality Disorders

416
Avoidant Personality Disorder

416

Dependent Personality Disorder 418
Obsessive-Compulsive Personality Disorder

420

Multicultural Factors: Research Neglect

422

Are There Better Ways to Classify
Personality Disorders?

423
The “Big Five” Theory of Personality and

Personality Disorders

424

Alternative Dimensional Approaches

425

PUTTING IT TOGETHER DISORDERS OF PERSONALITY
ARE REDISCOVERED

425

CRITICAL THOUGHTS 426
KEY TERMS 426
QUICK QUIZ 427
CYBERSTUDY 427

A CLOSER LOOK Gambling and Other Impulse Problems 405

THE MEDIA:1, SPEAKS Self-Cutting: The Wound
That Will Not Heal 409

PSYCH WATCH Lying: “Oh What a Tangled Web . . . ” 415

CHAPTER

Disorders of Childhood and
Adolescence

429
Childhood and Adolescence

430

Childhood Anxiety Disorders

431

Contents

Separation Anxiety Disorder 431
Treatments for Childhood Anxiety Disorders 432

Childhood Mood Disorders 434
Major Depressive Disorder 434
Bipolar Disorder 435

Oppositional Defiant Disorder and
Conduct Disorder 436

What Are the Causes of Conduct Disorder? 437
How Do Clinicians Treat Conduct Disorder? 437

Attention-Deficit/Hyperactivity Disorder 440
What Are the Causes of ADHD? 441
How Is ADHD Treated? 442
Multicultural Factors and ADHD 442

Elimination Disorders 444
Enuresis 444

Encopresis 446

Long-Term Disorders That Begin in
Childhood 447

Pervasive Developmental Disorders 447
Mental Retardation 454

PUTTING IT TOGETHER CLINICIANS DISCOVER CHILDHOOD
AND ADOLESCENCE 463

CRITICAL THOUGHTS 464
KEY TERMS 464
QUICK QUIZ 465
CYBERSTUDY 465

THE MEDIA SPEAK S Alone in a Parallel Life 433

PSYCH WATCH Bullying: A Growing Crisis? 438

A CLOSER LOOK Child Abuse 444

PSYCH WATCH A Special Kind of Talent 451

A CLOSER LOOK Reading and ‘Riting and ‘Rithmetic 456

* Disorders of Aging and

CHAPTER

Cognition 467

Old Age and Stress 468

Depression in Later Life 469

Anxiety Disorders in Later Life 470

Substance Abuse in Later Life 471

Psychotic Disorders in Later Life 473

xv

xvi :// Contents

Disorders of Cognition

Delirium

Dementia

Issues Affecting the Mental Health of the Elderly

PUTTING IT TOGETHER CLINICIANS DISCOVER
THE ELDERLY

CRITICAL THOUGHTS
KEY TERMS
QUICK QUIZ
CYBERSTU DY

A CLOSER LOOK Sleep and Sleep Disorders among
the Old and Not So Old

A CLOSER LOOK Amnestic Disorders: Forgetting
to Remember

PSYCH WATCH ABNORMALITY AND THE ARTS “You Are
the Music, while the Music Lasts”

THE MEDIA SPEAKS Doctor, Do No Harm

CHAPTER

Law, Society, and the Mental
Health Profession

Psychology in Law: How Do Clinicians Influence
the Criminal Justice System?

Criminal Commitment and Insanity during

Commission of a Crime

Criminal Commitment and Incompetence

to Stand Trial

Law in Psychology: How Does the Legal System
Influence Mental Health Care?

Civil Commitment

Protecting Patients’ Rights

In What Other Ways Do the Clinical and Legal
Fields Interact? 507

Malpractice Suits 507

Professional Boundaries 507

Jury Selection 507

Psychological Research of Legal Topics 507

Ethics and Mental Health Professionals? 510

Mental Health, Business, and Economics 512

Bringing Mental Health Services to the

Workplace 512

The Economics of Mental Health 513

The Person within the Profession 514

PUTTING IT TOGETHER OPERATING WITHIN A
LARGER SYSTEM 516

CRITICAL THOUGHTS 518
KEY TERMS 518
QUICK QUIZ 519
CYBERSTUDY 519

A CLOSER LOOK Famous Insanity Defense Cases 495

PSYCH WATCH Violence against Therapists 502

PSYCH WATCH Serial Murderers: Madness or
Badness? 509

PSYCH WATCH “Ask Your Doctor If This Medication
Is Right for You” 514

THE MEDIA ‘PEAICS “Mad Pride” Fights a Stigma 517

Glossary G-1

References R-1

Name Index NI-1

Subject Index SI-1

491

492

493

498

500

500

504

486

474

474

475

487
488
488
488
489

478

481

484

472

Chanpes and Features New trit ditibn

PREFACE

TI have been writing my textbooks Fundamentals of Abnormal Psychology and Abnormal
Psychology for close to three decades—almost half of my life. The current version,
Fundamentals of Abnormal Psychology, Sixth Edition, is the thirteenth edition of one or
the other of the textbooks. I am deeply gratified that so many students and profes

–

sors have embraced these books, and I feel privileged to have had the opportunity to
help educate more than a half-million readers over the past years.

My goal for each edition of the books has been that it be a fresh, comprehensive,
and exciting presentation of the current state of this ever-changing field and that it
include state-of-the-art pedagogical techniques and insights.This “new book” approach
to each edition is, I believe, the key reason for the continuing success of the textbooks,
and the current edition has been written in this same tradition.

In fact, this edition of Fundamentals of Abnormal Psychology includes even more
changes than those in previous editions for several reasons: (1) the field of abnormal
psychology has had a dramatic growth spurt over the past several years; (2) the field of
education has produced many new pedagogical tools; (3) the world of publishing has
developed new, striking ways of presenting material; (4) the world at large has changed
dramatically, featuring a monumental rise in the Internet’s impact on our lives, grow-
ing influence by the media, near-unthinkable economic and political events, and a
changing world order. Changes of this kind should find their way into a book about
the current state of human functioning, and I have worked hard to include them in a
stimulating way.

That said, I believe I have produced a new edition of Fundamentals of Abnormal
Psychology that will once again excite readers, open the field of abnormal psychology
to them, and speak to them and their times. Throughout the book I have again sought
to convey my passion for the field, and I have built on the generous feedback of my
colleagues in this enterprise—the students and professors who have used this textbook
over the years. Let me describe what I believe to be special about this edition, apologiz-
ing at the top if these descriptions at times seem grandiose or self-serving. I’m usually
better at hiding such traits.

In line with the enormous changes that have occurred over the past several years
in the fields of abnormal psychology, education, and publishing and in the world, I
have brought the following changes and new features to the current edition.

EXPANDED MULTICULTURAL COVERAGE In the twenty-first century, the study of
ethnic, racial, gender, and other cultural factors has, appropriately, been elevated
to a broad perspective—the multicultural perspective—a theoretical and treatment
approach to abnormal behavior that is now applied across all forms of psycho-
pathology and treatment. Consistent with this clinical movement, the current edition
includes the following:

1. Broad Multicultural Perspective sections in each chapter of the textbook, each
examining the impact of cultural issues on the diagnosis, development, and treat-
ment of the abnormal pattern in question. Chapter 2, Models of Abnormality,
for example, includes sections on culture-sensitive therapies and gender-sensitive
therapies (pages 61-62); Chapter 5, Stress Disorders, examines the ties
between race, culture, and posttraumatic stress disorder (pages 143-144); and

xvii

xviii :11 Preface

multicultural perspective sections in Chapter 7, Mood Disorders, consider the
links between gender, culture, and depression (pages 215-217).

2. Numerous Eye on Culture boxes appear throughout the text, further empha-
sizing multicultural issues. These boxes address topics such as Culture-Bound
Abnormality (Chapter 3), First Dibs on Antidepressant Drugs? (Chapter 7), Eating
Disorders across the World (Chapter 9), and First Dibs on Atypical Antipsychotic
Drugs? (Chapter 12).

3. Multicultural photography, figures, and cases. Even a quick look through the
pages of the textbook will reveal that it truly reflects the cultural diversity of our
society and of the field of abnormal psychology.

“NEW-WAVE” COGNITIVE AND COGNITIVE-BEHAVIORAL THEORIES AND
TREATMENTS Beginning in the 1960s, cognitive and cognitive-behavioral thera-
pists sought to help clients undo the maladaptive attitudes and thought processes
that contribute to their psychological dysfunctioning. This approach has been joined
in recent years by another focus, “new-wave” cognitive and cognitive-behavioral
theories and therapies that help clients “accept” and objectify maladaptive thoughts
that are resistant to change. The current edition of Fundamentals of Abnormal
Psychology fully covers these “new-wave” theories and therapies, including mind-
fulness-based cognitive therapy and Acceptance and Commitment Therapy (ACT),
presenting their propositions, techniques, and research in chapters throughout the
text (for example, pages 50, 103, 213, and 382).

EXPANDED NEUROSCIENCE COVERAGE The twenty-first century has witnessed
the continued growth and impact of remarkable brain-imaging techniques, genetic
mapping strategies, and other neuroscience approaches. Correspondingly, biologi-
cal theories and treatments for abnormal behavior have taken unprecedented leaps
forward during the past several years. The current edition brings these leaps to life.
In addition to the biochemical view of abnormal behavior on display in previous
editions, the current edition includes detailed coverage of the following:

1 Broader discussions of the genetic underpinnings of abnormal behavior (for
example, pages 34-35, 142-143, 198-199, and 365-366).

2. Detailed explanations of both the brain structures and brain functions at the
root of abnormal behavior, including, for example, presentations of how vari-
ous neural networks contribute to panic disorder (pages 117-118), obsessive-
compulsive disorder (page 128), depression (pages 199-200), and other forms
of psychopathology.

3. Neuroscience photography and art. This edition is filled with photos of exciting
brain scans that reveal the brain structures and activities at work in abnormality
(for example, pages 78, 221, 308, and 370). Similarly, numerous pieces of
new, current, and enlightening brain art fill each chapter of the book to help
readers better appreciate the locations and interactions of various brain struc-
tures (for example, pages 117, 118, 128, 200, and 369).

4. Analyses of how genetic factors, brain chemicals, and brain structures interact
with psychosocial factors to produce abnormal behavior (for example, pages
63-64, 129-130, and 282).

•NEW, THE MEDIA SPEAKS The media is an extraordinary force in our society.
And its role has become even more powerful in the twenty-first century as use of
the Internet has exploded and ordinary people are now able to communicate with
masses of unknown others through blogging, social networking, and the like. Given
the media’s profound impact on our behaviors, thoughts, and knowledge, I have
added an important recurring feature throughout the text—boxes called The Media
Speaks in which news and magazine writers offer pieces on subjects in abnormal

Preface xix

psychology (How Well Do Colleges Treat Depression? on page 207), individuals
write firsthand about their experiences with psychological disorders (Self-Cutting:
The Wound That Will Not Heal on page 409), and editorial writers consider the
clinical implications of pop culture (in Real Time, Amy Winehouse’s Deeper Descent
on page 313).

EXPANDED COVERAGE OF KEY DISORDERS AND TOPICS In line with the field’s
(and society’s) increased interest in certain psychological problems and treatments,
I have added or greatly expanded the coverage of topics such as torture, terrorism,
and psychopathology (pages 140-142), methamphetamine use (pages 298-299},
transgender issues (pages 348-353), childhood bipolar disorders (pages 435-
436), self-cutting (pages 407-409), dialectical behavior therapy (page 410), anti-
depressant drugs and suicide risk (page 246), music and suicide attempts (page
239), brain interventions such as vagus nerve stimulation, transcranial magnetic
stimulation, and deep brain stimulation (pages 204-205), and metaworry explana-
tions of generalized anxiety disorder (pages 100-103), among other topics.

EXPANDED COVERAGE OF PREVENTION AND OF THE PROMOTION OF MENTAL
HEALTH In accord with the clinical field’s growing emphasis on prevention, positive
psychology, and psychological wellness, I have increased significantly the text-
book’s attention to these important approaches (for example, pages 16-17, 60,
and 487).

RESTRUCTURED CHAPTER ON CHILDHOOD AND ADOLESCENT DISORDERS To
reflect current directions in the clinical field, I have made key changes to Chapter
14, Disorders of Childhood and Adolescence. Childhood disorders that parallel
adult disorders—particularly anxiety and mood disorders—are now covered in
depth in this chapter (rather than spread throughout the book), along with the dis-
orders that are more narrowly tied to young age, such as conduct disorder, ADHD,
and enuresis.

SPECIAL FOCUS ON TODAY’S WORLD An element that is often neglected in
textbooks—psychology and otherwise—is, oddly, the modern world! We live in
an ever-changing world that has in fact undergone a major face-lift over the past
decade. If a textbook is to speak to today’s readers, especially college-age readers,
the book’s elements—its topics, examples, cases, and photos—must represent the
world in which they live. With this in mind, I have included throughout the book
relevant discussions about “now” factors such as Facebook, MySpace, YouTube,
ecoanxiety, cell phone use, transgender issues, pop culture, emo music, Internet
addiction, and club drugs. The finished product is, in turn, a more complete book
about abnormal psychology—past and present—relevant to all.

NEW BOXES In this edition, I have grouped the boxes into four categories to bet-
ter orient the reader. In addition to The Media Speaks boxes and Eye on Culture
boxes mentioned earlier, the sixth edition contains A Closer Look boxes (boxes that
examine text topics in more depth) and Psych Watch boxes (boxes that look at
examples of abnormal psychology in movies, the news, and the world around us).
I have, of course, updated all the boxes retained from the last edition, and I have
also added 21 completely new boxes, including the following:

O The Media Speaks: Can You Live with the Voices in Your Head? (Chapter 12)

• Psych Watch: Dark Sites on the Internet (Chapter 3)

* Eye on Culture: Eating Disorders across the World (Chapter 9)

® The Media Speaks: Mad Pride Fights a Stigma (Chapter 16)

* Psych Watch: Surfing for Help (Chapter 2)

xx :/Preface

NEW, CURRENT, AND INNOVATIVE DESIGN The sixth edition of Fundamentals of
Abnormal Psychology has been strikingly redesigned to give it an eye-catching and
modern look—a look that builds on new trends in publishing and pedagogy, speaks
to the reader, and leads the way for new textbook designs. At the same time, the
design retains a popular feature from past editions—reader-friendly elements called
“Between the Lines” that appear in the book’s margins and include text-relevant
tidbits, surprising facts, current events, historical notes, interesting trends, fun lists,
and provocative quotes.

THOROUGH UPDATE In this edition I present recent theories, research, and events,
including more than 2,000 new references from the years 2007-2010, as well as
hundreds of new photos, tables, and figures.

In this edition, I have retained the themes, material, and techniques that have
worked successfully and been embraced enthusiastically by past readers.

MODERATE IN LENGTH, SOLID IN CONTENT Even though Fundamentals of
Abnormal Psychology is of moderate length, it offers probing coverage of its broad
subject. It expands and challenges students’ thinking rather than short-changing or
underestimating their intellectual capacity.

BREADTH AND BALANCE The field’s many theories, studies, disorders, and treat-
ments are presented completely and accurately. All major models—psychological,
biological, and sociocultural—receive objective, balanced, up-to-date coverage
without bias toward any single approach.

INTEGRATION OF MODELS Discussions throughout the text, particularly those
headed Putting It Together, help students better understand where and how the vari-
ous models work together and how they differ.

EMPATHY The subject of abnormal psychology is people—very often people in
great pain. I have therefore tried to write always with empathy and to impart this
awareness to students.

INTEGRATED COVERAGE OF TREATMENT Discussions of treatment are presented
throughout the book. In addition to a complete overview of treatment in the open-
ing chapters, each of the pathology chapters includes a full discussion of relevant
treatment approaches.

RICH CASE MATERIAL I integrate numerous and culturally diverse clinical examples
to bring theoretical and clinical issues to life. More than 25 percent of the clinical
material in this edition is new or revised significantly.

TOPICS OF SPECIAL INTEREST I devote considerable attention to important subjects
that are of special interest to college-age readers, such as eating disorders, the
impact of managed care, direct-to-consumer advertising, the rise in use of Ritalin,
virtual reality treatments, and the right to commit suicide.

DSM CHECKLISTS The discussion of each disorder is accompanied by a detailed
checklist of the DSM-IV-TR criteria used to diagnose the disorder.

MARGIN GLOSSARY Hundreds of key words are defined in the margins of pages
on which the words appear. In addition, a traditional glossary is available at the
back of the book.

Preface :11 xxi

PUTTING IT TOGETHER This section toward the end of each chapter asks whether
competing models can work together in a more integrated approach and also sum-
marizes where the field now stands and where it may be going.

FOCUS ON CRITICAL THINKING The textbook provides tools for thinking critically
about abnormal psychology. In particular, toward the end of each chapter a section
called Critical Thoughts poses questions that help students to analyze and apply
the material they have just read. Twenty-five percent of these questions are new to
the sixth edition.

CHAPTER-ENDING KEY TERMS AND QUICK QUIZ SECTIONS These sections, keyed
to appropriate pages in the chapter for easy reference, allow students to review and
test their knowledge of chapter materials.

CYBERSTUDY Each chapter ends with a CyberStudy guide that integrates the chap-
ter material with videos and other features found in the Fundamentals of Abnormal
Psychology Video Tool Kit.

STIMULATING ILLUSTRATIONS Concepts, disorders, treatments, and applications
are illustrated with stunning photographs, diagrams, graphs, and anatomical fig-
ures. All the figures, graphs, and tables, many new to this edition, reflect the most
up-to-date data available.

ADAPTABILITY Chapters are self-contained, so they can be assigned in any order
that makes sense to the professor.

I have been delighted by the enthusiastic responses of both professors and students
to the supplements that accompany my textbooks. This edition offers those supple-
ments once again, revised and enhanced, and adds a number of exciting new
ones.

FOR PROFESSORS

•NEW. VIDEO SEGMENTS FOR ABNORMAL PSYCHOLOGY, THIRD EDITION, pro-
duced and edited by Ronald Comer, Princeton University, and Gregory Corner,
Princeton Academic Resources. Faculty Guide included. This incomparable video
series offers 125 clips—half of them new to this edition—that depict disorders, show
historical footage, and illustrate clinical topics, pathologies, treatments, experi-
ments, and dilemmas. Videos are available on DVD or CD-ROM. I have also written
an accompanying guide that fully describes and discusses each video clip so that
professors can make informed decisions about the use of the segments in lectures.

In addition, Nicholas Greco, College of Lake County, has written a completely new
set of questions to accompany each video segment in the series. The questions
have been added to the Faculty Guide (now available in the Instructor’s Resource
Manual) and are also available in PowerPoinP on the companion Web site or the
Instructor’s Resource CD-ROM (for use with Worth Publishers’ iClicker Classroom
Response System).

CLINICAL VIDEO CASE FILE FOR ABNORMAL PSYCHOLOGY, produced and edited
by Ronald Cotner and Gregory Corner. Faculty Guide included. I have produced a
set of 10 longer authentic video case studies that bring to life particularly interest-
ing cases of psychopathology and treatment. The videos are available on DVD or
CD-ROM.

xxii : Preface

POWERPOINT® SLIDES, available at www.worthpublishers.com/comer or on the
Instructor’s Resource CD-ROM. These PowerPoint® slides can be used directly or
customized to fit a professor’s needs. There are two customizable slide sets for
each chapter of the book—one featuring chapter text, the other featuring all chapter
photos and illustrations.

POWERPOINT® PRESENTATION SLIDES, by Karen Clay Rhines, Northampton
Community College, available at www.worthpublishers.com/comer or on the
Instructor’s Resource CD-ROM. These customized slides focus on key text terms and
themes, reflect the main points in significant detail, and feature tables, graphs, and
figures from the book. Each set of chapter slides is accompanied by a set of hand-
outs, which can be distributed to students for use during lectures. The handouts are
based on the instructor slides, with key points replaced by “fill-in” items. Answer
keys and suggestions for use are also provided.

STEP UP TO ABNORMAL PSYCHOLOGY: A PowerPoint® Review Game, by John
Schulte, Cape Fear Community College and University of North Carolina, available
at www.worthpublishers.com/comer or on the Instructor’s Resource CD-ROM. This
PowerPoinP-based review adopts a game-show approach: students divide into teams
to compete to climb the pyramid by answering questions related to chapter material.

DIGITAL PHOTO LIBRARY, available at www.worthpublishers.com/comer or on
the Instructor’s Resource CD-ROM. This collection provides access to all the photo-
graphs used in Fundamentals of Abnormal Psychology, Sixth Edition.

INSTRUCTOR’S RESOURCE MANUAL by Karen Clay Rhines, Northampton
Community College. This comprehensive guide ties together the ancillary package
for professors and teaching assistants. The manual includes detailed chapter out-
lines, lists of principal learning objectives, ideas for lectures, discussion launchers,
classroom activities, extra credit projects, word search and crossword puzzles, and
precise DSM-IV-TR criteria for each of the disorders discussed in the text. It also
offers strategies for using the accompanying media, including the video segments
series, the CD-ROM, the companion Web site, and the transparencies. Finally, it
includes a comprehensive list of valuable materials that can be obtained from out-
side sources—items such as relevant feature films, documentaries, and Internet sites
related to abnormal psychology.

ASSESSMENT TOOLS

PRINTED TEST BANK, by John H. Hull, Bethany College, and Debra B. Hull,
Wheeling Jesuit University. The comprehensive test bank offers more than 2,200
multiple-choice, fill-in-the-blank, and essay questions. Each question is graded
according to difficulty, identified as factual or applied, and keyed to the topic and
page in the text where the source information appears.

DIPLOMA COMPUTERIZED TEST BANK, available as a Windows and Macintosh
dual-platform CD-ROM, guides professors step by step through the process of
creating a test and allows them to add an unlimited number of questions, edit or
scramble questions, format a test, and include pictures, equations, and multimedia
links. The accompanying grade book enables them, among other things, to record
students’ grades throughout the course and includes the capacity to sort student
records and view detailed analyses of test items, curve tests, generate reports, and
add weights to grades. The CD-ROM also provides the access point for Diploma
Online Testing, as well as Blackboard- and WebCT -formatted versions of the Test
Bank for Fundamentals of Abnormal Psychology, Sixth Edition.

ONLINE TESTING, POWERED BY DIPLOMA, available at www.wimba.com/
products/diplom

a.

With Diploma, professors can create and administer secure

Preface :1/ xxiii

exams over a network and over the Internet, with questions that incorporate
multimedia and interactive exercises. The program also allows them to restrict tests
to specific computers or time blocks and includes a suite of grade-book and result-
analysis features.

ONLINE QUIZZING, POWERED BY QUESTIONMARK, accessed via the companion
Web site at www.worthpublishers.com/comer . Professors can easily and securely
quiz students online using provided multiple-choice questions for each chapter (note
that questions are not from the Test Bank). Students receive instant feedback and
can take the quizzes multiple times. Professors can view results by quiz, student, or
question, or can get weekly results via e-mail.

FOR STUDENTS

NEW• PSYCHPORTAL, integrating the best online material Worth offers. PsychPortal
is an innovative course space that combines a powerful quizzing engine with unpar-
alleled media resources. PsychPortal conveniently offers all the functionality you
need to support your online or hybrid course, yet it is flexible, customizable, and
simple enough to enhance your traditional course. The following interactive learning
materials contained in PsychPortal make it truly unique.

• Interactive eBook allows students to highlight, bookmark, and make their
own notes just as they would with a printed textbook.

• Online Study Center combines PsychPortal’s powerful assessment engine
with Worth’s unparalleled collection of interactive study resources. Based on
their quiz results, students receive Personalized Study Plans that direct them to
sections in the book and other activities that will help them succeed in mastering
the concepts. Instructors can access reports indicating students’ strengths and
weaknesses (based on class quiz results) and browse suggestions for helpful
presentation materials (from Worth’s renowned videos and demonstrations) to
focus their teaching efforts accordingly.

• Abnormal Psychology Video Tool Kit for Introductory Psychology
is available in PsychPortal or on its own.

.NEW. ABNORMAL PSYCHOLOGY VIDEO TOOL KIT, produced and edited by Ronald
Cotner, Princeton University, and Gregory Comer, Princeton Academic Resources.
Tied directly to the CyberStudy sections in the text, the Student Tool Kit offers 57
intriguing video cases running 3 to 7 minutes each. The video cases focus on per-
sons affected by disorders discussed in the text. Students first view a video case
and then answer a series of thought-provoking questions about it. Additionally, the
Student Tool Kit contains multiple-choice practice test questions with built-in instruc-
tional feedback for every option.

STUDENT WORKBOOK by Ronald Corner, Princeton University, and Gregory
Corner, Princeton Academic Resources. The engaging exercises in this student guide
actively involve students in the text material. Each chapter includes a selection of
practice tests and exercises, as well as key concepts, guided study questions, and
section reviews.

FUNDAMENTALS OF ABNORMAL PSYCHOLOGY COMPANION WEB SITE by
Nicholas Greco, College of Lake County, and Jason Spiegelman, Community
College of Baltimore County, accessible at www.worthpublishers.com/comer . This
Web site provides students with a virtual study guide, 24 hours a day, 7 days
a week. These resources are free and do not require any special access codes
or passwords. The tools on the site include chapter outlines, quizzes, interactive
flash cards, research exercises, and frequently asked questions about clinical
psychology. In addition, the site includes nine case studies by Elaine Cassel,

Marymount University and Lord Fairfax Community College, Danae L. Hudson,
Missouri State University, and Brooke L. Whisenhunt, Missouri State University.
Each case describes an individual’s history and symptoms and is accompanied by
a set of guided questions that point to the precise DSM-IV-TR criteria for the disorder
and suggest a course of treatment.

CASE STUDIES IN ABNORMAL PSYCHOLOGY by Ethan E. Gorenstein, Behavioral
Medicine Program, New York—Presbyterian Hospital, and Ronald Corner, Princeton
University. This casebook provides 20 case histories, each going beyond DSM-IV-TR
diagnoses to describe the individual’s history and symptoms, a theoretical discus-
sion of treatment, a specific treatment plan, and the actual treatment conducted.
The casebook also provides three cases without diagnoses or treatment so that
students can identify disorders and suggest appropriate therapies. In addition, case
study evaluations by Ann Brandt-Williams, Glendale Community College, are avail-
able at www.worthpublishers.com/comer . Each evaluation accompanies a specific
case and can be assigned to students to assess their understanding as they work
through the text.

THE SCIENTIFIC AMERICAN READER TO ACCOMPANY FUNDAMENTALS OF
ABNORMAL PSYCHOLOGY, SIXTH EDITION, edited by Ronald Corner, Princeton
University. On request, this reader is free when packaged with the text. Drawn
from Scientific American, the articles in this full-color collection enhance coverage
of important topics covered by the course. Keyed to specific chapters, the selections
provide a preview of and discussion questions for each article.

SCIENTIFIC AMERICAN EXPLORES THE HIDDEN MIND: A COLLECTOR’S EDITION.
On request, this reader is free when packaged with the text. In this special edition,
Scientific American provides a compilation of updated articles that explore and
reveal the mysterious inner workings of our wondrous minds and brains.

iCLICKER RADIO FREQUENCY CLASSROOM RESPONSE SYSTEM, offered by Worth
Publishers in partnership with ;Clicker. ;Clicker is Worth’s new polling system,
created by educators for educators. This radio frequency system is the hassle-free
way to make your class time more interactive. Among other functions, the system
allows you to pause to ask questions and instantly record responses, as well as take
attendance, direct students through lectures, and gauge students’ understanding of
the material.

COURSE MANAGEMENT

•ENHANCED. COURSE MANAGEMENT SOLUTIONS: SUPERIOR CONTENT, ALL IN
ONE PLACE, available for WebCT, Blackboard, Desire2Learn, and Angel at www.
bfwpub.com/cms . As a service for adopters, Worth Publishers is offering an
enhanced turnkey course for Fundamentals of Abnormal Psychology, Sixth Edition.
The enhanced course includes a suite of robust teaching and learning materials
in one location, organized so that you can quickly customize the content for your
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includes the complete Test Bank and all PowerPoint© slides. For students, we offer
interactive flash cards, quizzes, crossword puzzles, chapter outlines, annotated
Web links, research exercises, and case studies.

I am very grateful to the many people who have contributed to writing and pro-
ducing this book. I particularly thank Marlene Comer for her outstanding work on
the manuscript and her constant good cheer. In addition, I sincerely appreciate

Preface :At xxv

the superb work of the book’s research assistants, including Dina Altshuler, Linda
Chamberlin, Jon Comer, Greg Corner, Lindsay Downs, Jomi Furr, and Jamie
Hambrick.

I am greatly indebted to the outstanding academicians and clinicians who
have reviewed the manuscript of this new edition of Fundamentals of Abnormal
Psychology, along with that of its partner, Abnormal Psychology, Seventh Edition,
and have commented with great insight and wisdom on its clarity, accuracy, and
completeness. Their collective knowledge has in large part shaped the sixth edi-
tion of Fundamentals: Dave W. Alfano, Community College of Rhode Island; Jillian
Bennett, University of Massachusetts Boston; Jeffrey A. Buchanan, Minnesota State
University; Miriam Ehrenberg, John Jay College of Criminal Justice; Carlos A. Escoto,
Eastern Connecticut State University; David M. Fresco, Kent State University; Alan
J. Fridlund, University of California, Santa Barbara; Jinni A. Harrigan, California
State University, Fullerton; Lynn M. Kemen, Hunter College; Audrey Kim, University
of California, Santa Cruz; Barbara Lewis, University of West Florida; Regina
Miranda, Hunter College; Linda M. Montgomery, University of Texas, Permian
Basin; Crystal Park, University of Connecticut; Julie C. Piercy, Central Virginia
Community College; Lloyd R. Pilkington, Midlands Technical College; Laura A.
Rabin, Brooklyn College; Susan J. Simonian, College of Charleston; Joanne H.
Stohs, California State University, Fullerton; Mitchell Sudolsky, University of Texas
at Austin.

also thank the professors and clinicians around the country who offered spe-
cial counsel during the writing of the text: Jeffrey Cohn, University of Pittsburgh;
Marie Dacey, Massachusetts College of Pharmacy and Health Sciences; Elizabeth
Lindner, Madison Area Technical College; Professor Joni Mihura, University of
Toledo, Professor David Mrad, Missouri State University; Salma Osmani, University
of Leicester, UK; Deborah Podwika, Kankakee Community College; Irving Weiner,
President, Society of Personality Assessment.

Earlier I also received valuable feedback from academicians and clinicians
who reviewed portions of the first five editions of Fundamentals of Abnormal
Psychology. Certainly their collective knowledge has also helped shape the sixth
edition, and I gratefully acknowledge their important contributions: Kent G. Bailey,
Virginia Commonwealth University; Sonja Barcus, Rochester College; Mama S.
Barnett, Indiana University of Pennsylvania; Otto A. Berliner, Alfred State College;
Allan Berman, University of Rhode Island; Douglas Bernstein, University of Toronto,
Mississauga; Greg Bolich, Cleveland Community College; Barbara Brown, Georgia
Perimeter College; Jeffrey A. Buchanan, Minnesota State University, Mankato;
Gregory M. Buchanan, Beloit College; Laura Burlingame-Lee, Colorado State
University; Loretta Butehorn, Boston College; Glenn M. Callaghan, San Jose State
University; E. Allen Campbell, University of St. Francis; Julie Carboni, San Jose
College and National University; David N. Carpenter, Southwest Texas University;
Sarah Cirese, College of Marin; June Madsen Clausen, University of San Francisco;
Victor B. Cline, University of Utah; E. M. Coles, Simon Fraser University; Michael
Connor, California State University, Long Beach; Frederick L. Coolidge, University
of Colorado, Colorado Springs; Timothy K. Daugherty, Winthrop University; Mary
Dozier, University of Delaware; S. Wayne Duncan, University of Washington,
Seattle; Morris N. Eagle, York University; Anne Fisher, University of Southern Florida;
William F. Flack Jr., Bucknell University; John Forsyth, State University of New York,
Albany; Alan Fridlund, University of California, Santa Barbara; Stan Friedman,
Southwest Texas State University; Dale Fryxell, Chaminade University; Lawrence
L. Galant, Gaston College; Karla Gingerich, Colorado State University; Nicholas
Greco, College of Lake County; Jane Halonen, James Madison University; James
Hansel], University of Michigan; Neth Hansjoerg, Rensselaer Polytechnic Institute;

ABNORvAL
PSYCHOLOGY:
PAST AND PRESENT

lisha cries herself to sleep every night. She is certain that the future holds nothing but
misery. Indeed, this is the only thing she does feel certain about. “I’m going to suffer
and suffer and suffer, and my daughters will suffer as well. We’re doomed. The world

1…1 is ugly. I hate every moment of my life.” She has great trouble sleeping. She is afraid to
close her eyes. When she does, the hopelessness of her life—and the ugly future that awaits
her daughters—becomes all the clearer to her. When she drifts off to sleep, her dreams are
nightmares filled with terrible images—bodies, flooding, decay, death, destruction.

Some mornings Alisha even has trouble getting out of bed. The thought of facing another day
overwhelms her. She wishes that she and her daughters were dead. “Get it over with. We’d all
be better off.” She feels paralyzed by her depression and anxiety, overwhelmed by her sense of
hopelessness, too tired to move, too negative to try anymore. On such mornings, she huddles
her daughters close to her, makes sure that the shades of her trailer home are drawn and the
door locked, and sits away the day in the darkened room. She feels she has been assaulted by
society and then deserted by the world and left to rot. She is both furious at life and afraid of
it at the same time.

During the past year Brad has been hearing mysterious voices that tell him to quit his job, leave
his family, and prepare far the coming invasion. These voices have brought tremendous confu-
sion and emotional turmoil to Brad’s life. He believes that they come from beings in distant
parts of the universe who are somehow wired to him. Although it gives him a sense of purpose
and specialness to be the chosen target of their communications, they also make him tense
and anxious. He dreads the coming invasion, When he refuses an order, the voices insult and
threaten him and turn his days into a waking nightmare.

Brad has put himself on a sparse diet against the possibility that his enemies may be contami-
nating his food. He has found a quiet apartment far from his old haunts where he has laid in
a good stock of arms and ammunition. His family and friends have tried to reach out to Brad,
to understand his problems, and to dissuade him from the disturbing course he is taking. Every
day, however, he retreats further into his world of mysterious voices and imagined dangers.

Most of us would probably consider Alisha’s and Brad’s emotions, thoughts, and
behavior psychologically abnormal, the result of a state sometimes called psychopa-
thology, maladjustment, emotional disturbance, or mental illness.These terms have been
applied to the many problems that seem closely tied to the human brain or mind.
Psychological abnormality affects the famous and the unknown, the rich and the
poor. Actors, writers, politicians, and other public figures of the present and the
past have struggled with it. Psychological problems can bring great suffering, but
they can also be the source of inspiration and energy.

Because they are so common and so personal, these problems capture the
interest of us all. Hundreds of novels, plays, films, and television programs have
explored what many people see as the dark side of human nature, and self-help
books flood the market. Mental health experts are popular guests on both televi-
sion and radio, and some even have their own shows.

TOPIC OVERVIEW
What Is Psychological Abnormality?
Deviance
Distress

Dysfunction
Danger
The Elusive Nature of Abnormality

What Is Treatment?

How Was Abnormality Viewed
and Treated in the Past?
Ancient Views and Treatments
Greek and Roman Views
and Treatments

Europe in the Middle Ages:
Demonology Returns

The Renaissance and the Rise
of Asylums

The Nineteenth Century:
Reform and Moral Treatment
The Early Twentieth Century:
The Somatogenic and Psychogenic
Perspectives

Current Trends

How Are People with Severe
Disturbances Cared For?

How Are People with Less Severe
Disturbances Treated?
A Growing Emphasis on Preventing
Disorders and Promoting Mental
Health

Multicultural Psychology
The Growing Influence
of Insurance Coverage
What Are Today’s Leading
Theories and Professions?

What Do Clinical Researchers Do?

The Case Study

The Correlational Method
The Experimental Method

What Are the Limits of Clinical
Investigations?

Putting It Together:
A Work in Progress

•abnormal psychology•The scien-
tific study of abnormal behavior in an
effort to describe, predict, explain, and
change abnormal patterns of functioning.

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

pculture•A people’s common history,
values, institutions, habits, skills, technol-
ogy, and arts.

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The field devoted to the scientific study of the problems we find so fascinating is
usually called abnormal psychology. As in any science, workers in this field, called
clinical scientists, gather information systematically so that they may describe, predict, and
explain the phenomena they study. The knowledge that they acquire is then used by
clinical practitioners to detect, assess, and treat abnormal patterns of functioning.

,,,:What Is Psychological Abnormality?
Although their general goals are similar to those of other scientific professionals, clinical
scientists and practitioners face problems that make their work especially difficult. One
of the most troubling is that psychological abnormality is very hard to define. Consider
once again Alisha and Brad. Why are we so ready to call their responses abnormal?

While many definitions of abnormality have been proposed over the years, none has
won total acceptance (Regier et al., 2009; Boysen, 2007). Still, most of the definitions
have some common features, often called “the four Ds”: deviance, distress, dysfunction,
and danger. That is, patterns of psychological abnormality are typically deviant (differ-
ent, extreme, unusual, perhaps even bizarre), distressing (unpleasant and upsetting to the
person), dysfunctional (interfering with the person’s ability to conduct daily activities in
a constructive way), and possibly dangerous. This definition offers a useful starting point
from which to explore the phenomena of psychological abnormality. As you will see,
however, it has key limitations.

Deviance
Abnormal psychological functioning is deviant, but deviant from what? Alisha’s and
Brad’s behaviors, thoughts, and emotions are different from those that are considered
normal in our place and time.We do not expect people to cry themselves to sleep each
night, hate the world, wish themselves dead, or obey voices that no one else hears.

In short, abnormal behavior, thoughts, and emotions are those that differ markedly
from a society’s ideas about proper functioning. Each society establishes norms—stated
and unstated rules for proper conduct. Behavior that breaks legal norms is considered
to be criminal. Behavior, thoughts, and emotions that break norms of

psychological

functioning are called abnormal.

Judgments of abnormality vary from society to society.A society’s norms grow
from its particular culture—its history, values, institutions, habits, skills, technol-
ogy, and arts. A society that values competition and assertiveness may accept ag-
gressive behavior, whereas one that emphasizes cooperation and gentleness may
consider aggressive behavior unacceptable and even abnormal. A society’s values
may also change over time, causing its views of what is psychologically abnormal
to change as well. In Western society, for example, a woman’s participation in the
business world was widely considered inappropriate and strange a hundred years
ago. Today the same behavior is valued.

Judgments of abnormality depend on specific circumstances as well as on cultural
norms. What if, for example, we were to learn that the desperate unhappiness of
Alisha was in fact occurring in the days, weeks, and months following Hurricane
Katrina, the deadly storm that struck New Orleans in the summer of 2005—a
storm whose aftermath destroyed her home and deprived her of all of her earthly
possessions, shattering the modest but happy life she and her family had once
known? In the weeks and months that followed the storm, Alisha came to ap-
preciate that help was not coming and that she would probably not be reunited
with the friends and neighbors who had once given her life so much meaning.
As she and her daughters moved from one temporary run-down location to
another throughout Louisiana and Mississippi,Alisha gradually gave up all hope
that her life would ever return to normal. In this light, Alisha’s reactions do not
seem quite so inappropriate. If anything is abnormal here, it is her situation. Many
human experiences produce intense reactions—large-scale catastrophes and di-

2 ://CHAPTER 1

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Abnormal Psychology: Past and Present :1/ 3

sasters, rape, child abuse, war, terminal illness, chronic pain (Miller, 2007).
Is there an “appropriate” way to react to such things? Should we ever call
reactions to them abnormal?

Distress
Even functioning that is considered unusual does not necessarily qualify as
abnormal.According to many clinical theorists, behavior, ideas, or emotions
usually have to cause distress before they can be labeled abnormal. Consider
the Ice Breakers, a group of people in Michigan who go swimming in lakes
throughout the state every weekend from November through February.
The colder the weather, the better they like it. One man, a member of the
group for 17 years, says he loves the challenge of man against nature. A
37-year-old lawyer believes that the weekly shock is good for her health.
“It cleanses me,” she says. “It perks me up and gives me strength.”

Certainly these people are different from most of us, but is their be-
havior abnormal? Far from experiencing distress, they feel energized and
challenged. Their positive feelings must cause us to hesitate before we
decide that they are functioning abnormally.

Should we conclude, then, that feelings of distress must always be
present before a person’s functioning can be considered abnormal? Not
necessarily. Some people who function abnormally maintain a positive frame of mind.
Consider once again Brad, the young man who hears mysterious voices. Brad does ex-
perience distress over the coming invasion and the life changes he feels forced to make.
But what if he enjoyed listening to the voices, felt honored to be chosen, and looked
forward to saving the world? Shouldn’t we still regard his functioning as abnormal?

Dysfunction
Abnormal behavior tends to be dysfunctional; that is, it interferes with daily functioning.
It so upsets, distracts, or confuses people that they cannot care for themselves properly,
participate in ordinary social interactions, or work productively. Brad, for example, has
quit his job, left his family, and prepared to withdraw from the productive life he once
led.

Here again one’s culture plays a role in the definition of abnormality. Our society
holds that it is important to carry out daily activities in an effective manner.Thus Brad’s
behavior is likely to be regarded as abnormal and undesirable, whereas that of the Ice
Breakers, who continue to perform well in their jobs and enjoy fulfilling relationships,
would probably be considered simply unusual.

Danger
Perhaps the ultimate in psychological dysfunctioning is behavior that becomes danger-
ous to oneself or others. Individuals whose behavior is consistently careless, hostile, or
confused may be placing themselves or those around them at risk. Brad, for example,
seems to be endangering both himself, with his diet, and others, with his buildup of
arms and ammunition.

Although danger is often cited as a feature of abnormal psychological functioning,
research suggests that it is actually the exception rather than the rule (Freedman et al.,
2007). Most people struggling with anxiety, depression, and even bizarre thinking pose
no immediate danger to themselves or to anyone else.

The Eiusive Nature of Abnormality
Efforts to define psychological abnormality typically raise as many questions as they
answer. Ultimately, a society selects general criteria for defining abnormality and then
uses those criteria to judge particular cases.

What Is Psychological Abnormality’?

The field devoted to the scientific study of abnormal behavior is called abnormal
psychology. Abnormal functioning is generally considered to be deviant, distressful,
dysfunctional, and dangerous. Behavior must also be considered in the context in
which it occurs, however, and the concept of abnormality depends on the norms
and values of the society in question.

4 ://CHAPTER 1

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One clinical theorist, Thomas Szasz (2006, 1997, 1960), places such
emphasis on society’s role that he finds the whole concept of mental illness
to be invalid, a myth of sorts. According to Szasz, the deviations that society
calls abnormal are simply “problems in living,” not signs of something wrong
within the person. Societies, he is convinced, invent the concept of mental
illness so that they can better control or change people whose unusual pat-
terns of functioning upset or threaten the social order.

Even if we assume that psychological abnormality is a valid concept and
that it can indeed be defined, we may be unable to apply our definition
consistently. If a behavior—excessive use of alcohol among college students,
say—is familiar enough, the society may fail to recognize that it is devi-
ant, distressful, dysfunctional, and dangerous. Thousands of college students
throughout the United States are so dependent on alcohol that it interferes
with their personal and academic lives, causes them great discomfort, jeop-
ardizes their health, and often endangers them and the people around them.
Yet their problem often goes unnoticed and undiagnosed.Alcohol is so much
a part of the college subculture that it is easy to overlook drinking behavior
that has become abnormal.

Conversely, a society may have trouble separating an abnormality that needs interven-
tion from an eccentricity, an unusual pattern with which others have no right to interfere.
From time to time we see or hear about people who behave in ways we consider strange,
such as a man who lives alone with two dozen cats and rarely talks to other people. The
behavior of such people is deviant, and it may well be distressful and dysfunctional, yet
many professionals think of it as eccentric rather than abnormal.

In short, while we may agree to define psychological abnormalities as patterns of
functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we
should be clear that these criteria are often vague. In turn, few of the current categories
of abnormality that you will read about in this book are as clear-cut as they may seem,
and most continue to be debated by clinicians.

jb 4

*What Is Treatment?
Once clinicians decide that a person is indeed suffering from some form of psychologi-
cal abnormality, they seek to treat it. Treatment, or therapy, is a procedure to help change
abnormal behavior into more normal behavior; it, too, requires careful definition. For
clinical scientists, the problem is closely related to defining abnormality. Consider the
case of Bill:

February: He cannot leave the house; Bill knows that for a fact. Home is the only place
where he feels safe—safe from humiliation, danger, even ruin. If he were to go to work,
his co-workers would somehow reveal their contempt for him. A pointed remark, a quizzi-
cal look—that’s all it would take for him to get the message. If he were to go shopping,
before long everyone in the store would be staring at him. Surely others would see his dark

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

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

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

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

(AMA 1997; WEEKS & JAMES, 1995)
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Abnormal Psydralagy: Past and Present :11 5

C $E

!hese famous persons have been called
eccentrics. The dictionary defines an

eccentric as a person who deviates from
common behavior patterns or displays odd
or whimsical behavior. But how can we
separate a psychologically healthy person
who has unusual habits from a person
whose oddness is a symptom of psycho-
pathology? Little research has been done
on eccentrics, but a few studies seem to
offer some insights (Pickover, 1999; Weeks
& James, 1995).

Researcher David Weeks studied 1,000
eccentrics and estimated that as many as

1 in 5,000 persons may be “classic, full-
time eccentrics.” Weeks pinpointed 15
characteristics common to the eccentrics in
his study: nonconformity, creativity, strong
curiosity, idealism, extreme interests and
hobbies, lifelong awareness of being dif-
ferent, high intelligence, outspokenness,
noncompetitiveness, unusual eating and
living habits, disinterest in others’ opinions
or company, mischievous sense of humor,
nonmarriage, eldest or only child, and
poor spelling skills.

Weeks suggests that eccentrics do not
typically suffer from mental disorders.

Whereas the unusual behavior of persons
with mental disorders is thrust upon them
and usually causes them suffering, ec-
centricity is chosen freely and provides
pleasure. In short, “Eccentrics know they’re
different and glory in it” (Weeks & James,
1995, p. 14). Similarly, the thought
processes of eccentrics are not severely
disrupted and do not leave these persons
dysfunctional. In fact, Weeks found that
eccentrics in his study actually had fewer
emotional problems than individuals in
the general population. Perhaps being an
“original” is good for mental health.

mood and thoughts; he wouldn’t be able to hide them. He dare not even go for a walk
alone in the woods—his heart would probably start racing again, bringing him to his knees
and leaving him breathless, incoherent, and unable to get home. No, he’s much better off
staying in his room, trying to get through another evening of this curse coiled life.

July: Bill’s life revolves around his circle of friends: Bob and Jack, whom he knows from
the office, where he was recently promoted to director of customer relations, and Frank
and Tim, his weekend tennis partners. The gong meets for dinner every week at some-
one’s house, and they chat about life, politics, and their jobs. Particularly special in Bill’s
life is Lisa. They go to movies, restaurants, and shows together. She thinks Bill’s just
terrific, and Bill finds himself beaming whenever she’s around. Bill looks forward to work
each day and to his one-on-one dealings with customers. He is enjoying life and basking in
the glow of his many activities and relationships.

Bill’s thoughts, feelings, and behavior interfered with all parts of his life in Febru-
ary. Yet most of his symptoms had disappeared by July. All sorts of factors may have
contributed to Bill’s improvement—advice from friends and family members, a new

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job or vacation, or perhaps a big change in his diet or exercise regimen. Any or all of
these things may have been useful to Bill, but they could not be considered treatment,
or therapy. Those terms are usually reserved for special, systematic procedures for help-
ing people overcome their psychological difficulties. According to the clinical theorist
Jerome Frank, all forms of therapy have three key features:

1. A sufferer who seeks relief from the healer.

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

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

(Frank, 1973, pp. 2-3)

Despite this straightforward definition, clinical treatment is surrounded by conflict and
confusion. Carl Rogers, a pioneer in the modern clinical field (you will meet him in
Chapter 2), noted that “therapists are not in agreement as to their goals or aims. . ..They
are not in agreement as to what constitutes a successful outcome of their work. They
cannot agree as to what constitutes a failure. It seems as though the field is completely
chaotic and divided.”

Some clinicians view abnormality as an illness and so consider therapy a procedure
that helps cure the illness. Others see abnormality as a problem in living and therapists as
teachers of more functional behavior and thought. Clinicians even differ on what to call
the person who receives therapy: those who see abnormality as an illness speak of the
“patient,” while those who view it as a problem. in living refer to the “client.” Because
both terms are so common, this book will use them interchangeably.

Despite their differences, most clinicians do agree that large numbers of people need
therapy of one kind or another. Later we shall encounter evidence that therapy is indeed
often helpful (Hofinann & Weinberger, 2007).

What Is Trec ,:ment?

Therapy is a systematic process for helping people overcome their psychological
difficulties. It may differ from problem to problem and from therapist to therapist, but
it typically includes a patient, a therapist, and a series of therapeutic contacts.

*Flow Was Abnormality Viewed
and Treated in the Past?
In any given year as many as 30 percent of the adults and 19 percent of the children and
adolescents in the United States display serious psychological disturbances and are in
need of clinical treatment (Kessler et al., 2009,2007,2005; Kazdin, 2003,2000; Narrow
et al., 2002). The rates in other countries are similarly high. Furthermore, most people
have difficulty coping at various times and go through periods of extreme tension, de-
jection, or other forms of psychological discomfort.

It is tempting to conclude that something about the modern world is responsible
for these many emotional problems—perhaps rapid technological change, the growing
threat of terrorism, or a decline in religious, family, or other support systems (Corner
& Kendall, 2007). Although the pressures of modern life probably do contribute to
psychological dysfunctioning, they are hardly its primary cause. Every society, past and
present, has witnessed psychological abnormality. Perhaps, then, the proper place to
begin our examination of abnormal behavior and treatment is in the past.

6 . //CHAPTER 1

More than a Haircut

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.:•••

Abnormal Psychology: Past and Present :fi 7

Ancient Views and Treatments
Historians who have examined the unearthed bones, artwork, and other remnants
of ancient societies have concluded that these societies probably regarded abnormal
behavior as the work of evil spirits. People in prehistoric societies apparently believed
that all events around and within them resulted from the actions of magical beings
who controlled the world. In particular, they viewed the human body and mind as a
battleground between external forces of good and evil.Abnormal behavior was typically
interpreted as a victory by evil spirits, and the cure for such behavior was to force the
demons from a victim’s body.

This supernatural view of abnormality may have begun as far back as the Stone Age,
a half-million years ago. Some skulls from that period recovered in Europe and South
America show evidence of an operation called trephination, in which a stone instru-
ment, or trephine, was used to cut away a circular section of the skull. Some historians
have concluded that this early operation was performed as a treatment for severe abnor-
mal behavior—either hallucinations, in which people saw or heard things not
actually present, or melancholia, which was characterized by extreme sad-
ness and immobility. The purpose of opening the skull was to release the j
evil spirits that were supposedly causing the problem (Selling, 1940).

Later societies also explained abnormal behavior by pointing to
possession by demons. Egyptian, Chinese, and Hebrew writings all
accounted for psychological deviance this way, and the Bible describes
how an evil spirit from the Lord affected King Saul and how David
pretended to be mad to convince his enemies that he was visited by
divine forces.

The treatment for abnormality in these early societies was often
exorcism. The idea was to coax the evil spirits to leave or to make the
person’s body an uncomfortable place in which to live.A shaman, or
priest, might recite prayers, plead with the evil spirits, insult them,
perform magic, make loud noises, or have the person ingest bitter
drinks. If these techniques failed, the shaman performed a more extreme
form of exorcism, such as whipping or starving the person.

Greek and Roman Views and Treatments
In the years from roughly 500 B.C. to 500 AM. , when the Greek and Roman civilizations
thrived, philosophers and physicians often offered different explanations for abnormal
behaviors. Hippocrates (460-377 B.c.), often called the father of modern medicine,
taught that illnesses had natural causes. He saw abnormal behavior as a disease caused
by internal physical problems. Specifically, he believed that some form of brain disease
was to blame and that it resulted—like all other forms of disease, in his view—front an
imbalance of four fluids, or humors, that flowed through the body: yellow bile, black bile,
blood, and phlegm (Arikha, 2007). An excess of yellow bile, for example, caused frenzied
activity; an excess of black bile was the source of unshakable sadness.

To treat psychological dysfunctioning, Hippocrates sought to correct the underlying
physical pathology. He believed, for instance, that the excess of black bile underlying
sadness could be reduced by a quiet life, a diet of vegetables, exercise, celibacy, and even
bleeding. Hippocrates’ focus on internal causes for abnormal behavior was shared by
the great Greek philosophers Plato (427-347 B.c.) and Aristotle (384-322 B.c.) and by
influential Greek and Roman physicians.

Europe in the Middle Ages: Demonology Returns
The enlightened views of Greek and Roman physicians and scholars were not enough
to shake ordinary people’s belief in demons. And with the decline of Rome, demono-
logical views and practices became popular once again. A growing distrust of science
spread throughout Europe.

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

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

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easylum•A type of institution that first
became popular in the sixteenth century
to provide care for persons with mental
disorders. Most became virtual prisons.

‘moral treatmentDA nineteenth-century
approach to treating people with men-
tal dysfunction that emphasized moral
guidance and humane and respectful
treatment.

From 500 to 1350 A.D., the period known as the Middle Ages, the power of the
clergy increased greatly throughout Europe. In those days the church rejected scientific
Corms of investigation, and it controlled all education. Religious beliefs, which were
highly superstitious and demonological, came to dominate all aspects of life. Once
again behavior was usually interpreted as a conflict between good and evil, God and the
devil. Deviant behavior, particularly psychological dysfunctioning, was seen as evidence
of Satan’s influence. Although some scientists and physicians still insisted on medical
explanations and treatments, their views carried little weight in this atmosphere.

The Middle Ages were a time of great stress and anxiety—a time of war, urban
uprisings, and plagues. People blamed the devil for these troubles and feared being
possessed by him. Abnormal behavior apparently increased greatly during this period
(Henley & Thorne, 2005). In addition, there were outbreaks of mass madness, in which
large numbers of people apparently shared absurd false beliefs and imagined sights or
sounds. In one such disorder, tarantism (also known as Saint Vitus’ dance), groups of people
would suddenly start to jump, dance, and go into convulsions (Sigerist, 1943).All were
convinced that they had been bitten and possessed by a wolf spider, now called a taran-
tula, and they sought to cure their disorder by performing a dance called a tarantella.
In another form of mass madness, lycanthron people thought they were possessed by
wolves or other animals. They acted wolflike and imagined that fur was growing all
over their bodies.

Not surprisingly, some of the earlier demonological treatments for psychological ab-
normality reemerged during the Middle Ages. Once again the key to the cure was to rid
the person’s body of the devil that possessed it. Exorcisms were revived, and clergymen,
who generally were in charge of treatment during this period, would plead, chant, or
pray to the devil or evil spirit (Sluhovsky, 2007). If these techniques did not work, they
had others to try, such as starving, whipping, scalding, or stretching the individual.

It was not until the Middle Ages drew to a close that demonology and its meth-
ods began to lose favor. Towns throughout Europe grew into cities, and government
officials gained more power and took over nonreligious activities. Among their other
responsibilities, they began to run hospitals and direct the care of people suffering from
mental disorders. Medical views of abnormality gained favor, and many people with
psychological disturbances received treatment in medical hospitals, such as the Trinity
Hospital in England (Allderidge, 1979, p. 322).

The Renaissance and the Rise of Asylums
During the early part of the Renaissance, a period of flourishing cultural and scientific
activity from about 1400 to 1700, demonological views of abnormality continued to
decline. German doctor Johann Weyer (1515-1588), the first physician to specialize in
mental illness, believed that the mind was as susceptible to sickness as the body was. He
is now considered the founder of the modern study of psychopathology.

The care of people with mental disorders continued to improve in this
atmosphere. In England such individuals might be kept at home while
their families were aided financially by the local parish. Across Europe
religious shrines were devoted to the humane and loving treatment of
people with mental disorders. Perhaps the best known of these shrines was
at Gheel in Belgium. Beginning in the fifteenth century, people came to it
from all over the world for psychic healing. Local residents welcomed these
pilgrims into their homes, and many stayed on to form the world’s first
“colony” of mental patients. Gheel was the forerunner of today’s community
mental health programs, and it continues to demonstrate that people with
psychological disorders can respond to loving care and respectful treatment
(van Walsum, 2004; Aring, 1975, 1974). Many patients still live in foster
homes there, interacting with other residents, until they recover.

Unfortunately, these improvements in care began to fade by the mid-
sixteenth century. Government officials discovered that private homes and

8 ://CHAPTER

Abnormal Psychology: Past and Present :// 9

community residences could house only a small percentage of those with
severe mental disorders and that medical hospitals were too few and too small.
More and more, they converted hospitals and monasteries into asylums, in-
stitutions whose primary purpose was to care for people with mental illness.
These institutions began with every intention of providing good care. Once
the asylums started to overflow; however, they became virtual prisons where
patients were held in filthy conditions and treated with unspeakable cruelty.

In 1547, for example, Bethlehem Hospital was given to the city of Lon-
don by Henry VIII for the sole purpose of confining the mentally ill. In this
asylum patients bound in chains cried out for all to hear.The hospital actually
became a popular tourist attraction; people were eager to pay to look at the
howling and gibbering inmates.The hospital’s name, pronounced “Bedlam” by the local
people, has come to mean a chaotic uproar.

The Nineteenth Century: Reform and Moral Treatment
As 1800 approached, the treatment of people with mental disorders began to improve
once again (Maher & Maher, 2003). Historians usually point to La Bic6tre, an asylum
in Paris for male patients, as the first site of asylum reform. In 1793, during the French
Revolution, Philippe Pinel (1745-1826) was named the chief physician there. He ar-
gued that the patients were sick people whose illnesses should be treated with sympathy
and kindness rather than chains and beatings (van Walsum, 2004). He allowed them to
move freely about the hospital grounds, replaced the dark dungeons with sunny, well-
ventilated rooms, and offered support and advice. Pinel’s approach proved remarkably
successful. Many patients who had been shut away for decades improved greatly over a
short period of time and were released. Pinel later brought similar reforms to a mental
hospital in Paris for female patients, La Salpetriere.

Meanwhile, an English Quaker named William Tuke (1732-1819) was bringing
similar reforms to northern England. In 1796 he founded theYork Retreat, a rural estate
where about 30 mental patients lived as guests in quiet country houses and were treated
with a combination of rest, talk, prayer, and manual work (Charland, 2007).

The Spread of Mor i Tref trnent The methods of Pinel and Tuke, called moral
treatment because they emphasized moral guidance and humane and respectful tech-
niques, caught on throughout Europe and the United States. Patients with psychologi-
cal problems were increasingly perceived as potentially
productive human beings whose mental functioning had
broken down under stress.They were considered deserv-
ing of individual care, including discussions of their prob-
lems, useful activities, work, companionship, and quiet.

The person most responsible for the early spread
of moral treatment in the United States was Benjamin
Rush (1745-1813), an eminent physician at Pennsylvania
Hospital who is now considered the father of American
psychiatry. Limiting his practice to mental illness, Rush
developed humane approaches to treatment (Whitaker,
2002). For example, lie required that the hospital hire
intelligent and sensitive attendants to work closely with
patients, reading and talking to them and taking them
on regular walks. He also suggested that it would be
therapeutic for doctors to give small gifts to their patients
now and then.

Rush’s work was influential, but it was a Boston
schoolteacher named Dorothea Dix (1802-1887) who
made humane care a public concern in the United States.
From 1841 to 1881 Dix went from state legislature to

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state legislature and to Congress speaking of the horrors she had
observed at asylums and calling for reform. Dix’s campaign led to
new laws and greater government funding to improve the treatment
of people with mental disorders. Each state was made responsible for
developing effective public mental hospitals, or state hospitals, all of
which intended to offer moral treatment (Boardman & Makari, 2007).
Similar hospitals were established throughout Europe.

The Decline of Moral Treatment By the 1850s, a number of
mental hospitals throughout Europe and America reported success
using moral approaches. By the end of that century, however, several
factors led to a reversal of the moral treatment movement (Bockoven,
1963). One factor was the speed with which the movement had spread.
As mental hospitals multiplied, severe money and staffing shortages
developed, and recovery rates declined.Another factor was the assump-
tion behind moral treatment that all patients could be cured if treated
with humanity and dignity. For some, this was indeed sufficient. Others,
however, needed more effective treatments than any that had yet been
developed. An additional factor contributing to the decline of moral

treatment was the emergence of a new wave of prejudice against people with mental
disorders. As more and more patients disappeared into large, distant mental hospitals,
the public came to view them as strange and dangerous. In turn, people were less open-
handed when it came to making donations or allocating government funds.

By the early years of the twentieth century, the moral treatment movement had
ground to a halt in both the United States and Europe. Public mental hospitals were
providing only custodial care and ineffective medical treatments and were becoming
more overcrowded every year. Long-term hospitalization became the rule once again.

• state hospitals•State-run public mental
institutions in the United States.

• somatogenic perspective•The view
that abnormal psychological Functioning
has physical causes.

spsychoenic perspective•The view
that the chief causes of abnormal func-
tioning are psychological.

The Early Twentieth Century:
The Somatogenic and Psychogenic Perspectives
As the moral movement was declining in the late 1800s, two opposing perspectives
emerged and began to compete for the attention of clinicians: the somatogenic per-
spective, the view that abnormal psychological functioning has physical causes, and the
psychogenic perspective, the view that the chief causes of abnormal functioning are
psychological. These perspectives came into full bloom during the twentieth century.

The Sornatogenic Perspective The somatogenic perspective has at least a 2,400-
year history—remember Hippocrates’ view that abnormal behavior resulted from brain
disease and an imbalance of humors? Not until the late nineteenth century, however, did
this perspective make a triumphant return and begin to gain wide acceptance.

Two factors were responsible for this rebirth. One was the work of an eminent
German researcher, Emil Kraepelin (1856-1926). In 1883 Kraepelin published an influ-
ential textbook arguing that physical factors, such as fatigue, are responsible for mental
dysfunction. In addition, as you will see in Chapter 3, he developed the first modern
system for classifying abnormal behavior (de Vries et al., 2008; Engstrom et al., 2006).

New biological discoveries also triggered the rise of the somatogenic perspective.
One of the most important discoveries was that an organic disease, syphilis, led to gen-
eral paresis, an irreversible disorder with both physical and mental symptoms, including
paralysis and delusions of grandeur. In 1897 Richard von Krafft-Ebing (1840-1902),
a German neurologist, injected matter from syphilis sores into patients suffering from
general paresis and found that none of the patients developed symptoms of syphilis.
Their immunity could have been caused only by an earlier case of syphilis. Since all
patients with general paresis were now immune to syphilis, Krafft-Ebing theorized that
syphilis had been the cause of their general paresis.

The work of Kraepelin and the new understanding of general paresis led many
researchers and practitioners to suspect that physical factors were responsible for many

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Abnormal Psyrbolog: Past and Present :// 11

mental disorders, perhaps all of them. These theories and the possibility of quick medi-
cal solutions for mental disorders were especially welcomed by those who worked in
mental hospitals, where patient populations were now growing at an alarming rate.

Despite the general optimism, biological approaches yielded mostly disappointing
results throughout the first half of the twentieth century. Although many medical treat-
ments were developed for patients in mental hospitals during that time, most of the
techniques failed to work. Physicians tried tooth extraction, tonsillectomy, hydrotherapy
(alternating hot and cold baths), and lobotomy, a surgical cutting of certain nerve fibers
in the brain. Even worse, biological views and claims led, in some circles, to proposals
for immoral solutions such as eugenic sterilization, the elimination (through medical or
other means) of individuals’ ability to reproduce (see Table 1-1). Not until the 1950s,
when a number of effective medications were finally discovered, did the somatogenic
perspective truly begin to pay off for patients.

The Psychogenic Perspective The late nineteenth century also saw the emer-
gence of the psychogenic perspective, the view that the chief causes of abnormal func-
tioning are often psychological. This view, too, had a long history, but it did not gain
much of a following until studies of hypnotism demonstrated its potential.

Hypnotism is a procedure that places people in a trancelike mental state during
which they become extremely suggestible. It was used to help treat psychological dis-
orders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer
(1734-1815) started a clinic in Paris. His patients suffered from hysterical disorders, mys-
terious bodily ailments that had no apparent physical basis. Mesmer had his patients sit
in a darkened room filled with music; then he appeared, dressed in a colorful costume,
and touched the troubled area of each patient’s body with a special rod. A surprising
number of patients seemed to be helped by this treatment, called mesmerism. Their pain,
numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing
a trancelike state in his patients and that this state was causing their symptoms to disap-
pear (Marcel, 2009; Lynn & Kirsch, 2006).The treatment was so controversial, however,
that eventually Mesmer was banished from Paris.

Eugenics and Mental Disorders

Year Event
1896 Connecticut became the first state in the United States to prohibit

persons with mental disorders from marrying.

1896-1933 Every state in the United States passed a law prohibiting marriage by
persons with mental disorders.

1907 Indiana became the first state to pass a bill calling for people with
mental disorders, as well as criminals and other “defectives,” to
undergo sterilization.

1927 The U.S. Supreme Court ruled that eugenic sterilization was
constitutional.

1907-1945 Around 45,000 Americans were sterilized under eugenic sterilization
laws; 21,000 of them were patients in state mental hospitals.

1929-1932 Denmark, Norway, Sweden, Finland, and Iceland passed eugenic
sterilization laws.

1933 Germany passed a eugenic sterilization law, under which 375,000
people were sterilized by 1940.

1940 Nazi Germany began to use “proper gases” to kill people with mental
disorders; 70,000 or more people were killed in less than two years.

Source: Whitaker, 2002. 1

abnormal
psychopathology
psychiatric

maladjustment

insanity
distressed
disturbed unbalanced unstable freak-out

mental
illness

“nuts”
(slang)

mentally
handicapped

deviant

psychological

buts
, use words like “abnormal” and

‘ I “mental disorder” so often that it is
easy to forget that there was a time not

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

print as expressions of psychological dys-
functioning? The Oxford English Dictionary
offers the following dates.

1300 1400

madness

1600

“crazy”
(slang)

1700 1800 1900 2000

dysfunctional

1500 1200

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It was not until years after Mesmer died that many researchers
had the courage to investigate his procedure, later called hypnotism
(from hypnos, the Greek word for “sleep”), and its effects on hysteri-
cal disorders. The experiments of two physicians practicing in the city
of Nancy in France, Hippolyte-Marie Bernheim (1840-1919) and
Ambroise-Auguste Liebault (1823-1904), showed that hysterical dis-
orders could actually be produced in otherwise normal people while
they were under the influence of hypnosis.That is, the physicians could
make normal people experience deafness, paralysis, blindness, or numb-
ness by means of hypnotic suggestion—and they could remove these
artificial symptoms by the same means. Thus they established that a
mental process—hypnotic suggestion—could both cause and cure even
a physical dysfunction. Leading scientists concluded that hysterical
disorders were largely psychological in origin, and the psychogenic
perspective rose in popularity.

Among those who studied the effects of hypnotism on hysterical disorders was Josef
Breuer (1842-1925) of Vienna. This physician discovered that his patients sometimes
awoke free of hysterical symptoms after speaking candidly under hypnosis about past
upsetting events. During the 1890s Breuer was joined in his work by another Viennese
physician, Sigmund Freud (1856-1939). As you will see in Chapter 2, Freud’s work
eventually led him to develop the theory of psychoanalysis, which holds that many
forms of abnormal and normal psychological functioning are psychogenic. In particular,
he believed that unconscious psychological processes are at the root of such functioning.

Freud also developed the technique of psychoanalysis, a form of discussion in which
clinicians help troubled people gain insight into their unconscious psychological pro-
cesses. He believed that such insight, even without hypnotic procedures, would help the
patients overcome their psychological problems.

Freud and his followers offered psychoanalytic treatment primarily to those patients
who did not typically require hospitalization. These patients visited therapists in their
offices for sessions of approximately an hour and then went about their daily activities—
a format of treatment now known as outpatient therapy. By the early twentieth century,
psychoanalytic theory and treatment were widely accepted throughout the Western
world.

12 :41/CHAPTER

Ati.,74[11r;

Abnormal Psychology: Past and Present :1/ 13

•psychoanalysis.Either the theory or
the treatment of abnormal mental func-
tioning that emphasizes unconscious
psychological forces as the cause of
psychopathology.

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

How Was Abnormality Viewed and Treated in the Past?

The history of psychological disorders stretches back to ancient times. Prehistoric
societies apparently viewed abnormal behavior as the work of evil spirits. There
is evidence that Stone Age cultures used trephination, a primitive form of brain
surgery, to treat abnormal behavior. People of early societies also sought to drive
out evil spirits by exorcism.

Physicians of the Greek and Roman empires offered more enlightened explana-
tions of mental disorders. Hippocrates believed that abnormal behavior was caused
by an imbalance of the four bodily fluids, or humors.

Unfortunately, throughout history each period of enlightened thinking about
psychological functioning has been followed by a period of backward thinking. In
the Middle Ages, for example, Europeans returned to demonological explanations
of abnormal behavior. The clergy was very influential and held that mental disorders
were the work of the devil. As the Middle Ages drew to a close, such explana-
tions and treatments began to decline, and care of people with mental disorders
improved during the early part of the Renaissance. Certain religious shrines offered
humane treatment. Unfortunately, this enlightened approach was short-lived, and
by the middle of the sixteenth century persons with mental disorders were being
warehoused in asylums.

Care of people with mental disorders started to improve again in the nine-
teenth century. Moral treatment began in Europe and spread to the United States,
where Dorothea Dix’s national campaign helped lead to the establishment of state
hospitals. Unfortunately, the moral treatment movement disintegrated by the late
nineteenth century, and public mental hospitals again became warehouses where
inmates received minimal care.

The turn of the twentieth century saw the return of the

somatogenic perspective,

the view that abnormal psychological functioning is caused primarily by physical
factors. The same period saw the rise of the psychogenic perspective, the view
that the chief causes of abnormal functioning are psychological. Sigmund Freud’s
psychogenic approach, psychoanalysis, eventually gained wide acceptance and
influenced future generations of clinicians.

“,`Current Trends
It would hardly be accurate to say that we now live in a period of great enlightenment
about or dependable treatment of mental disorders. In fact, surveys have found that 43
percent of respondents believe that people bring mental disorders on themselves and
that 35 percent consider such disorders to be caused by sinful behavior (Stanford, 2007;
NMHA, 1999). Nevertheless, the past 50 years have brought major changes in the
ways clinicians understand and treat abnormal functioning. More theories and types of
treatment exist, as do more research studies, more information, and, perhaps for these
reasons, more disagreements about abnormal functioning today than at any time in
the past. In some ways the study and treatment of psychological disorders have come a
long way, but in other respects clinical scientists and practitioners are still struggling to
make a difference.

How Are People with Severe Disturbances Cared For?
In the 1950s researchers discovered a number of new psychotropic medications—
drugs that primarily affect the brain and reduce many symptoms of mental dysfunction-
ing. They included the first antipsychotic drugs, which correct extremely confused and

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1950 1990 2000

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distorted thinking; antidepressant drugs, which lift the mood of depressed
people; and antianxiety drugs, which reduce tension and worry.

When given these drugs, many patients who had spent years in
mental hospitals began to show signs of improvement. Hospital ad-
ministrators, encouraged by these results and pressured by a growing
public outcry over the terrible conditions in public mental hospitals,
began to discharge patients almost immediately.

After the discovery of these medications, mental health profession-
als in most of the developed nations of the world followed a policy of
deinstitutionalization, releasing hundreds of thousands of patients
from public mental hospitals. On any given day in 1955, close to
600,000 people lived in public mental institutions across the United
States (see Figure 1-1). Today the daily patient population in the same
kinds of hospitals is around 60,000 (Torrey, 2006, 2001).

In short, outpatient care has now become the primary mode of
treatment for people with severe psychological disturbances as well as
for those with more moderate problems. Today when very disturbed
people do need institutionalization, they are usually given short-term
hospitalization. Ideally, they are then given outpatient psychotherapy
and medication in community programs and residences (McEvoy &
Richards, 2007).

Chapters 2 and 12 will look more closely at this recent emphasis on cornmu-
nity care for people with severe psychological disturbances—a philosophy called the
community mental health approach. The approach has been helpful for many patients, but
too few community programs are available to address current needs in the United States
(Rosenberg & Rosenberg, 2006). As a result, hundreds of thousands of persons with
severe disturbances fail to make lasting recoveries, and they shuttle back and forth be-
tween the mental hospital and the community. After release from the hospital, they at
best receive minimal care and often wind up living in decrepit rooming houses or on
the streets. In fact, only 40 percent of persons with severe psychological disturbances
currently receive treatment of any kind (Wang et al., 2007, 2005). At least 100,000
individuals with such disturbances are homeless on any given day; another 135,000
or more are inmates of jails and prisons (Bonin et al., 2009; Cutler et al., 2002). Their
abandonment is truly a national disgrace.

14 ://CHAPTER 1

How Are People with Less Severe Disturbances Treated?
The treatment picture for people with moderate psychological disturbances has been
more positive than that for people with severe disorders. Since the 1950s, outpatient

care has continued to be the preferred mode of treatment for them,

of the

leis
opy _or ropy

f people with Mild to se-ver,
ogical disturbances is widely avai

‘dIvidual , group, and family farM

and the number and types of facilities that offer such care have
expanded to meet the need.

Before the 1950s, almost all outpatient care took the form of
private psychotherapy, an arrangement by which an individual directly
pays a psychotherapist for counseling services.This tended to be an
expensive form of treatment, available only to the wealthy. Since
the 1950s, however, most health insurance plans have expanded
coverage to include private psychotherapy, so that it is now also
widely available to people with more modest incomes. In addition,
outpatient therapy is now offered in a number of less expensive set-
tings, such as community mental health centers, crisis intervention
centers, family service centers, and other social service agencies.
The new settings have spurred a dramatic increase in the number of
persons seeking outpatient care for psychological problems. Surveys
suggest that nearly 1 of every 5 adults in the United States receives
treatment for psychological disorders in the course of a year (Wang

Abnormal Psychology: Past and Present 1 5

_rn Pressures: Modern Problems
he twenty-first century, like each of
the centuries before it, has spawned

new fears that are tied to its unique techno-
logical advances, community threats, and
environmental dangers. These fears have
received little study. They may or may not
reflect abnormal functioning. Indeed, we
could argue that some of them represent
appropriate concerns about very real
problems. Either way, they have caught the
attention of the media and clinical observ-
ers and, perhaps most importantly, have
received catchy names.

“Ea:I-Anxiety” People who suffer from
this problem are tormented by concern
and a sense of doom over our polluted
and endangered environment. They often
complain of panic attacks, loss of appe-
tite, irritability, and unexplained bouts of
weakness and sleeplessness. These fears
are fueled by abundant media cover-
age of crises such as global warming,
collapsed fisheries, and food shortages
(Nobel, 2007). A treatment approach
called ecopsychology is now practiced
by hundreds of therapists to help reduce
the anxiety of such individuals (Glaser,
2008).

“Terrorism Terror” Global terrorism
is a major source of anxiety in contem-
porary society, particularly since the Sep-
tember 11, 2001, attacks on the World
Trade Center in New York City and the
Pentagon in Washington, DC. Everyday
hassles of the past have turned into po-
tential threats by their association with
the actions of terrorists (Furedi, 2007).
When boarding planes, subway cars,
or buses, for example, many travelers

who formerly worried only about the low
risks of flying or the possibility of being
late for work may now find themselves
worrying that the transporting vehicles
are about to become targets or tools of
terrorist actions.

“Crime Phobia” People today have
become increasingly anxious about
crime. Some observers note that the
fear of crime—predominantly armed
violence—has restructured the lives of
Americans. Says political scientist Jona-
than Simon, “Fear of crime governs us
in our choices of where to live, where
to work, where to send our children to
school” (quoted in Bergquist, 2002).
Many theorists point to disproportionate
media coverage of violent crimes as a
major cause of crime phobia, particu-
larly given that crime anxiety seems to

keep rising even while actual crime rates
are falling (Stearns, 2006).

“Cyber Fear” Some people, particu-
larly individuals in the workplace, are
literally afraid of their computers. They
fear that they will break the computers or
be unable to learn new computer tasks.
Among more sophisticated computer
users, many live in fear of computer
crashes, server overloads, or computer
viruses. And some, stricken by a combi-
nation of crime phobia and cyber fear,
worry constantly about e-crimes, such as
computer hoaxes or scams, computer-
identity theft, or cyberterrorism. The flip
side of cyber fear is Internet addiction,
the uncontrollable need to be online—yet
another technology-driven problem that
you’ll be coming across in Chapter 13.

et al., 2007, 2005). The majority of clients are seen for fewer than five sessions during
the year.

Outpatient treatments are also becoming available for more and more kinds of
problems. When Freud and his colleagues first began to practice, most of their patients
suffered from anxiety or depression.Almost half of today’s clients suffer from those same
problems, but people with other kinds of disorders are also receiving therapy. In addition,
at least 20 percent of clients enter therapy because of problems in living—problems with
marital, family, job, peer, school, or community relationships (Druss et al., 2007).

•cieinstitutionaiization•The practice,
begun in the 1960s, of releasing hun-
dreds of thousands of patients from
public mental hospitals.

16 ://CHAPTER 1

• prevention•Interventions aimed at
deterring disorders before they develop.

•positive psychology•The study and
enhancement of positive feelings, traits,
and abilities.

•multicultural psychology•The field
that examines the impact of culture, race,
gender, and similar factors on our behav-
iors and focuses on how such factors
may influence abnormal behavior.

•managed care program•A system
of health care coverage in which the
insurance company largely controls the
nature, scope, and cost of services.

Yet another change in outpatient care since the 1950s has been the development of
programs devoted exclusively to one kind of psychological problem. We now have, for
example, suicide prevention centers, substance abuse programs, eating disorder programs,
phobia clinics, and sexual dysfunction programs. Clinicians in these programs have the
kind of expertise that can be acquired only by concentration in a single area.

A Growing Emphasis on Preventing Disorders
and Promoting Mental Health
Although the community mental health approach often has failed to address the needs
of people with severe disorders, it has given rise to an important principle of mental
health care—prevention (Evans, 2009; Bond & Hauf, 2007). Rather than wait for
psychological disorders to occur, many of today’s community programs try to correct
the social conditions that give rise to psychological problems (poverty or community
violence, for example) and to help individuals who are at risk for developing emotional
problems (for example, teenage mothers or the children of people with severe psycho-
logical disorders). As you will see later, community prevention programs are not always
successful and they often suffer from limited funding, but they have grown in number
throughout the United States and Europe, offering great promise as the ultimate form
of intervention.

Psychology: Happiness Is All Around Us
6udging from many websites, TV news

:gshows, and the spread of self-help

books, you might think that happiness is

rare. But there’s good news. Research
indicates that people’s lives are, in gen-
eral, more upbeat than we think. In fact,

most people around the world say
they’re happy—including most of
those who are poor, unemployed,
elderly, and disabled (Becchetti &
Santoro, 2007; Pugno, 2007).
Men and women are equally
likely to declare themselves sat-
isfied or very happy. Wealthy
people appear only slightly hap-
pier than those of modest means
(Easterbrook, 2005; Diener et al.,
1993). Overall, only 1 person in
10 reports being “not too happy”
(Myers, 2000; Myers & Diener,
1996), and only 1 in 7 reports
waking up unhappy (Wallis,
2005).

Of course, some people are indeed
happier than others. Particularly happy
people seem to remain happy from decade
to decade, regardless of job changes,
moves, and family changes (Becchetti &
Santoro, 2007; Diener et al., 2000).
Such people adjust to negative events and
return to their usual cheerful state within a
few months (Diener et al., 2009, 2006,
1992). Conversely, unhappy people are
not cheered in the long term even by posi-
tive events.

Some research indicates that happiness
is linked to personality characteristics and
interpretive styles (Diener et al., 2006;
Stewart et al., 2005). Happy people are,
for example, generally optimistic, outgoing,
curious, and tender-minded; they also tend
to persevere, have several close friends,
possess high self-esteem, be spiritual, and
have a sense of control over their lives
(Peterson et al., 2007; Sahoo et al., 2005).

A better understanding of the roots of
happiness is likely to emerge from the cur-
rent flurry of research. In the meantime, we
can take comfort in the knowledge that the
human condition isn’t quite as unhappy as
news stories (and textbooks on abnormal
psychology) may make it seem.

Abnormal Psychology: Past and Present :1/ 17

Prevention programs have been further energized in the past few years by the field
of psychology’s growing interest in positive psychology (Seligman, 2007). Positive
psychology is the study and encouragement of positive feelings such as optimism and
happiness; positive traits like hard work and wisdom; positive abilities such as social skills;
and group-directed virtues, including generosity and tolerance.

In the clinical arena, positive psychology suggests that practitioners can help people
best by promoting positive development and psychological wellness. While researchers
study and learn more about positive psychology in the laboratory, clinicians with this
orientation teach people coping skills that help protect them from stress and adversity
and encourage them to become more involved in meaningful activities and relationships
(Bond & Hauf, 2007). In this way, the clinicians are trying to promote mental health
and prevent mental disorders.

Multicultural Psychology
We are, without question, a society of multiple cultures, races, and languages. Indeed, in
the coming decades, members of racial and ethnic minority groups in the United States
will, collectively, outnumber white Americans (Gordon, 2005; U.S. Census Bureau,
2000). This change is partly because of shifts in immigration trends and partly because
of higher birth rates among minority groups in the United States.The majority of new
immigrants to this country are Hispanic (34 percent) or Asian (34 percent). Moreover,
while the average number of children born to white Americans is 1.7, the number born
to African Americans and Hispanic Americans is 2.4 and 2.9, respectively.

In response to this growing diversity, a new area of study called multicultural
psychology has emerged. Multicultural psychologists seek to understand how culture,
race, ethnicity, gender, and similar factors affect behavior and thought and how people
of different cultures, races, and genders may differ psychologically (Alegria et al., 2009,
2007, 2004). As you will see throughout this book, the field of multicultural psychology
has begun to have a powerful effect on our understanding and treatment of abnormal
behavior.

The Growing Influence of Insurance Coverage
So many people now seek therapy that private insurance companies have changed their
coverage for mental health patients.Today the leading form of coverage is the managed
care program—a program in which the insurance company determines such key
issues as which therapists its clients may choose, the cost of sessions, and the number of
sessions for which a client may be reimbursed (Shore, 2007; Reed & Eisman, 2006).

At least 75 percent of all privately insured persons in the United States are cur-
rently enrolled in managed care programs (Deb et al., 2006; Kiesler, 2000).The coverage
for mental health treatment under such programs follows the same basic principles as
coverage for medical treatment, including a limited pool of practitioners from which
patients can choose, preapproval of treatment by the insurance company, strict standards
for judging whether problems and treatments qualify for reimbursement, and ongoing
reviews and assessments. In the mental health realm, both therapists and clients typically
dislike managed care programs (Cutler, 2007). They fear that the programs inevitably
shorten therapy (often for the worse), unfairly favor treatments whose results are not
always lasting (for example, drug therapy), pose a special hardship for those with severe
mental disorders, and put control of therapy into the hands of the insurance companies
rather than the therapists (Whitaker, 2007).

A key problem with insurance coverage—both managed care and other kinds of
insurance programs—is that reimbursements for mental disorders tend to be lower than
those for medical disorders. This places persons with psychological difficulties at a dis-
tinct disadvantage. Recently the federal government and 35 states passed so-called parity
laws that direct insurance companies to provide equal coverage for mental and medical
problems (Pear, 2008; Steverman, 2007). It is not yet clear, however, whether these laws
will indeed lead to improved coverage or better treatment (Busch et al., 2006).

Gender Shift

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Profiles of Mental Health Professionals in the United States

Degree
Began to
Practice

Current
Number

Percent
Female

Psychiatrists M.D., D.O. 1840s 33,000 25

Psychologists Ph.D., Psy.D., Ed.D. Late 1940s 152,000 52

Social workers M.S.W., D.S.W. Early 1950s 405,000 77

Counselors Various Early 1950s 375,000 50

Source: U.S. Bureau of Labor Statistics, 2008, 2002;
AMA, 2007; APA, 2005; Weissman, 2000.

18 ://CHAPTER 1

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What Are Today’s Leading Theories
and Professions?
One of the most important developments in the clinical field
has been the growth of numerous theoretical perspectives
that now coexist in the clinical field. Before the 1950s, the
psychoanalytic perspective, with its emphasis on unconscious
psychological problems as the cause of abnormal behavior, was
dominant. Then the discovery of effective psychotropic drugs
inspired new respect for the somatogenic, or biological, view.
As you will see in Chapter 2, other influential perspectives
that have emerged since the 1950s are the behavioral, cognitive,
humanistic-existential, and sociocultural schools of thought. At
present no single viewpoint dominates the clinical field as the
psychoanalytic perspective once did. In fact, the perspectives
often conflict and compete with one another, yet in some
instances they complement each other and together provide

more complete explanations and treatments for psychological disorders.
In addition, a variety of professionals now offer help to people with psychological

problems (Wang et al., 2006). Before the 1950s, psychotherapy was offered only by psy-
chiatrists, physicians who complete three to four additional years of training after medical
school (a residency) in the treatment of abnormal mental functioning. After World War
II, however, with millions of soldiers returning home to countries throughout North
America and Europe, the demand for mental health services expanded so rapidly that
other professional groups had to step in to fill the need.

Among those other groups are clinical psychologists—professionals who earn a doc-
torate in clinical psychology by completing four to five years of graduate training in
abnormal functioning and its treatment and also complete a one-year internship at a
mental health setting. Psychotherapy and related services are also provided by counseling
psychologists, educational and school psychologists, psychiatric nurses, marriage therapists, family
therapists, and—the largest group psychiatricsocial workers (see Table 1-2). Each of these
specialties has its own graduate training programs. Theoretically, each conducts therapy
in a distinctive way, but in reality clinicians from the various specialties often use similar
techniques.

One final key development in the study and treatment of mental disorders since
World War II has been a growing appreciation of the need for effective research
(Goodwin, 2007, 2002). Clinical researchers have tried to determine which concepts best

explain and predict abnormal behavior, which treatments are most effective, and what
kinds of changes may be required. Today well-trained clinical researchers conduct stud-
ies in universities, medical schools, laboratories, mental hospitals, mental health centers,
and other clinical settings throughout the world.

Abnormal Psychology: Past and Present :1/ 19

•scientific method•The process of
systematically gathering and evaluating
information through careful observa-
tions to gain an understanding of a
phenomenon.

Current Trends

In the 1950s, researchers discovered a number of new psychotropic medications,
drugs that mainly affect the brain and reduce many symptoms of mental dysfunc-
tioning. Their success contributed to a policy of deinstitutionalization, under which
hundreds of thousands of patients were released from public mental hospitals. In
addition, outpatient treatment has become the main approach for most persons
with mental disorders, both mild and severe; prevention programs are growing in
number and influence; the field of multicultural psychology has begun to influence
how clinicians view and treat abnormality; and insurance coverage is having a
significant impact on the way treatment is conducted. Finally, a variety of perspec-
tives and professionals have come to operate in the field of abnormal psychology,
and many well-trained clinical researchers now investigate the field’s theories and
treatments.

*What Do Clinical Researchers Do?
Research is the key to accuracy in all fields of study; it is particularly important in
abnormal psychology because wrong beliefs in this field can lead to great suffering. At
the same time, clinical researchers, also called clinical scientists, face certain challenges
that make their work very difficult. They must figure out how to measure such elusive
concepts as unconscious motives, private thoughts, mood changes, and human potential;
they must consider the different cultural backgrounds, races, and genders of the people
they choose to study; and they must always ensure that the rights of their research
participants, both human and animal, are not violated (Barnard, 2007; Kazdin, 2003).
Let us examine the leading methods used by today’s researchers so that we can better
understand their work and judge their findings.

Clinical researchers try to discover broad laws, or principles, of abnormal psycho-
logical functioning. They search for a general, or nomothetic, understanding of the the
nature, causes, and treatments of abnormality (Harris, 2003).They do not typically assess,
diagnose, or treat individual clients; that is the job of clinical practitioners.To gain broad
insights, clinical researchers, like scientists in other fields, use the scientific method—
that is, they collect and evaluate information through careful observations.These obser-
vations in turn enable them to pinpoint and explain relationships between variables.

Simply stated, a variable is any characteristic or event that can vary, whether from
time to time, from place to place, or from person to person.Age, sex, and race are human
variables. So are eye color, occupation, and social status. Clinical researchers
are interested in variables such as childhood upsets, present life experiences,
moods, social functioning, and responses to treatment. They try to deter-
mine whether two or more such variables change together and whether a
change in one variable causes a change in another.Will the death of a parent
cause a child to become depressed? If so, will a given treatment reduce that
depression?

Such questions cannot be answered by logic alone because scientists, like
all human beings, frequently make errors in thinking. Thus clinical research-
ers rely mainly on three methods of investigation: the case study, which typi-
cally focuses on one individual, and the correlational method and experimental
method, approaches that usually gather information about many individuals.
Each is best suited to certain kinds of circumstances and questions (Martin
& Hull, 2007). As a group, these methods enable scientists to form and test
hypotheses, or hunches, that certain variables are related in certain ways—and
to draw broad conclusions as to why.

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20 :A/CHAPTER 1

The Case Study
A case study is a detailed description of one person’s life and psychological problems.
It describes the person’s history, present circumstances, and symptoms. It may also specu-
late about why the problems developed, and it may describe the person’s treatment. One
of the field’s best known case studies, called The Three Faces of Eve, describes a woman
with dissociative identity disorder; or multiple personality disorder. The case study focuses
on the woman’s three alternating personalities, each having a distinct set of memories,
preferences, and personal habits (Thigpen & Cleckley, 1957).

Most clinicians take notes and keep records in the course of treating their patients,
and some further organize those notes into a formal case study to be shared with other
professionals.The clues offered by a case study may help a clinician better understand or
treat the person under discussion (Stricker & Trierweiler, 1995). In addition, case stud-
ies may play nomothetic roles that go far beyond the individual clinical case (Martin
Sc Hull, 2007).

How Are Case Studies Helpful? Case studies can be a source of new ideas about
behavior and “open the way for discoveries” (Bolgar, 1965). Freud’s theory of psycho-
analysis was based mainly on the patients he saw in private practice. In addition, a case
study may offer tentative support for a theory. Freud used case studies in this way as well,
regarding them as evidence for the accuracy of his ideas. Conversely, case studies may
serve to challenge a theory’s assumptions (Elms, 2007).

Case studies may also show the value of new therapeutic techniques or unique applica-
tions of existing techniques. And, finally, case studies may offer opportunities to study
unusual problems that do not occur often enough to permit a large number of obser-
vations (Martin & Hull, 2007). Investigators of problems such as multiple personality
disorder once relied entirely on case studies for information.

What Are the Limitations of Case Studies? Case studies also have limita-
tions. First, they are reported by biased observers, that is, by therapists who have a personal
stake in seeing their treatments succeed (Markin & Kivlighan, 2007).The therapists must
choose what to include in a case study, and their choices may at times be self-serving.
Second, case studies rely upon subjective evidence. Is a client’s problem really caused by the
events that the therapist or client says are responsible? After all, those are only a fraction of
the events that may be contributing to the situation. Finally, case studies provide little basis

for generalization. Events or treatments that seem important in one case may be of no help
at all in efforts to understand or treat others.

The limitations of the case study are largely addressed by two other methods of
investigation: the correlational method and the experimental method. They do not offer the
rich detail that makes case studies so interesting, but they do help investigators draw
broad conclusions about abnormality in the population at large. Thus they are now the
preferred methods of clinical investigation.

Three features of the correlational and experimental methods enable clinical inves-
tigators to gain general insights: (1) The researchers typically observe many individuals;
(2) the researchers apply procedures uniformly, and can thus repeat, or replicate, their
investigations; and (3) the researchers use statistical tests to analyze the results of a study.

The Correlational Method
Correlation is the degree to which events or characteristics vary with each other.The
correlational method is a research procedure used to determine this “co-relationship”
between variables. This method can, for example, answer the question, “Is there a cor-
relation between the amount of stress in people’s lives and the degree of depression they
experience?” That is, as people keep experiencing stressful events, are they increasingly
likely to become depressed?

To test this question, researchers have collected life stress scores (for example, the
number of threatening events experienced during a certain period of time) and de-
pression scores (for example, scores on a depression survey) from individuals and have

`outtt ,‘ 0

Abnormal Psychology: Past and Present :// 21

correlated these scores. The people who are chosen for a study are its subjects, or
participants, the term preferred by today’s investigators. Typically, investigators have
found that the life stress and depression variables increase or decrease together
(Monroe et al., 2007). That is, the greater someone’s life stress score, the higher his
or her score on the depression scale. When variables change the same way, their cor-
relation is said to have a positive direction and is referred to as a positive correlation.

Alternatively, correlations can have a negative rather than a positive direction. In
a negative correlation, the value of one variable increases as the value of the other vari-
able decreases. Researchers have found, for example, a negative correlation between
depression and activity level. The greater one’s depression, the lower the number of
one’s activities.

There is yet a third possible outcome for a correlational study.The variables may
be unrelated, meaning that there is no consistent relationship between them. As the
measures of one variable increase, those of the other variable sometimes increase
and sometimes decrease. Studies have found, for example, that depression and intel-
ligence are unrelated.

In addition to knowing the direction of a correlation, researchers need to know
its magnitude, or strength.That is, how closely do the two variables correspond? Does
one always vary along with the other, or is their relationship less exact? When two
variables are found to vary together very closely in person after person, the correla-
tion is said to be high, or strong.

The direction and magnitude of a correlation are often calculated numerically and
expressed by a statistical term called the correlation coefficient. The correlation coefficient
can vary from +1.00, which indicates a perfect positive correlation between two vari-
ables, down to -1.00, which represents a perfect negative correlation. The sign of the
coefficient (+ or -) signifies the direction of the correlation; the number represents its
magnitude. The closer the correlation coefficient is to .00, the weaker, or lower in mag-
nitude, it is. Thus correlations of +.75 and -.75 are of equal magnitude and are equally
strong, whereas a correlation of +.25 is weaker than either.

Everyone’s behavior is changeable, and many human responses can be measured
only approximately. Most correlations found in psychological research, therefore, fall
short of a perfect positive or negative correlation. For example, one study of life stress
and depression in 68 adults found a correlation of +.53 (Miller, Ingham, & Davidson,
1976). Although hardly perfect, a correlation of this magnitude is considered large in
psychological research.

When C n Correlations Be Trusted? Scientists must decide whether the cor-
relation they find in a given group of participants accurately reflects a real correlation in
the general population. Could the observed correlation have occurred by mere chance?
They can test their conclusions with a statistical analysis of their data, using principles of
probability_ In essence, they calculate how likely it is that the study’s particular findings
have occurred by chance. If the statistical analysis indicates that chance is unlikely to ac-
count for the correlation they found, researchers may conclude that their findings reflect
a real correlation in the general population.

What Are the Merits of the Correlational Method? The correlational
method has certain advantages over the case study (see Table 1-3 on the next page). Be-
cause researchers measure their variables, observe many participants, and apply statistical
analyses, they are in a better position to generalize their correlations to people beyond
the ones they have studied. Furthermore, researchers can easily repeat correlational stud-
ies using new groups of participants to check the results of earlier studies.

Although correlations allow researchers to describe the relationship between two
variables, they do not explain the relationship (Proctor & Capaldi, 2006). When we
look at the positive correlation found in many life stress studies, we may be tempted to
conclude that increases in recent life stress cause people to feel more depressed. In fact,
however, the two variables may be correlated for any one of three reasons: (1) Life stress
may cause depression; (2) depression may cause people to experience more life stress

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•case study•A detailed account of a
person’s life and psychological problems.

•correlation•The degree to which
events or characteristics vary along with
each other.

•correlational methocl•A research
procedure used to determine how much
events or characteristics vary along with
each other.

Relative Strengths and Weaknesses of Research Methods

Provides
Individual

Information

Provides
General

Information

Provides
Causal

Information

Statistical
Analysis
Possible Replicable

Case study Yes No No No No

Correlational method No Yes No Yes Yes

Experimental method No Yes Yes Yes Yes

22 ://CHAPTER 1

•epidemiological studrA study that
measures the incidence and prevalence
of a disorder in a given population,

• longitudinal studrA study that
observes the same participants on many
occasions over a long period of time.

(for example, a depressive approach to life may cause people to mismanage their money
or may interfere with social relationships); or (3) depression and life stress may each be
caused by a third variable, such as financial problems (Monroe & Reid, 2009).

Special Forms of Correlational Rese rch Epidemiological studies and longitu-
dinal studies are two kinds of correlational research used widely by clinical investigators.
Epidemiological studies reveal the incidence and prevalence of a disorder in a par-
ticular population. Incidence is the number of new cases that emerge during a given pe-
riod of time. Prevalence is the total number of cases in the population during a given time
period; prevalence includes both existing and new cases.

Over the past 30 years clinical researchers
throughout the United States have worked on
the largest epidemiological study ever con-
ducted, the Epiderniologic Catchment Area
Study.They have interviewed more than 20,000
people in five cities to determine the preva-
lence of many psychological disorders and the
treatment programs used (Eaton et al., 2007;
Narrow et al., 2002). Two other large-scale
epidemiological studies in the United States,
the National Comorbidity Survey and the Na-
tional Comorbidity Survey Replication, have
questioned more than 9,000 individuals (Druss
et al., 2007; Kessler et al., 2007, 2005). All of
these studies have been further compared with

epidemiological studies of specific groups, such as Hispanic and Asian American popula-
tions, or with epidemiological studies conducted in other countries, to see how rates of
mental disorders and treatment programs vary from group to group and from country
to country (Alegria et al., 2007, 2004, 2000).

Such epidemiological studies have helped researchers detect groups at risk for
particular disorders. Women, it turns out, have a higher rate of anxiety disorders and
depression than men, while men have a higher rate of alcoholism than women. Elderly
people have a higher rate of suicide than young people. Hispanic Americans experience
posttraumatic stress disorder more than other racial and ethnic groups in the United
States. And people in some countries have higher rates of certain mental disorders than
those in other countries.

In longitudinal studies, correlational studies of another kind, researchers observe
the same individuals on many occasions over a long period of time (Donnellan &
Conger, 2007). In one such study, investigators have observed the progress over the years
of normally functioning children whose mothers or fathers suffered from schizophrenia
(Schiffman et al., 2006, 2005; Mednick, 1971).The researchers have found, among other
things, that the children of the parents with the most severe cases of schizophrenia were
particularly likely to develop a psychological disorder and to commit crimes at later
points in their development.

Abnormal Psychology: Past and Present :1/ 23

HOME SEND 1°— EXPLORE ) ———

On Facebook, Scholars Link Up with Data
BY STEPHANIE ROSENBLOOM, NEW YORK TIMES, DECEMBER 17, 2007

…

mT6-ia i a
.
it-,=i4 –

inch day about 1,700 juniors at an East Coast college log
on to Facebook.corn to accumulate “friends,” compare

movie preferences, share videos and exchange cybercocktails
and kisses. Unwittingly, these students have become the subjects
of academic research.

To study how personal tastes, habits and values affect the
formation of social relationships (and how social relationships
affect tastes, habits and values), a team of researchers from
Harvard and the University of California, Los Angeles, are moni-
toring the Facebook profiles of an entire class of students at one
college, which they declined to name because it could compro-
mise the integrity of their research. . . .

In other words, Facebook—where users rate one another as
“hot or not,” play games like “Pirates vs. Ninjas” and throw
virtual sheep at one another—is helping scholars explore funda-
mental social science questions.

“We’re on the cusp of a new way of doing social science,”
said Nicholas Christakis, a Harvard sociology professor who is
also part of the research. “Our predecessors could only dream
of the kind of data we now have.”

Social scientists at Indiana, Northwestern, Pennsylvania State,
Tufts, the University of Texas and other institutions are mining
Facebook to test traditional theories in their fields about relation-
ships, identity, self-esteem, popularity, collective action, race and
political engagement.. .. In a few studies, the Facebook users
do not know they are being examined. A spokeswoman for
Facebook says the site has no policy prohibiting scholars from
studying profiles of users who have not activated certain privacy
settings. .

. . . The site’s users have mixed feelings about being put
under the microscope. [One student] said she found it “fascinat-
ing that professors are using [Facebook],” but [another] said,

“I don’t feel like academic research has a place on a Web site
like Facebook.” He added that if that if it was going to happen,
professors should ask students’ permission.

Although federal rules govern academic study of human sub-
jects, universities, which approve professors’ research methods,
have different interpretations of the guidelines. “The rules were
made for a different world, a pre-Facebook world,” said Samuel
D. Gosling, an associate professor of psychology at the University
of Texas, Austin, who uses Facebook to explore perception and
identity. “There is a rule that you are allowed to observe public
behavior, but it’s not clear if online behavior is public or not.” .. .

Copyright Cll 2007 The NewYork Times. All rights reserved. Used by
permission and protected by the Copyright laws of the United States.

The printing, copying, redistribution, or retransmission of the
material without express written permission is prohibited.

V ‘,

The Experimental Method
An experiment is a research procedure in which a variable is manipulated and the
manipulation’s effect on another variable is observed.The manipulated variable is called
the independent variable, and the variable being observed is called the dependent
variable.

One of the questions that clinical scientists ask most often is, “Does a particular
therapy relieve the symptoms of a particular disorder?” (Nathan, 2007). Because this
question is about a causal relationship, it can be answered only by an experiment. That
is, experimenters must give the therapy in question to people who are suffering from a
disorder and then observe whether they improve. Here the therapy is the independent
variable, and psychological improvement is the dependent variable.

•experiment•A research procedure in
which a variable is manipulated and the
effect of the manipulation is observed.

• independent variable•The variable
in an experiment that is manipulated to
determine whether it has an effect on
another variable.

•dependent variable•The variable
in an experiment that is expected to
change as the independent variable is
manipulated.

24 ://cHAPIER 1

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‘control group•In an experiment,
a group of participants who are not
exposed to the independent variable.

•experimental group•In an experi-
ment, the participants who are exposed
to the independent variable.

‘random assignment•A selection
procedure that ensures that participants
are randomly placed either in the control
group or in the experimental group.

•blind desir•An experiment in which
participants do not know whether they
are in the experimental or the control
condition.

•quasi-experiment•An experiment in
which investigators make use of control
and experimental groups that already
exist in the world at large. Also called a
mixed design.

•natural experiment•An experiment
in which nature, rather than an experi-
menter, manipulates an independent
variable.

As with correlational studies, investigators must then do a sta-
tistical analysis on their data and find out how likely it is that the
observed differences are the result of chance.Again, if the likelihood
is very low, the observed differences are considered to be statistically
significant, and the experimenter may conclude with some confi-
dence that they are caused by the independent variable.

If the true cause of changes in the dependent variable cannot
be separated from other possible causes, then an experiment gives
very little information. Thus, experimenters must try to eliminate
all con founds from their studies—variables other than the indepen-
dent variable that may also be affecting the dependent variable.
When there are confounds in an experiment, they, rather than the
independent variable, may be causing the observed changes.

For example, situational variables, such as the location of the
therapy office (say, a quiet country setting) or soothing music
piped into the office, may have a therapeutic effect on participants

in a therapy study. Or perhaps the participants are unusually motivated or have high
expectations that the therapy will work, factors that thus account for their improve-
ment. To guard against confounds, researchers include three important features in their
experiments—a control group, random assignment, and a blind design.

The Control Group A control group is a group of research participants who are
not exposed to the independent variable under investigation but whose experience is
similar to that of the experimental group, the participants who are exposed to the
independent variable. By comparing the two groups, an experimenter can better deter-
mine the effect of the independent variable.

To study the effectiveness of a particular therapy, for example, experimenters typi-
cally divide participants into two groups. The experimental group may come into an
office and receive the therapy for an hour, while the control group may simply come
into the office for an hour. If the experimenters find later that the people in the experi-
mental group improve more than the people in the control group, they may conclude
that the therapy was effective above and beyond the effects of time, the office setting,
and any other confounds. To guard against confounds, experimenters try to provide all
participants, both control and experimental, with experiences that are identical in every
way—except for the independent variable.

Random Assignment Researchers must also watch out for differences in the makeup
of the experimental and control groups, since those differences may also confound a
study’s results. In a therapy study, for example, the experimenter may unintentionally put
wealthier participants in the experimental group and poorer ones in the control group.
This difference, rather than their therapy, may be the cause of the greater improvement
later found among the experimental participants.To reduce the effects of preexisting dif-
ferences, experimenters typically use random assignment.This is the general term for
any selection procedure that ensures that every participant in the experiment is as likely
to be placed in one group as the other. Researchers might, for example, select people by
flipping a coin or picking names out of a hat.

Blind Design A final confound problem is bias. Participants may bias an experiment’s
results by trying to please or help the experimenter (Fritsche & Linneweber, 2006). In a
therapy experiment, for example, if those participants who receive the treatment know
the purpose of the study and which group they are in, they might actually work harder to
feel better or fulfill the experimenter’s expectations. If so, subject, or participant, bias rather
than therapy could be causing their improvement.

To avoid this bias, experimenters can prevent participants from finding out which
group they are in. This experimental strategy is called a blind design because the in-
dividuals are blind as to their assigned group. In a therapy study, for example, control
participants could be given a placebo (Latin for “I shall please”), something that looks or

1.1 I

– ;

III tf.r;i1) qi?

Abnormal Psychology: Past and Present :1/ 25

tastes like real therapy but has none of its key ingredients. This “imitation” therapy is
called placebo therapy. If the experimental (true therapy) participants then improve more
than the control (placebo therapy) participants, experimenters have more confidence
that the true therapy has caused their improvement.

An experiment may also be confounded by experimenter bias (Kazdin, 2003)—that is,
experimenters may have expectations that they unintentionally transmit to the partici-
pants in their studies. In a drug therapy study, for example, the experimenter might smile
and act confident when providing real medications to the experimental participants but
frown and appear hesitant when offering placebo drugs to the control participants.This
kind of bias is sometimes referred to as the Rosenthal effect, after the psychologist who
first identified it (Rosenthal, 1966). Experimenters can eliminate their own bias by ar-
ranging to be blind themselves. In a drug therapy study, for example, an aide could make
sure that the real medication and the placebo drug look identical. The experimenter
could then administer treatment without knowing which participants were receiving
true medications and which were receiving false medications. While either the partici-
pants or the experimenter may be kept blind in an experiment, it is best that both be
blind—a research strategy called a double -blind design. In fact, most medication experi-
ments now use double-blind designs to test promising drugs (Marder et al., 2007).

Alternative Experimental Designs Clinical researchers often must settle for
experimental designs that are less than ideal. The most common such variations are the
quasi-experimental design, the natural experiment, the analogue experiment, and the single-
subject experiment.

In quasi-experiments, or mixed designs, investigators do not randomly assign
participants to control and experimental groups but instead make use of groups that
already exist in the world at large (Wampold, 2006). For example, because investigators
of the effects of child abuse cannot abuse a randomly chosen group of children, they
must instead compare children who already have a history of abuse with children who
do not.To make this comparison as valid as possible, they may further use matched control
participants. That is, they match the experimental participants with control participants
who are similar in age, sex, race, socioeconomic status, type of neighborhood, or other
characteristics. For every abused child in the experimental group, they choose a child
who is not abused but who has similar characteristics to be included in the control
group (Widow et al., 2007).

In natural experiments nature itself manipulates the independent variable, and the
experimenter observes the effects. Natural experiments must be used for studying the
psychological effects of unusual and unpredictable events, such as floods, earthquakes,

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26 :A/CHAPTER 1

plane crashes, and fires. Because the participants in these studies are selected by an ac-
cident of fate rather than by the investigators’ design, natural experiments are actually
a kind of quasi-experiment.

On December 26, 2004, an earthquake occurred beneath the Indian Ocean off
the coast of Sumatra, Indonesia. The earthquake triggered a series of massive tsunamis
that inundated the ocean’s coastal communities, killed more than 225,000 people, and
injured and left millions of survivors homeless.Within months of this disaster, research-
ers conducted natural experiments in which they collected data from several hundred
survivors and from control groups of people who lived in areas not directly affected by
the tsunamis.The disaster survivors scored significantly higher on anxiety and depression
measures (dependent variables) than the controls did. The survivors also experienced
more sleep problems, feelings of detachment, difficulties concentrating, and guilt feelings
than the controls did (Bhushan & Kumar, 2007; Tang, 2007, 2006).

Experimenters often run analogue experiments. Here they induce laboratory
participants—either animals or humans—to behave in ways that seem to resemble real-
life abnormal behavior and then conduct experiments on the participants in the hope
of shedding light on the real-life abnormality. For example, as you’ll see in Chapter 7,
investigator Martin Seligman has produced depression-like symptoms in laboratory par-
ticipants—both animals and humans—by repeatedly exposing them to negative events
(shocks, loud noises, task failures) over which they have no control. In these “learned
helplessness” analogue studies, the participants seem to give up, lose their initiative, and
become sad.

Finally, scientists sometimes do not have the luxury of experimenting on many
participants. They may, for example, be investigating a disorder so rare that few par-
ticipants are available. Experimentation is still possible, however, with a single-subject
experimental design. Here a single participant is observed both before and after the
manipulation of an independent variable.

For example, using a particular single-subject design called an ARAB, or reversal,
design, one researcher sought to determine whether the systematic use of rewards would
reduce a teenage boy’s habit of disrupting his special education class with loud talk
(Deitz, 1977). He rewarded the boy, who suffered from mental retardation, with extra
teacher time whenever he went 55 minutes without interrupting the class more than
three times. In condition A, the student was observed prior to receiving any reward, and
he was found to disrupt the class frequently with loud talk. In condition B, the boy was
given a series of teacher reward sessions (introduction of the independent variable); as

•analogue experiment•A research
method in which the experimenter
produces abnormal-like behavior in labo-
ratory participants and then conducts
experiments on the participants.

•single-subject experimental design.
A research method in which a single
participant is observed and measured
both before and after the manipulation
of an independent variable.

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Abnormal Psychology. Past and Present :1,1 27

expected, his loud talk decreased dramatically. Then the rewards from the teacher were
stopped (condition A again), and the student’s loud talk increased once again. Appar-
ently the independent variable had indeed been the cause of the improvement. To be
still more confident about this conclusion, the researcher had the teacher apply reward
sessions yet again (condition B again). Once again the student’s behavior improved.

What Are the Limits of Clinical Investigations?
We began this section by noting that clinical scientists look for general laws that will
help them understand, treat, and prevent psychological disorders. As we have seen, how-
ever, circumstances can interfere with their progress.

Each method of investigation that we have observed addresses some of the problems
involved in studying human behavior, but no one approach overcomes them all. Thus, it
is best to view each research method as part of a team of approaches that together may
shed considerable light on abnormal human functioning.When more than one method
has been used to investigate a disorder, it is important to ask whether all the results seem
to point in the same direction. If they do, clinical scientists are probably making prog-
ress toward understanding and treating that disorder. Conversely, if the various methods
seem to produce conflicting results, the scientists must admit that knowledge in that
particular area is still limited.

F.

What Do Clinical Researchers Do?

Clinical researchers use the scientific method to uncover general principles of abnor-
mal psychological functioning. They depend primarily on three methods of investiga-
tion: the case study, the correlational method, and the experimental method.

A case study is a detailed account of one person’s life and psychological
problems.

Correlational studies systematically observe the degree to which events or char-
acteristics vary together. This method allows researchers to draw broad conclusions
about abnormality in the population at large. Two widely used forms of the correla-
tion method are epidemiological studies and longitudinal studies.

In experiments, researchers manipulate suspected causes to see whether ex-
pected effects will result. This method allows researchers to determine the causes
of various conditions or events. Clinical experimenters must often settle for experi-
mental designs that are less than ideal, including the quasi-experiment, the natural
experiment, the analogue experiment, and the single-subject experiment.

PUTTING IT… together
A Work in Progress

Since ancient times, people have tried to explain, treat, and study abnormal behavior.
By examining the way past societies responded to such behaviors, we can better un-
derstand the roots of our present views and treatments. In addition, a look backward
helps us appreciate just how far we have come—how humane our present views are,
how impressive our recent discoveries are, and how important our current emphasis
on research is.

At the same time we must recognize the many problems in abnormal psychology
today.The field has yet to agree on one definition of abnormality. It is currently made up
of conflicting schools of thought and treatment whose members are often unimpressed
by the claims and accomplishments of the others. Clinical practice is carried out by a

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28 ://CHAPTER 1

variety of professionals trained in different ways. And current research methods each
have flaws that limit our knowledge and use of clinical information.

As you proceed through the topics in this book and look at the nature, treatment,
and study of abnormal functioning, keep in mind the field’s current strengths and weak-
nesses, the progress that has been made, and the journey that lies ahead. Perhaps the
most important lesson to be learned from our look at the history of this field is that our
current understanding of abnormal behavior represents a work in progress. The clinical
field stands at a crossroads, with some of the most important insights, investigations, and
changes yet to come.

\\\ nPITIrAL THOUr.;HITS///

,-, 1. Why are movies and novels with

fj themes of abnormal functioning so
popular? pp. 1 -2

/7-
2. What behaviors might fit the criteria

:7A of deviant, distressful, dysfunctional,
7j,-. or dangerous but would not be con-
• sidered abnormal by most people?
/7.7. • pp. 2-4

/7″:.. . ..

gists to develop an interest in positive
psychology? p. 17

5. Even when there are well-known
research findings to the contrary,
many people hold on to false beliefs
about human behavior, particularly
abnormal behavior. Why does
research fail to change their views?

you think it took so long for psycholo- pp. 19, 27

• •; • • • • •.:f • W122:U:::!;•;;•14;. ,•>•••5 • • • • • • ::•11;■• •:/YeY1:7•7;• • • • • •tl•t• •:7 •

3. What episodes of “mass madness”
have occurred in recent times? How
might the Internet, cable television,
or other forms of modern technology
contribute to new forms of mass mad-
ness? p. 8

4. Positive behaviors have been around
as long as negative ones. Why do

abnormal psychology, p. 2

deviance, p. 2

norms, p. 2

culture, p. 2

distress, p. 3

dysfunction, p. 3

danger, p. 3

treatment, p. 4

trephination, p. 7

humors, p. 7

asylum, p. 9

moral treatment, p. 9

state hospitals, p. 10

somatogenic perspective,

psychogenic perspective,

general paresis, p. 10

hypnotism, p. 12

psychoanalysis, p. 12

psychotropic medications, p. 13

deinstitutioncrlization, p. 14

private psychotherapy, p. 14

prevention, p. 16

positive psychology, p. 17

multicultural psychology, p. 17

managed care program, p. 17

scientific method, p. 19

case study, p. 20

correlation, p. 20

10 correlational method, p. 20

10

incidence, p. 22

prevalence, p. 22

longitudinal study, p. 22

experiment, p. 23

in

dependent variable, p. 23

dependent variable, p. 23

control group, p. 24

experimental group, p. 24

random assignment, p. 24

blind design, p. 24

quasi-experiment, p. 25

natural experiment, p. 25

analogue experiment, p. 26

single-subject experimental design,
p. 26

P.

P.

(3;;02;,M /71/0/:49.;;Z:,;„.„;: •
epidemiological study, p. 22

Nirx r)ui -2///:

Abnormal Psychology: Past and Present :11 29

7
7

3. Give examples of the somatogenic
view of psychological abnormality

7•,A from Hippocrates, the Renaissance,
the nineteenth century, and the
recent past. pp. 7- 14

.o4/7
4. Discuss the rise and fall of moral

treatment. pp. 9- 10

5. Describe the role of hypnotism and
hysterical disorders in the develop-
ment of the psychogenic view.
pp, 1 1 – 12

6. How did Sigmund Freud come to
develop the theory and technique
of psychoanalysis? p. 12

7. Describe the major changes that
have occurred since the 1950s in
the treatment of people with mental
disorders. pp. 13-18

8. What are the advantages and
disadvantages of the case study,

correlational method, and experi-
mental method? pp. 20-27

9. What techniques do researchers
include in experiments to guard
against the influence of confounds?
pp. 24-25

10. Describe four alternative kinds of
experiements that researchers often
use. pp. 25-27

1. What features are common to
abnormal psychological function-
ing? pp. 2-4

2. Name two forms of past treatments
that reflect a demonological view
of abnormal behavior. pp. 7-9

4 .4` e

Search the Fundamentals of Abnormal Psychology Video Tool Kit
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A Chapter 1 Video Cases
Benjamin Rush’s Moral Treatments
Early Hospital Treatments for Severe Mental Disorders
Shameful Past Institutions for Persons with Developmental Disabilities
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– -•-•,-■ •• •

MODELS OF
ABNORMALITY CHAPTER

hilip Berman, a 25-year-old single unemployed former copy editor fora large publishing
house, . . . had been hospitalized after a suicide attempt in which he deeply gashed his

1 wrist with a razor blade. He described (to the therapist] how he had sat on the bathroom
floor and watched the blood drip into the bathtub for some time before he telephoned

his father at work for help. He and his father went to the hospital emergency room to have
the gash stitched, but he convinced himself and the hospital physician that he did not need
hospitalization. The next day when his father suggested he needed help, he knocked his dinner
to the floor and angrily stormed to his room. When he was calm again, he allowed his father
to take him back to the hospital.

The immediate precipitant for his suicide attempt was that he had run into one of his former
girlfriends with her new boyfriend. The patient stated that they had a drink together, but all the
while he was with them he could not help thinking that “they were dying to run off and jump
in bed.” He experienced jealous rage, got up from the table, and walked out of the restaurant.
He began to think about how he could “pay her back.”

Mr. Berman had felt frequently depressed for brief periods during the previous several years. He
was especially critical of himself for his limited social life and his inability to hove managed to
have sexual intercourse with a woman even once in his life. As he related this to the therapist,
he lifted his eyes from the floor and with a sarcastic smirk said, “l’m a 25-year-old virgin. Go
ahead, you can laugh now.” He has had several girlfriends to date, whom he described as very
attractive, but who he said had lost interest in him. On further questioning, however, it became
apparent that Mr. Berman soon became very critical of them and demanded that they always
meet his every need, often to their own detriment. The women then found the relationship very
unrewarding and would soon find someone else.

During the past two years Mr. Berman had seen three psychiatrists briefly, one of whom had
given him a drug, the name of which he could not remember, but that had precipitated some
sort of unusual reaction for which he had to stay in a hospital overnight. . . . Concerning his
hospitalization, the patient said that “It was a dump,” that the staff refused to listen to what
he had to say or to respond to his needs, and that they, in fact, treated all the patients “sadisti-
cally.” The referring doctor corroborated that Mr. Berman was a difficult patient who demanded
that he be treated as special, and yet was hostile to most staff members throughout his stay.
After one angry exchange with an aide, he left the hospital without leave, and subsequently
signed out against medical advice.

Mr. Berman is one of two children of a middle-class family. His father is 55 years old and
employed in a managerial position for on insurance company. He perceives his father as weak
and ineffectual, completely dominated by the patient’s overbearing and cruel mother. He states
that he hates his mother with “a passion l can barely control.” He claims that his mother used
to call him names like “pervert” and “sissy” when he was growing up, and that in an argument
she once “kicked me in the balls.” Together, he sees his parents as rich, powerful, and selfish,
and, in turn, thinks that they see him as lazy, irresponsible, and a behavior problem. When his
parents called the therapist to discuss their son’s treatment, they stated that his problem began
with the birth of his younger brother, Arnold, when Philip was 10 years old. After Arnold’s birth
Philip apparently became an “ornery” child who cursed a lot and was difficult to discipline. Philip
recalls this period only vaguely. He reports that his mother once was hospitalized for depression,
but that now she doesn’t believe in psychiatry.”

TOPIC OVERVIEW
The Biological Model
How Do Biological Theorists
Explain Abnormal Behavior?

Biological Treatments

Assessing the Biological Model

The Psychodynamic Model
How Did Freud Explain Normal
and Abnormal Functioning?

How Do Other Psychodynamic
Explanations Differ from Freud’s?

Psychodynamic Therapies

Assessing the Psychodynamic Model

The Behavioral Model
How Do Behaviorists Explain
Abnormal Functioning?

Behavioral Therapies

Assessing the Behavioral Model

The Cognitive Model

How Do Cognitive Theorists Explain
Abnormal Functioning?

Cognitive Therapies

Assessing the Cognitive Model

The Humanistic-Existential Model
Rogers’s Humanistic Theory
and Therapy

Gestalt Theory and Therapy
Spiritual Views and Interventions
Existential Theories and Therapy

Assessing the Humanistic-Existential
Model

The Sociocultural Model: Family-
Social and Multicultural Perspectives
How Do Family-Social Theorists
Explain Abnormal Functioning?

Family-Social Treatments

How Do Multicultural Theorists
Explain Abnormal Functioning?

Multicultural Treatments

Assessing the Sociocultural Model

Putting It Together:
Integration of the Models

Famous Psych Linos from
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omoderoA set of assumptions and
concepts that help scientists explain and
interpret observations. Also called a
paradigm.

oneuronGA nerve cell.
osynapseoThe tiny space between the
nerve ending of one neuron and the den-
drite of another.

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

Mr. Berman had graduated from college with average grades. Since graduating he had worked at three
different publishing houses, but at none of them for more than one year. He always found some justifica-
tion for quitting. He usually sat around his house doing very little for two or three months after quitting a
job, until his parents prodded him into getting a new one. He described innumerable interactions in his
life with teachers, friends, and employers in which he felt offended or unfairly treated, . . . and frequent
arguments that left him feeling bitter . . . and spent most of his time alone, “bored.” He was unable to
commit himself to any person, he held no strong convictions, and he felt no allegiance to any group.

The patient appeared as a very thin, bearded, and bespectacled young man with pale skin who main-
tained little eye contact with the therapist and who had an air of angry bitterness about him. Although
he complained of depression, he denied other symptoms of the depressive syndrome. He seemed
preoccupied with his rage at his parents, and seemed particularly invested in conveying a despicable
image of himself . . .

(Spitzer et al., 1983, pp. 59- 61)

Philip Berman is clearly a troubled person, but how did he come to be that way? How
do we explain and correct his many problems? To answer these questions, we must first
look at the wide range of complaints we are trying to understand: Philip’s depression
and anger, his social failures, his lack of employment, his distrust of those around him,
and the problems within his family. Then we must sort through all kinds of potential
causes—internal and external, biological and interpersonal, past and present.

Although we may not realize it, we all use theoretical frameworks as we read about
Philip. Over the course of our lives, each of us has developed a perspective that helps
us make sense of the things other people say and do. In science, the perspectives used
to explain events are known as models, or paradigms. Each model spells out the
scientist’s basic assumptions, gives order to the field under study, and sets guidelines for
its investigation (Kuhn, 1962). It influences what the investigators observe as well as the
questions they ask, the information they seek, and how they interpret this information

2008).To understand how a clinician explains or treats a specific set of symptoms,
such as Philip’s, we must know his or her preferred model of abnormal functioning.

Until recently, clinical scientists of a given place and time tended to agree on a
single model of abnormality—a model greatly influenced by the beliefs of their culture.
The demonological model that was used to explain abnormal functioning during the
Middle Ages, for example, borrowed heavily from medieval society’s concerns with
religion, superstition, and warfare. Medieval practitioners would have seen the devil’s
guiding hand in Philip Berman’s efforts to commit suicide and his feelings of depres-
sion, rage, jealousy, and hatred. Similarly, their treatments for him—from prayers to
whippings—would have sought to drive foreign spirits from his body.

Today several models are used to explain and treat abnormal functioning. This va-
riety has resulted from shifts in values and beliefs over the past half-century, as well as
improvements in clinical research. At one end of the spectrum is the biological model,
which sees physical processes as key to human behavior. In the middle are four mod-
els that focus on more psychological and personal aspects of human functioning: The
psychodynamic model looks at people’s unconscious internal processes and conflicts, the
behavioral model emphasizes behavior and the ways in which it is learned, the cognitive
model concentrates on the thinking that underlies behavior, and the humanistic-existential
model stresses the role of values and choices. At the far end of the spectrum is the socio-
cultural model, which looks to social and cultural forces as the keys to human functioning.
This model includes the family-social perspective, which focuses on an individual’s family
and social interactions, and the multicultural perspective, which emphasizes an individual’s
culture and the shared beliefs, values, and history of that culture.

Given their different assumptions and concepts, the models are sometimes in conflict.
Those who follow one perspective often scoff at the “naive” interpretations, investigations,
and treatment efforts of the others.Yet none of the models is complete in itself. Each
focuses mainly on one aspect of human functioning, and none can explain all aspects of
abnormality.

32 :41/CHAPTER 2

Cerebral cortex

,Basal ganglia

Corpus
callosum

-H ippocam pus

Models of Abnormality :1/ 33

one Biological Model
Philip Berman is a biological being. His thoughts and feelings are the results of bio-
chemical and bioelectrical processes throughout his brain and body. Proponents of
the biological model believe that a full understanding of Philip’s thoughts, emotions, and
behavior must therefore include an understanding of their biological basis. Not surpris-
ingly, then, they believe that the most effective treatments for Philip’s problems will be
biological ones.

How Do Biological Theorists Explain Abnormal Behavior?
Adopting a medical perspective, biological theorists view abnormal behavior as an ill-
ness brought about by malfunctioning parts of the organism. Typically, they point to
problems in brain anatomy or brain chemistry as the cause of such behavior (Garrett,
2009; Lambert & Kinsley, 2005).

Brain Anatomy and Abnormal Behavior The brain is made up of approxi-
mately 100 billion nerve cells, called neurons, and thousands of billions of support cells,
called glia (from the Greek meaning “glue”).Within the brain large groups of neurons
form distinct areas, or brain regions. Toward the top of the brain, for example, is a cluster
of regions, collectively referred to as the cerebrum, which includes the cortex, corpus cal-
losum, basal ganglia, hippocampus, and amygdala (see Figure

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2-1).The neurons in each of these brain regions control
important functions. The cortex is the outer layer of the
brain, the corpus callosum connects the brain’s two ce-
rebral hemispheres, the basal ganglia plays a crucial role
in planning and producing movement, the hippocampus
helps control emotions and memory, and the amygdala
plays a key role in emotional memory. Clinical research-
ers have discovered connections between certain psy-
chological disorders and problems in specific areas of the
brain. One such disorder is Huntington’s disease, a disorder
marked by violent emotional outbursts, memory loss,
suicidal thinking, involuntary body movements, and ab-
surd beliefs. This disease has been traced to a loss of cells
in the basal ganglia.

Brain Chemistry and Abnormal Behavior
Biological researchers have also learned that psychologi-
cal disorders can be related to problems in the transmis-
sion of messages from neuron to neuron. Information is
communicated throughout the brain in the form of electrical impulses that travel from
one neuron to one or more others. An impulse is first received by a neuron’s dendrites,
antenna-like extensions located at one end of the neuron. From there it travels down
the neuron’s axon, a long fiber extending from the neuron’s body. Finally, it is transmit-
ted through the nerve ending at the end of the axon to the dendrites of other neurons (see
Figure 2-2 on the next page).

But how do messages get from the nerve ending of one neuron to the dendrites of
another? After all, the neurons do not actually touch each other.A tiny space, called the
synapse, separates one neuron from the next, and the message must somehow move
across that space.When an electrical impulse reaches a neuron’s ending, the nerve ending
is stimulated to release a chemical, called a neurotransmitter, that travels across the
synaptic space to receptors on the dendrites of the neighboring neurons. After binding to
the receiving neuron’s receptors, some neurotransmitters tell the receiving neurons to
“fire,” that is, to trigger their own electrical impulse. Other neurotransmitters carry an
inhibitory message; they tell receiving neurons to stop all firing. Obviously, neurotrans-
mitters play a key role in moving information through the brain.

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34 //CHAPTER 2

Nerve ending

Electrical impulse

Synapse.„.,

reurotransmitters
Release of
neurotransmitters

Axon

Receptor sites on
receiving neuron

Researchers have identified dozens of neurotransmitters in the brain, and
they have learned that each neuron uses only certain kinds. Studies indicate
that abnormal activity by certain neurotransmitters can lead to specific mental
disorders (Sarter et al., 2007). Depression, for example, has been linked to low
activity of the neurotransmitters serotonin and norepinephrine. Perhaps low se-
rotonin activity is partly responsible for Philip Berman’s pattern of depression
and rage.

In addition to focusing on neurons and neurotransmitters, researchers have
learned that mental disorders are sometimes related to abnormal chemical
activity in the body’s endocrine system. Endocrine glands, located throughout
the body, work along with neurons to control such vital activities as growth,
reproduction, sexual activity, heart rate, body temperature, energy, and responses
to stress. The glands release chemicals called hormones into the bloodstream,
and these chemicals then propel body organs into action. During times of stress,
for example, the adrenal glands, located on top of the kidneys, secrete the hor-
mone cortisol. Abnormal secretions of this chemical have been tied to anxiety
and mood disorders.

Sources of Biological Abnormalities Why do some people have brain
structures or biochemical activities that differ from the norm? Three factors have
received particular attention in recent years—genetics, evolution, and viral infections.

GENETICS AND ABNORMAL BEHAVIOR Abnormalities in brain anatomy or chemistry
are sometimes the result of genetic inheritance. Each cell in the human brain
and body contains 23 pairs of chromosomes, with each chromosome in a pair
inherited from one of the person’s parents. Every chromosome contains numer-
ous genes—segments that control the characteristics and traits a person inherits.
Altogether, each cell contains between 30,000 and 40,000 genes (Andreasen,
2005, 2001). Scientists have known for years that genes help determine such
physical characteristics as hair color, height, and eyesight. Genes can make
people more prone to heart disease, cancer, or diabetes, and perhaps to possess-

ing artistic or musical skill. Studies suggest that inheritance also plays a part in mood
disorders, schizophrenia, and other mental disorders.

The precise contributions of various genes to mental disorders have become clearer
in recent years, thanks in part to the completion of the Human Genome Project in 2000.
In this major undertaking, scientists used the tools of molecular biology to map, or
sequence, all of the genes in the human body in great detail. With this information in
hand, researchers hope eventually to be able to prevent or change genes that help cause
medical or psychological disorders (Holman et al., 2007).

Models of Abnormality :// 35

EVOLUTION AND ABNORMAL BEHAVIOR Genes that contribute to mental disorders are typi-
cally viewed as unfortunate occurrences—almost mistakes of inheritance. The respon-
sible gene may be a mutation, an abnormal form of the appropriate gene that emerges
by accident_ Or the problematic gene may be inherited by an individual after it has
initially entered the family line as a mutation. According to some theorists, however,
many of the genes that contribute to abnormal functioning are actually the result of
normal evolutionary principles (Fabrega, 2007, 2006, 2002).

In general, evolutionary theorists argue that human reactions and the genes respon-
sible for them have survived over the course of time because they have helped individu-
als to thrive and adapt. Ancestors who had the ability to run fast, for example, or the
craftiness to hide were most able to escape their enemies and to reproduce. Thus, the
genes responsible for effective walking, running, or problem solving were particularly
likely to be passed on from generation to generation to the present day.

Similarly, say evolutionary theorists, the capacity to experience fear was, and in many
instances still is, adaptive. Fear alerted our ancestors to dangers, threats, and losses, so that
persons could avoid or escape potential problems. People who were particularly sensitive
to danger—those with greater fear responses—were more likely to survive catastrophes,
battles, and the like and to reproduce, and so to pass on their fear genes. Of course, in
today’s world pressures are more numerous, subtle, and complex than they were in the
past, condemning many individuals with such genes to a near-endless stream of fear
and arousal. That is, the very genes that helped their ancestors to survive and reproduce
might now leave these individuals particularly prone to fear reactions, anxiety disorders,
or related psychological disorders.

The evolutionary perspective is controversial in the clinical field and has been re-
jected by many theorists. Imprecise and at times impossible to research, this explanation
requires leaps of faith that many scientists find unacceptable.

VIRAL INFECTIONS AND ABNORMAL BEHAVIOR Another possible source of abnor-
mal brain structure or biochemical dysfunctioning is viral ittfections. As you
will see in Chapter 12, for example, research suggests that schizophrenia, a
disorder marked by delusions, hallucinations, or other departures from real-
ity, may be related to exposure to certain viruses during childhood or before
birth (Meyer et al., 2008; Shirts et al., 2007). Studies have found that the
mothers of many individuals with this disorder contracted influenza or re-
lated viruses during their pregnancy. This and related pieces of circumstantial
evidence suggest that a damaging virus may enter the fetus’s brain and remain
dormant there until the individual reaches adolescence or young adulthood.
At that time, the virus may produce the symptoms of schizophrenia. During
the past decade, researchers have sometimes linked viruses to anxiety and
mood disorders, as well as to psychotic disorders (Dale et al., 2004).

Bioiogical Treatments
Biological practitioners look for certain kinds of clues when they try to understand
abnormal behavior. Does the person’s family have a history of that behavior, and hence
a possible genetic predisposition to it? (Philip Berman’s case history mentions that his
mother was once hospitalized for depression.) Is the behavior produced by events that
could have had a physiological effect? (Philip was having a drink when he flew into a
jealous rage at the restaurant.)

Once the clinicians have pinpointed physical sources of dysfunctioning, they are in
a better position to choose a biological course of treatment. The three leading kinds of
biological treatments used today are drug therapy, electroconvulsive therapy, and psychosurgery.
Drug therapy is by far the most common of these approaches.

In the 1 950s, researchers discovered several effective psychotropic medications,
drugs that mainly affect emotions and thought processes. These drugs have greatly
changed the outlook for a number of mental disorders and today are used widely, ei-
ther alone or with other forms of therapy. However, the psychotropic drug revolution

ohormonesolle chemicals released by
endocrine glands into the bloodstream.

egeneeChromosome segments that
control the characteristics and traits we
inherit.

opsychotropic medicationsoDru9s
that primarily affect the brain and
reduce many symptoms of mental
dysfunctioning.

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has also produced some major problems. Many people believe, for example, that the
drugs are overused. Moreover, while drugs are effective in many cases, they do not help
everyone (see Figure 2-3).

Four major psychotropic drug groups are used in therapy: antianxiety, antidepressant,
antibipolar, and antipsychotic drugs. Antianxiety drugs, also called minor tranquilizers or
anxiolytics, help reduce tension and anxiety. Antidepressant dings help improve the mood
of people who are depressed. Antibipolar drugs, also called mood stabilizers, help steady
the moods of those with a bipolar disorder, a condition marked by mood swings from
mania to depression. And antipsychotic drugs help reduce the confusion, hallucinations,
and delusions of psychotic disorders, disorders (such as schizophrenia) marked by a loss of
contact with reality.

A second form of biological treatment, used primarily on depressed patients, is elec-
troconvulsive therapy (ECT). Two electrodes are attached to a patient’s forehead and an
electrical current of 65 to 140 volts is passed briefly through the brain.The current causes
a brain seizure that lasts up to a few minutes.After seven to nine ECT sessions, spaced two
or three days apart, many patients feel considerably less depressed.The treatment is used on
tens of thousands of depressed persons annually, particularly those whose depression fails
to respond to other treatments (Eschweiler et al., 2007; Pagnin et al., 2004).

A third form of biological treatment is psychosurgery, or neurosurgery, brain
surgery for mental disorders. It is thought to have roots as Ear back as trephining, the
prehistoric practice of chipping a hole in the skull of a person who behaved strangely.
Modern procedures are derived from a technique first developed in the late 1930s by
a Portuguese neuropsychiatrist, Antonio de Egas Moniz. In that procedure, known as a
lobotomy, a surgeon would cut the connections between the brain’s frontal lobes and the
lower regions of the brain. Today’s psychosurgery procedures are much more precise
than the lobotomies of the past. Even so, they are considered experimental and are used
only after certain severe disorders have continued for years without responding to any
other form of treatment (Sachdev & Chen, 2009).

36 :41/CHAPTER 2

Assessing the Biological Model
Today the biological model enjoys considerable respect. Biological research constantly
produces valuable new information. And biological treatments often bring great relief
when other approaches have failed. At the same time, this model has its shortcomings.

°electroconvulsive therapy (ECT)0
A form of biological treatment, used
primarily on depressed patients, in which
a brain seizure is triggered as an elec-
tric current passes through electrodes
attached to the patient’s forehead.

opsychosurgery°Brain surgery for men-
tal disorders. Also called neurosurgery.

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

to help determine its safety and
efficacy.

Clinical Phase 1:
Safety Screening (1.5 years)
Investigators test drug on human

subjects to determine its safety.
• Number of subjects: io—loo
• Typical cost: $10 million

Clinical Phase II:
Preliminary Testing (2 years)
Investigators conduct studies with human

subjects to determine how drug can
best be evaluated and to obtain
preliminary estimates of correct
dosage and treatment procedures.

• Number of subjects: 50-500
• Typical cost: $2o million

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

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

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

Review by FDA (2-5 years)
Research is reviewed by FDA, and drug

is approved or disapproved.

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

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

Models of Abnormality :11 37

Some of its proponents seem to expect that all human behavior can be explained in
biological terms and treated with biological methods. This view can limit rather than
enhance our understanding of abnormal functioning. Our mental life is an interplay
of biological and nonbiological factors, and it is important to understand that interplay
rather than to focus on biological variables alone.

Another shortcoming is that several of today’s biological treatments are capable of
producing significant undesirable effects. Certain antipsychotic drugs, for example, may
produce movement problems such as severe shaking, bizarre-looking contractions of
the face and body, and extreme restlessness. Clearly such costs must be addressed and
weighed against the drug’s benefits.

r.
•

The Biological Model

Biological theorists look at the biological processes of human functioning to explain
abnormal behavior, pointing to anatomical or biochemical problems in the brain
and body. Such abnormalities are sometimes the result of genetic inheritance, evo-
lution, or viral infections. Biological therapists use physical and chemical methods
to help people overcome their psychological problems. The leading ones are drug
therapy, electroconvulsive therapy, and, on rare occasions, psychosurgery.

OThe Psychodynamic Model
The psychodynamic model is the oldest and most famous of the modern psychological
models. Psychodynamic theorists believe that a person’s behavior, whether normal or
abnormal, is determined largely by underlying psychological forces of which he or she
is not consciously aware. These internal forces are described as dynamic— that is, they
interact with one another—and their interaction gives rise to behavior, thoughts, and
emotions.Abnormal symptoms are viewed as the result of conflicts between these forces
(Luborsky et al., 2008).

Psychodynamic theorists would view Philip Berman as a person in conflict. They
would want to explore his past experiences because, in their view, psychological con-
flicts are tied to early relationships and to traumatic experiences that occurred during
childhood. Psychodynamic theories rest on the deterministic assumption that no symp-
tom or behavior is “accidental”: All behavior is determined by past experiences. Thus
Philip’s hatred for his mother, his memories of her as cruel and overbearing, the weak-
ness of his father, and the birth of a younger brother when Philip was 10 may all be
important to the understanding of his current problems.

The psychodynamic model was first formulated by Viennese neurologist Sigmund
Freud (1856-1939) at the turn of the twentieth century. After studying hypnosis, Freud
developed the theory of psychoanalysis to explain both normal and abnormal psycho-
logical functioning and a corresponding method of treatment, a conversational approach
also called psychoanalysis. During the early 1900s, Freud and several of his colleagues
in the Vienna Psychoanalytic Society—including Carl Gustav Jung (1875-1961) and
Alfred Adler (1870-1937)—became the most influential clinical theorists in the Western
world.

How Did Freud Explain Normal and Abnormal Functioning?
Freud believed that three central forces shape the personality—instinctual needs, rational
thinking, and moral standards. All of these forces, he believed, operate at the unconscious
level, unavailable to immediate awareness; he further believed these forces to be dynamic,
or interactive. Freud called the forces the id, the ego, and the superego.

Defense

Repression

Operation

Person avoids anxiety by simply not
allowing painful or dangerous thoughts to
become conscious.

Example

An executive’s desire to run amok and attack his boss and
colleagues at a board meeting is denied access to his awareness.

Denial Person simply refuses to acknowledge the
existence of an external source of anxiety.

You are not prepared for tomorrow’s final exam, but you tell
yourself that it’s not actually an important exam and that there’s
no good reason not to go to a movie tonight.

Projection Person attributes own unacceptable
impulses, motives, or desires to other
individuals.

The executive who repressed his destructive desires may project
his anger onto his boss and claim that it is actually the boss who
is hostile.

Rationalization Person creates a socially acceptable
reason for an action that actually reflects
unacceptable motives.

A student explains away poor grades by citing the importance of
the “total experience” of going to college and claiming that too
much emphasis on grades would actually interfere with a well-
rounded education.

Displacement Person displaces hostility away from
a dangerous object and onto a safer
substitute.

After your parking spot is taken, you release your pent-up anger
by starting an argument with your roommate.

Intellectualization Person represses emotional reactions
in favor of overly logical response to a
problem.

A woman who has been beaten and raped gives a detached,
methodical description of the effects that such attacks may have
on victims.

Regression Person retreats from an upsetting conflict
to an early developmental stage at which
no one is expected to behave maturely or
responsibly.

A boy who cannot cope with the anger he feels toward his
rejecting mother regresses to infantile behavior, soiling his clothes
and no longer taking care of his basic needs.

The Defense Never Rests: Defense Mechanisms to the Rescue

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

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

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

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

efixationoAccording to Freud, a condi-
tion in which the id, ego, and superego
do not mature properly and are frozen
at an early stage of development.

The id Freud used the term id to denote instinctual needs, drives, and impulses. The
id operates in accordance with the pleasure principle; that is, it always seeks gratification.
Freud also believed that all id instincts tend to be sexual, noting that from the very earliest
stages of life a child’s pleasure is obtained from nursing, defecating, masturbating, or en-
gaging in other activities that he considered to have sexual ties. He further suggested that
a person’s libido, or sexual energy, fuels the id.

The Ego During our early years we come to recognize that our environment will not
meet every instinctual need. Our mother, for example, is not always available to do our
bidding. A part of the id separates off and becomes the ego. Like the id, the ego un-
consciously seeks gratification, but it does so in accordance with the reality principle, the
knowledge we acquire through experience that it can be unacceptable to express our id
impulses outright.The ego, employing reason, guides us to know when we can and can-
not express those impulses.

The ego develops basic strategies, called ego defense mechanisms, to control
unacceptable id impulses and avoid or reduce the anxiety they arouse. The most basic
defense mechanism, repression, prevents unacceptable impulses from ever reaching con-
sciousness.There are many other ego defense mechanisms, and each of us tends to favor
some over others (see Table 2-1).

The Superego The superego grows from the ego, just as the ego grows out of the
id. As we learn from our parents that many of our id impulses are unacceptable, we un-
consciously adopt our parents’ values. Judging ourselves by their standards, we feel good
when we uphold their values; conversely, when we go against them, we feel guilty. In
short, we develop a conscience.

According to Freud, these three parts of the personality—the id, the ego, and the
superego—are often in some degree of conflict. A healthy personality is one in which

38 : //CHAPTER 2

Models of Abnormality :// 39

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an effective working relationship, an acceptable compromise, has formed among the
three forces. If the id, ego, and superego are in excessive conflict, the person’s behavior
may show signs of dysfunction.

Freudians would therefore view Philip Berman as someone whose personality forces
have a poor working relationship. His ego and superego are unable to control his id im-
pulses, which lead him repeatedly to act in impulsive and often dangerous ways—suicide
gestures, jealous rages, job resignations, outbursts of temper, frequent arguments.

Developmental Stages Freud proposed that at each stage of development, from
infancy to maturity, new events challenge individuals and require adjustments in their
id, ego, and superego. If the adjustments are successful, they lead to personal growth. If
not, the person may become fixated, or stuck, at an early stage of development. Then
all subsequent development suffers, and the individual may well be headed for abnormal
functioning in the future. Because parents are the key figures during the early years of
life, they are often seen as the cause of improper development.

Freud named each stage of development after the body area that he considered most
important to the child at that time. For example, he referred to the first 18 months of
life as the oral stage. During this stage, children fear that the mother who feeds and com-
forts them will disappear. Children whose mothers consistently fail to gratify their oral
needs may become fixated at the oral stage and display an “oral character” throughout
their lives, one marked by extreme dependence or extreme mistrust. Such persons are
particularly prone to develop depression. As you will see in later chapters, Freud linked
fixations at the other stages of development—anal (18 months to 3 years of age), phallic
(3 to 5 years), latency (5 to 12 years), and genital (12 years to adulthood)—to yet other
kinds of psychological dysfunction.

How Do Other Psychodynamic
Explanations Differ from Freud’s?
Personal and professional differences between Freud and his colleagues led to a split
in the Vienna Psychoanalytic Society early in the twentieth century. Carl Jung, Alfred
Adler, and others developed new theories. Although the new theories departed from
Freud’s ideas in important ways, each held on to Freud’s belief that human functioning
is shaped by dynamic (interacting) psychological forces.Thus all such theories, including
Freud’s, are referred to as psychodynamic.

Three of today’s most influential psychodynamic theories are ego theory, self theory,
and object relations theory. Ego theorists emphasize the role of the ego and consider it
a more independent and powerful force than Freud did (Sharf, 2008). Self theorists, in
contrast, give the greatest attention to the role of the self—the unified personality. They

40 ://CHAPTER 2

believe that the basic human motive is to strengthen the whole-
ness of the self (Luborsky et al., 2008; Kohut, 2001, 1977). Object
relations theorists propose that people are motivated mainly by a
need to have relationships with others and that severe problems
in the relationships between children and their caregivers may
lead to abnormal development (Luhorsky et al., 2008; Kernberg,
2005, 2001, 1997).

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°free association0A psychodynamic
technique in which the patient describes
any thought, feeling, or image that
comes to mind, even if it seems
unimportant.

oresistanceoAn unconscious refusal to
participate fully in therapy.

etransferenceoAccording to psychody-
namic theorists, the redirection toward
the psychotherapist of feelings associated
with important figures in a patient’s life,
now or in the past.

odreamoA series of ideas and images
that form during sleep.

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

Psychodynarnic Therapoes
Psychodynamic therapies range from Freudian psychoanalysis to
modern therapies based on self theory or object relations theory.
All seek to uncover past traumas and the inner conflicts that have
resulted from them. All try to help clients resolve, or settle, those
conflicts and to resume personal development.

According to most psychodynamic therapists, therapists must
subtly guide therapy discussions so that the patients discover
their underlying problems for themselves. To aid in the process,

the therapists rely on such techniques as free association, therapist interpretation, catharsis,
and working through.

Free Association In psychodynamic therapies, the patient is responsible for starting
and leading each discussion.The therapist tells the patient to describe any thought, feel-
ing, or image that comes to mind, even if it seems unimportant.This practice is known as
free association. The therapist expects that the patient’s associations will eventually un-
cover unconscious events. Notice how free association helps this NewYorker to discover
threatening impulses and conflicts within herself:

Patient: So I started walking, and walking, and decided to go behind the museum and
walk through Central Park. So I walked and went through a back field and felt
very excited and wonderful. I saw a park bench next to a clump of bushes and
sat down. There was a rustle behind me and I got frightened. I thought of men
concealing themselves in the bushes. I thought of the sex perverts I read about in
Central Park. I wondered if there was someone behind me exposing himself. The
idea is repulsive, but exciting too. I think of father now and feel excited. I think
of an erect penis. This is connected with my father. There is something about this
pushing in my mind. I don’t know what it is, like on the border of my memory.
(Pause)

Therapist: Mm-hmm. (Pause) On the border of your memory?
Patient: (The patient breathes rapidly and seems to be under great tension.) As a little

girl, I slept with my father. I get a funny feeling. 1 get a funny feeling over my skin,
tingly-like. ft’s a strange feeling, like a blindness, like not seeing something. My
mind blurs and spreads over anything I look at. I’ve had this feeling off and on
since I walked in the park. My mind seems to blank off like I can’t think or ab-
sorb anything.

(Wolberg, 1967, p. 662)

Therapist Onterpretation Psychodynamic therapists listen carefully as patients talk,
looking for clues, drawing tentative conclusions, and sharing interpretations when they
think the patient is ready to hear them. Interpretations of three phenomena are particu-
larly important—resistance, transference, and dreams.

Patients are showing resistance, an unconscious refusal to participate fully in ther-
apy, when they suddenly cannot free associate or when they change a subject to avoid

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Models of Abnormality Al

a painful discussion. They demonstrate transference when they act and feel toward
the therapist as they did or do toward important persons in their lives, especially their
parents, siblings, and spouses. Consider again the woman who walked in Central Park.
As she continues talking, the therapist helps her to explore her transference:

Patient get so excited by what is happening here. I fee/ I’m being held back by needing
to be nice. I’d like to blast loose sometimes, but i don’t dare.

Therapist: Because you fear my reaction?
Patient: The worst thing would be that you wouldn’t like me. You wouldn’t speak to me

friendly; you wouldn’t smile; you’d feel you can’t treat me and discharge me from
treatment. But i know this isn’t so, I know it.

Therapist: Where do you think these attitudes come from?
Patient: When I was nine years old, i read a lot about great men in history. I’d quote

them and be dramatic. I’d want a sword at my side; I’d dress like an Indian.
Mother would scold me. Don’t frown, don’t talk so much. Sit on your hands, over
and over again. 1 did all kinds of things. i was a naughty child. She told me I’d
be hurt. Then at fourteen I fell off a horse and broke my back. I had to be in
bed. Mother told me on the day I went riding not to, that I’d get hurt because
the ground was frozen. I was a stubborn, self-willed child. Then i went against her
will and suffered an accident that changed my life, a fractured back. Her attitude
was, “1 told you so.” I was put in a cast and kept in bed for months.

(Wollierg, 1967, p. 662)

Finally, many psychodynamic therapists try to help patients interpret their dreams
(see Figure 2-4). Freud (1924) called dreams the “royal road to the unconscious.” He
believed that repression and other defense mechanisms operate less completely during
sleep and that dreams, if correctly interpreted, can reveal unconscious instincts, needs,
and wishes. Freud identified two kinds of dream content—manifest and latent. Manifest
content is the consciously remembered dream; latent content is its symbolic meaning. To
interpret a dream, therapists must translate its manifest content into its latent content.

Cash rsis Insight must be an emotional as well as an intellectual process. Psychody-
namic therapists believe that patients must experience catharsis, a reliving of past re-
pressed feelings, if they are to settle internal conflicts and overcome their problems.

Working Through A single episode of interpretation and catharsis will not change
the way a person functions.The patient and therapist must examine the same issues over
and over in the course of many sessions, each time with greater clarity.This process, called
working through, usually takes a long dine, often years.

42 ://CHAPTER 2

Instincts

n an August day in 1996, a 3-year-
jold boy climbed over a barrier at the

Brookfield Zoo in Illinois and fell 24 feet
onto the cement floor of the gorilla com-
pound. An 8-year-oid 160-pound gorilla
named Binti-Jua picked up the child and
cradled his limp body in her arms. The
child’s mother, fearing the worst, screamed
out, “The gorilla’s got my baby!” But Binti
protected the boy as if he were her own.
She held off the other gorillas, rocked him
gently, and carried him to the entrance
of the gorilla area, where rescue workers
were waiting. Within hours, the incident
was seen on videotape replays around the
world, and Binti was being hailed for her
maternal instincts.

When Binti was herself an infant, she
had been removed from her mother, Lulu,
who did not have enough milk. To make
up for this loss, keepers at the zoo worked
around the clock to nurture Binti; she was
always being held in someone’s arms.
When Binti became pregnant at age 6,
trainers were afraid that the early separa-
tion from her mother would leave her ill
prepared to raise an infant of her own.
So they gave her mothering lessons and
taught her to nurse and carry around a
stuffed doll.

After the incident at the zoo, clinical
theorists had a field day interpreting the
gorilla’s gentle and nurturing care for the

• • • • • • • • • • ” “” ” • ” °`• ” ” • • • • •

Contemporary Trends in Psychodynamic TherapyThe past 30 years have
witnessed substantial chan ges in the way many psychodynamic therapists conduct ses-
sions.An increased demand for focused, time-Iimited psychotherapies has resulted in ef-

forts to make psychodynamic therapy more efficient.Two contemporary psychodynamic

approaches that illustrate this trend are short-term psychodynamic therapies and relational
psychoanalytic therapy.

SHORT-TERM PSYCHODYNAMIC THERAPIES In several short versions of psychodynamic therapy,
patients choose a single problem—a dynamic focus—to work on, such as difficulty getting
along with other people (Charman, 2004).The therapist and patient focus on this prob-

lem throughout the treatment and work only on the psychodynamic issues that relate

to it (such as unresolved oral needs). Only a limited number of studies have tested the

effectiveness of these short-term psychodynamic therapies, but their findings do suggest

that the approaches are sometimes quite helpful to patients (Present et al., 2008).

RELATIONAL PSYCHOANALYTIC THERAPY Whereas Freud believed that psychodynamic thera-
pists should take on the role of a neutral, distant expert during a treatment session, a con-

child, each within his or her preferred
theory. Many evolutionary theorists, for
example, viewed the behavior as an ex-
pression of the maternal instincts that have
helped the gorilla species to survive and
evolve. Some psychodynamic theorists sug-
gested that the gorilla was expressing feel-
ings of attachment and bonding, already
experienced with her own 17-month-old

daughter. And behaviorists held that the
gorilla may have been imitating the nur-
turing behavior that she had observed in
human models during her own infancy or
enacting the parenting training that she
had received during her pregnancy. In
the meantime, Binti-Jua, the heroic gorilla,
returned to her relatively quiet and predict-
able life at the zoo.

a.

dill Abdul Freud
o • 4

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Models of Abnormality :// 43

temporary school of psychodynamic therapy referred to as relational psychoanalytic therapy
argues that therapists are key figures in the lives of patients–figures whose reactions and
beliefs should be included in the therapy process (Luborsky et al., 2008; Levenson, 1982).
Thus, a key principle of relational therapy is that therapists should also disclose things
about themselves, particularly their own reactions to patients, and try to establish more
equal relationships with patients.

Assessing the Psychodynamic Model
Freud and his followers have helped change the way abnormal functioning is under-
stood (Corey, 2008). Largely because of their work, a wide range of theorists today look
for answers outside of biological processes. Psychodynamic theorists have also helped us
to understand that abnormal functioning may be rooted in the same processes as nor-
mal functioning. Psychological conflict is a common experience; it leads to abnormal
functioning only if the conflict becomes excessive.

Freud and his many followers have also had a monumental impact on treatment.
They were the first to apply theory systematically to treatment.They were also the first
to demonstrate the potential of psychological, as opposed to biological, treatment, and
their ideas have served as starting points for many other psychological treatments.

At the same time, the psychodynamic model has its shortcomings. Its concepts are
hard to research (Nietzel et al., 2003). Because processes such as id drives, ego defenses,
and fixation are abstract and supposedly operate at an unconscious level, there is no
way of knowing for certain if they are occurring. Not surprisingly, then, psychodynamic
explanations and treatments have received limited research support over the years, and
psychodynamic theorists rely largely on evidence provided by individual case studies.
Nevertheless, recent research evidence suggests that long-term psychodynamic therapy
may be helpful for many persons with long-term complex disorders (Leichsenring
Rabung, 2008), and 15 percent of today’s clinical psychologists identify themselves as
psychodynamic therapists (Prochaska & Norcross, 2007).

The Psychodynarnic Model

Psychodynamic theorists believe that an individual’s behavior, whether normal or
abnormal, results from the interaction of underlying psychological forces. They
consider psychological conflicts to be rooted in early parent-child relationships and
traumatic experiences. The model was first developed by Sigmund Freud, who said
that three dynamic forces—the id, ego, and superego—interact to produce thought,
feeling, and behavior. Other psychodynamic theories are ego theory, self theory,
and object relations theory. Psychodynamic therapists help people uncover past
traumas and the inner conflicts that have resulted from them. They use a number
of techniques, including free association and interpretations of resistance, transfer-
ence, and dreams. Two of the leading contemporary psychodynamic approaches
are short-term psychodynamic therapies and relational psychoanalytic therapy.

– !The Behavioral Model
Like psychodynamic theorists, behavioral theorists believe that our actions are deter-
mined largely by our experiences in life. However, the behavioral model concentrates on
behaviors, the responses an organism makes to its environment. Behaviors can be exter-
nal (going to work, say) or internal (having a feeling or thought). In turn, behavioral
theorists base their explanations and treatments on principles of learning, the processes by
which these behaviors change in response to the environment.

44: ,j/CHAPTER 2

Many learned behaviors help people to cope with daily challenges and to lead happy,
productive lives. However, abnormal behaviors also can be learned. Behaviorists who
try to explain Philip Berman’s problems might view him as a man who has received
improper training: He has learned behaviors that offend others and repeatedly work
against him.

Whereas the psychodynamic model had its beginnings in the clinical work of phy-
sicians, the behavioral model began in laboratories where psychologists were running
experiments on conditioning, simple forms of learning. The researchers manipulated
stimuli and rewards, then observed how their manipulations affected the responses of
their research participants.

During the 1950s, many clinicians became frustrated with what they viewed as the
vagueness and slowness of the psychodynamic model. Some of them began to apply
the principles of learning to the study and treatment of psychological problems. Their
efforts gave rise to the behavioral model of abnormality.

How Do Behaviorists Explain Abnormal Functioning?
Learning theorists have identified several forms of conditioning, and each may produce
abnormal behavior as well as normal behavior. In operant conditioning, for example,
humans and animals learn to behave in certain ways as a result of receiving rewards–
any satisfying consequences—whenever they do so. In modeling, individuals learn
responses simply by observing other individuals and repeating their behaviors.

tir=1(f Aft 1.1
■r3 rol

1 14.0r4l■*7-iitt[=_fi

In a third form of conditioning, classical conditioning, learning occurs by tem-
poral association. When two events repeatedly occur close together in time, they become
fused in a person’s mind, and before long the person responds in the same way to both
events. If one event produces a response of joy, the other brings joy as well; if one event
brings feelings of relief, so does the other. A closer look at this form of conditioning
illustrates how the behavioral model can account for abnormal functioning.

Ivan Pavlov (1849-1936), a famous Russian physiologist, first demonstrated classi-
cal conditioning with animal studies. He placed a bowl of meat powder before a dog,
producing the natural response that all dogs have to meat: They start to salivate (see
Figure 2-5). Next Pavlov added a step: just before presenting the dog with meat pow-
der, he sounded a bell. After several such pairings of bell tone and presentation of meat
powder, Pavlov noted that the dog began to salivate as soon as it heard the bell.The dog
had learned to salivate in response to a sound.

In the vocabulary of classical conditioning, the meat in this demonstration is an
unconditioned stimulus (US). It elicits the unconditioned response (UR) of salivation, that is,
a natural response with which the dog is born. The sound of the bell is a conditioned
stimulus (CS), a previously neutral stimulus that comes to be linked with meat in the
dog’s mind. As such, it too produces a salivation response. When the salivation response
is produced by the conditioned stimulus rather than by the unconditioned stimulus, it
is called a conditioned response (CR).

Models of Abnormality :1/ 45

BEFORE CONDITIONING

CS:Tone No response

US: Meat -+ UR: Salivation

AFTER CONDITIONING

CS: Tone -* CR: Salivation

US: Meat UR: Salivation

Classical conditioning explains many familiar behaviors. The ro-
mantic feelings a young man experiences when he smells his girl-
friend’s perfume, say, may represent a conditioned response. Initially,
this perfume may have had little emotional effect on him, but because
the fragrance was present during several romantic encounters, it came
to elicit a romantic response.

Abnormal behaviors, too, can be acquired by classical conditioning.
Consider a young boy who is repeatedly frightened by a neighbor’s
large German shepherd dog. Whenever the child walks past the neigh-
bor’s front yard, the dog barks loudly and lunges at him, stopped only
by a rope tied to the porch. In this unfortunate situation, the boy’s
parents are not surprised to discover that he develops a fear of dogs.
They are stumped, however, by another intense fear the child displays,
a fear of sand. They cannot understand why he cries whenever they take him to the
beach and screams in fear if sand even touches his skin.

Where did this fear of sand come from? Classical conditioning. It turns out that a
big sandbox is set up in the neighbor’s front yard for the dog to play in. Every time the
dog barks and lunges at the boy, the sandbox is there too. After repeated pairings of this
kind, the child comes to fear sand as much as he fears the dog.

Behavioral Therapies
Behavioral therapy aims to identify the behaviors that are causing a person’s problems
and then tries to replace them with more appropriate ones by applying the principles of
classical conditioning, operant conditioning, or modeling (Wilson, 2008).The therapist’s
attitude toward the client is that of teacher rather than healer.

Classical conditioning treatments, for example, may be used to change abnormal
reactions to particular stimuli. Systematic desensitization is one such method,
often applied in cases of phobia—a specific and unreasonable fear. In this step-by-step
procedure, clients learn to react calmly instead of with intense fear to the objects or
situations they dread (Farmer & Chapman, 2008; Wolpe, 1997, 1995, 1990). First, they
are taught the skill of relaxation over the course of several sessions. Next, they construct
a fear hierarchy, a list of feared objects or situations, starting with those that are less feared
and ending with the ones that are most dreaded. Here is the hierarchy developed by a
man who was afraid of criticism, especially about his mental stability:

1. Friend on the street: “Hi, how are you?”

2. Friend on the street: “How are you feeling these days?”

3. Sister: “You’ve got to be careful so they don’t put you in the hospital.”

4. Wife: “You shouldn’t drink beer while you are taking medicine.”

5. Mother: “What’s the matter, don’t you feel good?”

6. Wife: “It’s just you yourself, it’s all in your head.”

7. Service station attendant: “What are you shaking for?”

8. Neighbor borrows rake: “Is there something wrong with your leg? Your
knees are shaking.”

9. Friend on the job: “Is your blood pressure okay?”

10. Service station attendant: “You are pretty shaky, are you crazy or something?”

(Marquis & Morgan, 1969, p. 28)

Desensitization therapists next have their clients either imagine or actually confront
each item on the hierarchy while in a state of relaxation. In step-by-step pairings of

oconditioning0A simple form of
learning.

°operant conditioning0A process of
learning in which behavior that leads to
satisfying consequences is likely to be
repeated.

omodelingoA process of learning in
which an individual acquires responses
by observing and imitating others.

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

°systematic desensitization0A behav-
ioral treatment in which clients with
phobias learn to react calmly instead of
with intense fear to the objects or situa-
tions they dread.

Behavioral 10%

Other 8%

Interpersonal 4%

Family systems 3%

Client-centered 1%

-4.–“” Existential i%

Gestalt 2%

46 : //CHAPTER 2

feared items and relaxation, clients move up the hierarchy until at last they
can face every one of the items without experiencing fear. As you will read
in Chapter 4, research has shown systematic desensitization and other clas-
sical conditioning techniques to be effective in treating phobias (Buchanan
& Houlihan, 2008).

.4l,/ i1 • iii

V-11,
f■

Assessing the Behavioral Model
The behavioral model has become a powerful force in the clinical field.
Various behavioral theories have been proposed over the years, and many
treatment techniques have been developed. As you can see in Figure 2-6,
approximately 10 percent of today’s clinical psychologists report that their
approach is mainly behavioral (Prochaska & Norcross, 2007).

Perhaps the greatest appeal of the behavioral model is that it can be
tested in the laboratory, whereas psychodynamic theories generally cannot.
The behaviorists’ basic concepts—stimulus, response, and reward—can be
observed and measured. Experimenters have, in fact, successfully used the
principles of learning to create clinical symptoms in laboratory participants,
suggesting that psychological disorders may indeed develop in the same
way. In addition, research has found that behavioral treatments can be help-
ful to people with specific fears, compulsive behavior, social deficits, mental
retardation, and other problems (Wilson, 2008).

At the same time, research has also revealed weaknesses in the model. Certainly behav-
ioral researchers have produced specific symptoms in participants. But are these symptoms
ordinarily acquired in this way? There is still no indisputable evidence that most people
with psychological disorders are victims of improper conditioning. Similarly, behavioral
therapies have limitations.The improvements noted in the therapist’s office do not always
extend to real life. Nor do they necessarily last without continued therapy.

Finally, some critics hold that the behavioral view is too simplistic, that its con-
cepts fail to account for the complexity of behavior. In 1977 Albert Bandura, a leading
behaviorist, argued that in order to feel happy and function effectively people must
develop a positive sense of self-efficacy. That is, they must know that they can master
and perform needed behaviors whenever necessary. Other behaviorists of the 1960s
and 1970s similarly recognized that human beings engage in cognitive behaviors, such as
anticipating or interpreting—ways of thinking that until then had been largely ignored
in behavioral theory and therapy. These individuals developed cognitive-behavioral expla-
nations that took unseen cognitive behaviors into greater account (Meichenbaum, 1993;
Goldiamond, 1965) and cognitive-behavioral therapies that helped clients to change both
counterproductive behaviors and dysfunctional ways of thinking. Cognitive-behavioral
theorists and therapists bridge the behavioral model and the cognitive model, the view
to which we turn next.

In’Their t fords

FIcrrio.j, hIneriOirAiti, 1945

Models of Abnormality :// 47

The Bel civioral Model

Behaviorists focus on behaviors and propose that the behaviors develop in accordance

with the principles of learning. They hold that three types of conditioning—classical

conditioning, operant conditioning, and modeling—account for all behavior,
whether normal or dysfunctional. The goal of the behavioral therapies is to identify

the client’s problematic behaviors and replace them with more appropriate ones,

using techniques based on one or more of the principles of learning. The classical
conditioning approach of systematic desensitization, for example, has been effec-

tive in treating phobias.

*The Cognitive Model
Philip Berman, like the rest of us, has cognitive abilities—special intellectual capacities to
think, remember, and anticipate. These abilities can help him accomplish a great deal in
life.Yet they can also work against him. As he thinks about his experiences, Philip may
misinterpret experiences in ways that lead to poor decisions, maladaptive responses, and
painful emotions.

In the early 1960s two clinicians,Albert Ellis (1962) and Aaron Beck (1967), proposed
that cognitive processes are at the center of behaviors, thoughts, and emotions and that
we can best understand abnormal functioning by looking to cognition—a perspective
known as the cognitive model. Ellis and Beck claimed that clinicians must ask questions
about the assumptions and attitudes that color a client’s perceptions, the thoughts run-
ning through that person’s mind, and the conclusions to which they are leading. Other
theorists and therapists soon embraced and expanded their ideas and techniques.

How Do Cognitive Theorists Explain Abnormal Functioning?
According to cognitive theorists, abnormal functioning can result from several kinds of
cognitive problems. Some people may make assumptions and adopt attitudes that are dis-
turbing and inaccurate (Beck &Weishaar, 2008; Ellis, 2008). Philip Berman, for example,
often seems to assume that his past history has locked him in his present situation. He
believes that he was victimized by his parents and that he is now forever doomed by
his past. He seems to approach all new experiences and relationships with expectations
of failure and disaster.

Illogical thinking processes are another source of abnormal functioning, ac-
cording to cognitive theorists. Beck, for example, has found that some people
consistently think in illogical ways and keep arriving at self-defeating conclu-
sions (Beck & Weishaar, 2008). As you will see in Chapter 7, he has identified
a number of illogical thought processes regularly found in depression, such as
overgeneralization, the drawing of broad negative conclusions on the basis of a
single insignificant event. One depressed student couldn’t remember the date
of Columbus’s third voyage to America during a history class. Overgeneralizing,
she spent the rest of the day in despair over her wide-ranging ignorance.

Cognitive Therapies
According to cognitive therapists, people with psychological disorders can
overcome their problems by developing new, more functional ways of thinking.
Because different forms of abnormality may involve different kinds of cogni-
tive dysfunctioning, cognitive therapists have developed a number of strategies.
Beck, for example, has developed an approach that is widely used, particularly
in cases of depression (Beck & Weishaar, 2008; Beck, 2002, 1967).

Sur:ii j for Help
oday, computers and the Internet
affect just about every area of life.

Thus it is not surprising that the growth of
cybertherapy has closely paralleled devel-
opments in computer technology.

The clinical field’s first excursion into
the digital world took the form of computer
software therapy programs (Tantum, 2006;
Moriley et al., 2004). These programs
seek to reduce emotional distress through
typed conversations between human users
and computer “therapists.” The computer
programs try to capture the basic prin-
ciples of actual therapy. One program, for
example, helps people state their problems
in “if-then” statements, a technique similar
to that used by cognitive therapists.

Advocates of computer software therapy
programs have argued that many people
find it easier to disclose sensitive personal
information to a computer than to a thera-
pist. Research indicates that some of the
programs are indeed helpful to at least
a modest degree (Lange et al., 2004;
Rochlen et al., 2004). Computer experts
currently are working to develop programs
for recognizing clients’ faces and emotions
and on programs that emulate emotion in
computer-generated animation, develop-
ments that will likely increase the versatility
and appeal of computer therapy programs.

Another form of cybertherapy, online
counseling, has exploded in popular-
ity over the past decade. Thousands of
therapists have set up online services that
invite persons with problems to e-mail their
questions and concerns (Chester & Glass,
2006; Rosen, 2005). Such services, often
called e-therapy, can cost as much as $2
per minute. Services of this kind have

raised concerns about the quality of care
and about confidentiality. Many e-thera-
pists do not even have advanced clinical
training. Nevertheless, the use of e-therapy
continues to grow by leaps and bounds.

Less common, but on the rise, is audio-
visual e-therapy. This kind of offering more
closely mimics the conventional therapy
experience. A client sets up an appoint-
ment with a therapist, and, with the aid
of a camera, microphone, and proper
computer tools, the two proceed to have
a face-to-face session. The advantage?
Clients can receive counseling conveniently
while sitting at home or in their office, and
they can have access to a counselor who
is located even thousands of miles away.
The key disadvantage? Once again, qual-
ity control.

Still more common than either online
counseling or audiovisual e-therapies are
Internet chat groups and “virtual” support
groups. Tens of thousands of these groups
are currently “in session” around the clock
for everything from depression to substance
abuse, anxiety, and eating disorders
(Moskowitz, 2008, 2001). Like in-person
self-help groups, the online chat groups pro-
vide opportunities for people with similar
problems to communicate with each other,
freely trading information, advice, and
empathy (Griffiths & Christensen, 2006).
Of course, unlike members of in-person self-
help groups, people who choose Internet
chat group therapy do not know who is on
the other end of the computer connection
or whether the advice they receive is well
intentioned or at all appropriate.

48 ://CHAPTER 2

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

In Beck’s approach, called simply cognitive therapy, therapists help clients rec-
ognize the negative thoughts, biased interpretations, and errors in logic that dominate
their thinking and, according to Beck, cause them to feel depressed.Therapists also guide
clients to challenge their dysfunctional thoughts, try out new interpretations, and ulti-
mately apply the new ways of thinking in their daily lives. As you will see in Chapter 7,
people with depression who are treated with Beck’s approach improve much more than
those who receive no treatment.

Models of Abnormality 49

In the excerpt that follows, a cognitive therapist guides a depressed 26-year-old
graduate student to see the link between the way she interprets her experiences and the
way she feels and to begin questioning the accuracy of her interpretations:

Therapist: How do you understand it?
Patient: I get depressed when things go wrong. Like when I fail a test.

Therapist: How can failing a test make you depressed?
Patient Well, if I fail I’ll never get into law school.

Therapist: So failing the test means a lot to you. But if failing a test could drive people into
clinical depression, wouldn’t you expect everyone who failed the test to have
a depression? … Did everyone who failed get depressed enough to require
treatment?

Patient No, but it depends on how important the test was to the person.
Therapist Right, and who decides the importance?

Patient: I do.
Therapist And so, what we have to examine is your way of viewing the test (or the way

that you think about the test) and how it affects your chances of getting into law
school. Do you agree?

Patient Right. . .
Therapist Now what did failing mean?

Patient: (Tearful) That I couldn’t get into law school.
Therapist And what does that mean to you?

Patient That I’m just not smart enough.
Therapist Anything else?

Patient That I can never be happy.
Therapist And how do these thoughts make you feel?

Patient: Very unhappy.
Therapist So it is the meaning of failing a test that makes you very unhappy. In fact, believ-

ing that you can never be happy is a powerful factor in producing unhappiness.
So, you get yourself into a trap—by definition, failure to get into law school
equals “I can never be happy.”

(Beck et al., 1979, pp, 145-146)

Assessing the Cognitive Model
The cognitive model has had very broad appeal. In addition to a large number of
cognitive-behavioral clinicians who apply both cognitive and learning principles in their
work, many cognitive clinicians focus exclusively on client interpretations, attitudes, as-
sumptions, and other cognitive processes. Altogether approximately 28 percent of today’s
clinical psychologists identify their approach as cognitive (Prochaska & Norcross, 2007).

The cognitive model is popular for several reasons. First, it focuses on a process
unique to human beings—the process of human thought—and many theorists from
varied backgrounds find themselves drawn to a model_ that considers thought to be the
primary cause of normal and abnormal behavior.

Cognitive theories also lend themselves to research. Investigators have found that
people with psychological disorders often make the kinds of assumptions and errors in
thinking the theorists claim (Ingram et at, 2007).Yet another reason for the popular-
ity of this model is the impressive performance of cognitive and cognitive-behavioral
therapies. They have proved very effective for treating depression, panic disorder, social
phobia, and sexual dysfunctions, for example (Beck & Weishaar, 2008).

Nevertheless, the cognitive model, too, has its drawbacks. First, although disturbed
cognitive processes are found in many forms of abnormality, their precise role has yet to
be detertnined,The cognitions seen in psychologically troubled people could well be a

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50 :1/CHAPTER 2

s.

result rather than a cause of their difficulties. Second, although cognitive
and cognitive-behavioral therapies are clearly of help to many people,
they do not help everyone. Is it enough simply to change cognitions?

Y. oz. 0 v./ N Can such changes make a general and lasting difference in the way
TEOlauS THAWS people feel and behave? Moreover, a growing body of research suggests

NEXT 200 MILES that the kinds of cognitive changes proposed by Beck and other cogni-
tive therapists are not always possible to achieve (Shall, 2008).

In response to such limitations, a new group of cognitive and
cognitive-behavioral therapies, sometimes called the new wave of cog-
nitive therapies, has emerged in recent years. These new approaches,
such as the widely used Acceptance and Commitment Therapy (ACT),
help clients to accept many of their problematic thoughts rather than
judge them, act on them, or try fruitlessly to change them (Levin &
Hayes, 2009). The hope is that by recognizing such thoughts for what
they are—just thoughts—clients will eventually be able to let them pass
through their awareness without being particularly troubled by them.

A final drawback of the cognitive model is that, like the other models you have read
about, it is narrow in certain ways. Although cognition is a very special human dimen-
sion, it is still only one part of human functioning. Aren’t human beings more than
the sum of their thoughts, emotions, and behaviors? Shouldn’t explanations of human
functioning also consider broader issues, such as how people approach life, what value
they extract from it, and how they deal with the question of life’s meaning? This is the
position of the humanistic-existential model.

•”Pq

The Cognitive Model

According to the cognitive model, we must understand human thought to under-
stand human behavior. When people display abnormal patterns of functioning,
cognitive theorists point to cognitive problems, such as maladaptive assumptions
and illogical thinking processes. Cognitive therapists try to help people recognize
and change their faulty ideas and thinking processes. Among the most widely used
cognitive treatments is Beck’s cognitive therapy.

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When Humanism and
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Ti;ghe Humanistic-Existential Model
Philip Berman is more than the sum of his psychological conflicts, learned behaviors,
or cognitions. Being human, he also has the ability to pursue philosophical goals such
as self-awareness, strong values, a sense of meaning in life, and freedom of choice. Ac-
cording to humanistic and existential theorists, Philip’s problems can be understood
only in the light of such complex goals. Humanistic and existential theorists are often
grouped together—in an approach known as the humanistic-existential model—because
of their common focus on these broader dimensions of human existence. At the same
time, there are important differences between them.

Humanists, the more optimistic of the two groups, believe that human beings are
born with a natural tendency to be friendly, cooperative, and constructive. People,
these theorists propose, are driven to self-actualize—that is, to fulfill this potential for
goodness and growth. They can do so, however, only if they honestly recognize and
accept their weaknesses as well as their strengths and establish satisfying personal values
to live by. Humanists further suggest that self-actualization leads naturally to a concern
for the welfare of others and to behavior that is loving, courageous, spontaneous, and
independent (Maslow, 1970).

Existentialists agree that human beings must have an accurate awareness of themselves
and live meaningful—they say “authentic”—lives in order to be psychologically well

Models of Abnormality 51

adjusted. These theorists do not believe, however, that people are naturally inclined to
live positively. They believe that from birth we have total freedom, either to face up to
our existence and give meaning to our lives or to shrink from that responsibility. Those
who choose to “hide” from responsibility and choice will view themselves as helpless
and may live empty, inauthentic, and dysfunctional lives as a result.

The humanistic and existential views of abnormality both date back to the 1940s.
At that time Carl Rogers (1902-1987), often considered the pioneer of the humanis-
tic perspective, developed client -centered therapy, a warm and supportive approach that
contrasted sharply with the psychodynamic techniques of the day. He also proposed a
theory of personality that paid little attention to irrational instincts and conflicts.

The existential view of personality and abnormality appeared during this same period.
Many of its principles came from the ideas of nineteenth-century European existential
philosophers who held that human beings are constantly defining and so giving meaning
to their existence through their actions (Mendelowitz & Schneider, 2008).

The humanistic and existential theories, and their uplifting implications, were ex-
tremely popular during the 1960s and 1970s, years of considerable soul-searching and
social upheaval in Western society. They have since lost some of their popularity, but
they continue to influence the ideas and work of many clinicians.

Rogers’s Humanistic Theory and Therapy
According to Carl Rogers (2000, 1987, 1951), the road to dysfunction begins in infancy.
We all have a basic need to receive positive regard from the important people in our lives
(primarily our parents). Those who receive unconditional (nonjudgmental) positive regard
early in life are likely to develop unconditional self- regard. That is, they come to recognize
their worth as persons, even while recognizing that they are not perfect. Such people
are in a good position to actualize their positive potential.

Unfortunately, some children repeatedly are made to feel that they are not worthy of
positive regard. As a result, they acquire conditions of worth, standards that tell them they
are lovable and acceptable only when they conform to certain guidelines. To maintain
positive self-regard, these people have to look at themselves very selectively, denying or
distorting thoughts and actions that do not measure up to their conditions of worth.
They thus acquire a distorted view of themselves and their experiences. They do not
know what they are truly feeling, what they genuinely need, or what values and goals
would be meaningful for them. Problems in functioning are then inevitable.

Rogers might view Philip Berman as a man who has gone astray. Rather than striv-
ing to fulfill his positive human potential, he drifts from job to job and relationship to re-
lationship. In every interaction he is defending himself, trying to interpret events in ways
he can live with, usually blaming his problems on other people. Nevertheless, his basic
negative self-image continually reveals itself. Rogers would probably link this problem
to the critical ways Philip was treated by his mother throughout his childhood.

Clinicians who practice Rogers’s client-centered therapy try to create a support-
ive climate in which clients feel able to look at themselves honestly and acceptingly
(Raskin, Rogers, & Witty, 2008). The therapist must display three important qualities
throughout the therapy— unconditional positive regard (full and warm acceptance for the
client), accurate empathy (skillful listening and restatements), and genuineness (sincere com-
munication). The following interaction shows the therapist using all these qualities to
move the client toward greater self-awareness:

•

Client: Yes, I know I shouldn’t worry about it, but I do. Lots of things—money, people,
clothes. in classes I feel that everyone’s just waiting for a chance to jump on
me. . . When I meet somebody l wonder what he’s actually thinking of me.
Then later on I wonder how I match up to what he’s come to think of me.

Therapist: You feel that you’re pretty responsive to the opinions of other people.
Client: Yes, but it’s things that shouldn’t worry me.

Gself-actualizationoThe humanistic pro-
cess by which people fulfill theft potential
for goodness and growth.

°client-centered therapyeThe human-
istic therapy developed by Carl Rogers
in which clinicians try to help clients by
conveying acceptance, accurate empa-
thy, and genuineness.

1 ‘

P. (Wp.t .

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

a

..1■C;;Io

52 ://CHAPTER 2

Therapist: You feel that it’s the sort of thing that shouldn’t be upsetting, but they do get you
pretty much worried anyway.

Client: Just some of them. Most of those things do worry me because they’re true. The
ones I told you, that is. But there are lots of little things that aren’t true… .
Things just seem to be piling up, piling up inside of me. . It’s a feeling that
things were crowding up and they were going to burst.

Therapist: You feel that it’s a sort of oppression with some frustration and that things are
just unmanageable.

Client: In a way, but some things just seem illogical. I’m afraid I’m not very clear here
but that’s the way it comes.

Therapist That’s all right. You say just what you think.

(Snyder 1947, pp. 2-24)

In such an atmosphere, clients are expected to feel accepted by their therapists.
They then may be able to look at themselves with honesty and acceptance. They begin
to value their own emotions, thoughts, and behaviors, and so they are freed from the
insecurities and doubts that prevent self-actualization.

Client-centered therapy has not fared very well in research (Sharf, 2008). Although
some studies show that participants who receive this therapy improve more than control
participants, many other studies have failed to find any such advantage. All the same,
Rogers’s therapy has had a positive influence on clinical practice (Raskin et al., 2008).
It was one of the first major alternatives to psychodynamic therapy, and it helped open
up the clinical field to new approaches. Rogers also helped pave the way for psychologists
to practice psychotherapy, which had previously been considered the exclusive territory
of psychiatrists.And his commitment to clinical research helped promote the systematic
study of treatment. Approximately 1 percent of today’s clinical psychologists, 2 percent
of social workers, and 4 percent of counseling psychologists report that they employ the
client-centered approach (Prochaska & Norcross, 2007).

Gestalt Theory and Therapy
Gestalt therapy, another humanistic approach, was developed in the 1950s by a
charismatic clinician named Frederick (Fritz) Perls (1893-1970). Gestalt therapists, like
client-centered therapists, guide their clients toward self-recognition and self-acceptance
(Yontef & Jacobs, 2008). But unlike client-centered therapists, they often try to achieve
this goal by challenging and even frustrating their clients. Some of Perls’s favorite tech-
niques were skillful frustration, role playing, and numerous rules and exercises.

In the technique of skillful frustration, gestalt therapists refuse to meet their clients’
expectations or demands.This use of frustration is meant to help people see how often
they try to manipulate others into meeting their needs. In the technique of role play-
ing, the therapists instruct clients to act out various roles. A person may be told to be
another person, an object, an alternative self, or even a part of the body. Role playing
can become intense, as individuals are encouraged to express emotions fully. Many cry
out, scream, kick, or pound.Through this experience they may come to “own” (accept)
feelings that previously made them uncomfortable.

Peels also developed a list of rules to ensure that clients will look at themselves more
closely. In some versions of gestalt therapy, for example, clients may be required to use
“I” language rather than “it” language.They must say,”I am frightened” rather than “The
situation is frightening.”Yet another common rule requires clients to stay in the here and
now. They have needs now, are hiding their needs now and must observe them now.

Approximately 1 percent of clinical psychologists and other kinds of clinicians
describe themselves as gestalt therapists (Prochaska & Norcross, 2007). Because they
believe that subjective experiences and self-awareness cannot be measured objectively,
proponents of gestalt therapy have not often performed controlled research on this
approach (Yontef & Jacobs, 2008; Striimpfel, 2006, 2004).

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Models of Abnormality :1/ 53

Spiritual Views and Interventions
For most of the twentieth century, clinical scientists viewed religion as a negative—or
at best neutral—factor in mental health (Blanch, 2007; Richards & Bergin, 2005,
2000). In the early 1900s, for example, Freud argued that religious beliefs were defense
mechanisms, “born from man’s need to make his helplessness tolerable” (1961, p. 23).
This negative view of religion now seems to be ending, however. During the past de-
cade, many articles and books linking spiritual issues to clinical treatment have been
published, and the ethical codes of psychologists, psychiatrists, and counselors have
each concluded that religion is a type of diversity that mental health professionals must
respect (Richards & Bergin, 2005, 2004). Researchers have learned that spirituality can,
in fact, be of psychological benefit to people. In particular, studies have examined the
mental health of people who are devout and who view God as warm, caring, helpful,
and dependable. Repeatedly, these individuals are found to be less lonely, pessimistic,
depressed, or anxious than people without any religious beliefs or those who view God
as cold and unresponsive (Loewenthal, 2007; Koenig, 2002). Such individuals also seem
to cope better with major life stressors—from illness to war—and to attempt suicide less
often. In addition, they are less likely to abuse drugs. In line with such findings, many
therapists now make a point of including spiritual issues when they treat religious clients
(Raab, 2007; Helineke & Sori, 2006), and some further encourage clients to use their
spiritual resources to help them cope with current stressors.

Existential Theories and Therapy
Like humanists, existentialists believe that psychological dysfunc tinning is caused by self-
deception; existentialists, however, are talking about a kind of self-deception in which
people hide from life’s responsibilities and fail to recognize that it is up to them to give
meaning to their lives. According to existentialists, many people become overwhelmed
by the pressures of present-day society and so look to others for explanations, guidance,
and authority. They overlook their personal freedom of choice and avoid responsibility
for their lives and decisions (Mendelowitz & Schneider, 2008). Such people are left with
empty, inauthentic lives. Their dominant emotions are anxiety, frustration, boredom,
alienation, and depression.

Existentialists might view Philip Berman as a man who feels overwhelmed by the
forces of society. He sees his parents as “rich, powerful, and selfish,” and he perceives teach-
ers, acquaintances, and employers as oppressing. He fails to appreciate his choices in life and
his capacity for finding meaning and direction. Quitting becomes a habit with him—he
leaves job after job, ends every romantic relationship, and flees difficult situations.

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

54 ://CHAPTER 2

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

In existential therapy people are encouraged to accept responsibility for their lives
and for their problems.Therapists try to help clients recognize their freedom so that they
may choose a different course and live with greater meaning (Schneider, 2008, 2003).
The precise techniques used in existential therapy vary from clinician to clinician.At the
same time, most existential therapists place great emphasis on the relationship between
therapist and client and try to create an atmosphere of candor, hard work, and shared
learning and growth.

Patient: I don’t know why 1 keep coming here. All I do is tell you the same thing
over and over. I’m not getting anywhere.

Doctor: I’m getting tired of hearing the some thing over and over, too.
Patient Maybe stop coming.
Doctor: it’s certainly your choice.

Patient: What do you think I should do?
Doctor: What do you want to do?
Patient: I want to get better.
Doctor: don’t blame you.
Patient If you think I should stay, ok, I will.
Doctor: You want me to tell you to stay?
Patient: You know what’s best; you’re the doctor.
Doctor: Do I act like a doctor?

(Keen, 1970, p. 200)

Existential therapists do not believe that experimental methods can adequately
test the effectiveness of their treatments. To them, research dehumanizes individuals by
reducing them to test measures. Not surprisingly, then, very little controlled research
has been devoted to the effectiveness of this approach (Schneider, 2008). Neverthe-
less, around 1 percent of today’s therapists use an approach that is primarily existential
(Prochaska & Norcross, 2007).

Assessing the Humanistic-Existential Model
The humanistic-existential model appeals to many people in and out of the clinical field.
In recognizing the special challenges of human existence, humanistic and existential
theorists tap into an aspect of psychological life that typically is missing from the other
models (Cain, 2007; Wampold, 2007). Moreover, the factors that they say are essential to
effective functioning—self-acceptance, personal values, personal meaning, and personal
choice—are certainly lacking in many people with psychological disturbances.

The optimistic tone of the humanistic-existential model is also an attraction. Indeed,
such optimism meshes quite well with the goals and principles of positive psychology,
a current movement described in Chapter 1. Theorists who follow the principles of
the humanistic-existential model offer great hope when they assert that, despite past
and present events, we can make our own choices, determine our own destiny, and ac-
complish much. Still another attractive feature of the model is its emphasis on health.
Unlike clinicians from some of the other models who see individuals as patients with
psychological illnesses, humanists and existentialists view them simply as people who
have yet to fulfill their potential.

At the same time, the humanistic-existential focus on abstract issues of human fulfill-
ment gives rise to a major problem from a scientific point of view:These issues are difficult
to research. In fact, with the notable exception of Rogers, who tried to investigate his
clinical methods carefully, humanists and existentialists have traditionally rejected the use
of empirical research. This antiresearch position is just now beginning to change. Human-
istic and existential researchers have conducted several recent studies that use appropriate

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The Humanistic-Exis.iential Model

The humanistic-existential model focuses on distinctly human issues such as self-
awareness, values, meaning, and choice.

Humanists believe that people are driven to self-actualize. When this drive is
interfered with, abnormal behavior may result. One group of humanistic therapists,
client-centered therapists, tries to create a very supportive therapy climate in which
people can look at themselves honestly and occeptingly, thus opening the door to
self-actualization. Another group, gestalt therapists, uses more active techniques to
help people recognize and accept their needs. Recently the role of religion as an
important factor in mental health and in psychotherapy has caught the attention of
researchers and clinicians.

According to existentialists, abnormal behavior results from hiding from life’s
responsibilities. Existential therapists encourage people to accept responsibility for
their lives, to recognize their freedom to choose a different course, and to choose
to live with greater meaning.

Gender IsWes in the:Workplace

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Models of Abnormality :/1 55

control groups and statistical analyses, and they have found that their therapies can be ben-
eficial in some cases (Schneider, 2008; Strampfel, 2006) This newfound interest in research
should lead to important insights about the merits of this model in the coming years.

•

*The Sociocultural Model:
Family-Social and Multicultural Perspectives
Philip Berman is also a social and cultural being. He is surrounded by people and by
institutions, he is a member of a family and a cultural group, he participates in social
relationships, and he holds cultural values. Such forces are always operating upon Philip,
setting rules and expectations that guide or pressure him, helping to shape his behaviors,
thoughts, and emotions.

According to the sociocultural model, abnormal behavior is best understood in fight
of the broad forces that influence an individual. What are the norms of the individual’s
society and culture? What roles does the person play in the social environment? What
kind of family structure or cultural background is the person a part of? And how do
other people view and react to him or her? In fact, the sociocultural model is comprised
of two major perspectives—the family-social perspective and the multicultural perspective.

How Do Family-Social Theorists Explain
Abnormal Functioning?
Proponents of the family-social perspective argue that clinical theorists should con-
centrate on those broad forces that operate directly on an individual as he or she moves
through life—that is, family relationships, social interactions, and community events.
They believe that such forces help account for both normal and abnormal behavior, and
they pay particular attention to three kinds of factors: social labels and roles, social networks,
and family structure and communication.

Social Labels and Roles Abnormal functioning can be influenced greatly by the
labels and roles assigned to troubled people (Link & Phelan, 2006; Link et al., 2004,
2001).When people stray from the norms of their society, the society calls them deviant
and, in many cases, “mentally ill.” Such labels tend to stick. Moreover, when people are
viewed in particular ways, reacted to as “crazy,” and perhaps even encouraged to act sick,
they gradually learn to accept and play the assigned social role. Ultimately the label seems
appropriate.

56 ://CHAPTER 2

Pressures of Poier

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A famous study by the clinical investigator David Rosenhan (1973) supports this
position. Eight normal people presented themselves at various mental hospitals, com-
plaining that they had been hearing voices say the words “empty,” “hollow,” and “thud.”
On the basis of this complaint alone, each was diagnosed as having schizophrenia and
admitted. In fact, the “pseudopatients” had a hard time convincing others that they were
well once they had been given the diagnostic label. Their hospitalizations ranged from
7 to 52 days, even though they behaved normally as soon as they were admitted. In
addition, the label kept influencing the way the staff viewed and dealt with them. For
example, one pseudopatient who paced the corridor out of boredom was, in clinical
notes, described as “nervous.” Overall, the pseudopatients came to feel powerless, invis-
ible, and bored.

Sod& Networks and Supports Family-social theorists are also concerned with
the social networks in which people operate, including their social and professional re-
lationships. How well do they communicate with others? What kind of signals do they
send to or receive from others? Researchers have often found ties between deficiencies
in social networks and a person’s functioning (Yen et al., 2007; Paykel, 2006, 2003).They
have observed, for example, that people who are isolated and lack social support or inti-
macy in their lives are more likely to become depressed when under stress and to remain
depressed longer than are people with supportive spouses or warm friendships.

Family Structure and Communication Of course, one of the important social
networks for an individual is his or her family. According to family systems theory,
the family is a system of interacting parts—the family members—who interact with
one another in consistent ways and follow rules unique to each family (Goldenberg &
Goldenberg, 2008). Family systems theorists believe that the structure and coinmunication
patterns of some families actually force individual members to behave in a way that oth-
envise seems abnormal. If the members were to behave normally, they would severely
strain the family’s usual manlier of operation and would actually increase their own and
their family’s turmoil.

Family systems theory holds that certain family systems are particularly likely to
produce abnormal functioning in individual members. Some families, for example, have
an enmeshed structure in which the members are grossly overinvolved in each other’s
activities, thoughts, and feelings. Children from this kind of family may have great dif-
ficulty becoming independent in life (Santiseban et al., 2001). Some families display
disengagement, which is marked by very rigid boundaries between the members. Chil-
dren from these families may find it hard to function in a group or to give or request
support (Corey, 2008, 2004).

Philip Berman’s angry and impulsive persona] style
might be seen as the product of a disturbed family struc-
ture. According to family systems theorists, the whole
family—mother, father, Philip, and his brother Arnold—
relate in such a way as to maintain Philip’s behavior.
Family theorists might be particularly interested in the
conflict between Philip’s mother and father and the
imbalance between their parental roles. They might see
Philip’s behavior as both a reaction to and stimulus for
his parents’ behaviors. With Philip acting out the role of
the misbehaving child, or scapegoat, his parents may have
little need or time to question their own relationship.

Family systems theorists would also seek to clarify the
precise nature of Philip’s relationship with each parent. Is
he enmeshed with his mother and/or disengaged from his
father? They would look too at the rules governing the
sibling relationship in the family, the relationship between
the parents and Philip’s brother, and the nature of parent-
child relationships in previous generations of the family.