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Challenges in Identifying Mental Disorders

Most mental disorders lie on a continuum with “normal” behavior at one end. For example, nearly everyone has a fear of something, but it does not rise to the level of a phobia. A behavior may seem abnormal in one context but completely normal in another context. These two aspects show why it can be challenging to properly identify mental disorders.

Using your textbook and the Argosy University online library resources, research the principles and methods of identifying mental disorders. Note particularly the diversity of views and the challenges of identification. Based on your research, write a reflective essay. Use the following question to direct your thoughts and organize your essay:

  • Why is determining abnormal behavior or a mental disorder so difficult?

To develop your essay, keep in mind issues such as the role of social norms in defining the abnormal, the multiplicity of indicators of what is abnormal, the stigma suffered by those identified as abnormal, and finally the need for objectivity in dealing with the concept.

Write a 2–3-page essay in Word format. Apply APA standards to citation of sources.

“For Dr. Equinox only”
CHAPTER 1 Understanding Abnormality A Look at History and Research Methods OUTLINE Case Report: Rebecca Hasbrouck 3 What Is Abnormal Behavior? 4 Defi ning Abnormality 5 Challenges Involved in Characterizing Abnormal Behavior 6 What Causes Abnormality? 7 Real Stories: Kelsey Grammer: Recovering from Trauma 8 Abnormality: A Biopsychosocial Perspective 10 Abnormal Psychology Throughout History 10 Prehistoric Times 11 Ancient Greece and Rome 11 The Middle Ages and Renaissance 12 Europe and the United States in the 1700s 14 The 1800s to the 1900s 16 The Twenty-First Century 18 Research Methods in Abnormal Psychology 21 The Scientifi c Method 21 The Experimental Method 23 The Correlational Method 25 The Survey Method 25 The Case Study Method 26 Single-Subject Design 27 Studies of Genetic Infl uence 27 The Human Experience of Psychological Disorders 28 Impact on the Individual 28 Impact on the Family 30 Impact on the Community and Society 31 Reducing Stigma 32 Bringing It All Together: Clinical Perspectives 32 Return to the Case 33 Summary 34 Key Terms 35 Answers to Review Questions 35 Internet Resource 35 haL7069X_ch01_002-035.indd Page 2 11/12/08 4:32:46 AM user-s173 haL7069X_ch01_002-035.indd Page 2 11/12/08 4:32:46 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 Twenty years of clinical practice had not prepared me for my encounter with Rebecca Hasbrouck. Working in the outpatient department of a large psychiatric facility, I had encountered hundreds of people whose stories would move me, but, for some reason, Rebecca’s seemed unusually trou- bling. Perhaps it was her similarity to me in so many ways that stirred me up. Like me, she was in her mid-forties and had mothered two sons when she was in her early thirties. She had been raised in a middle-class family and had attended excellent schools. In fact, when I fi rst spoke with Rebecca, my attention was drawn to the faded Polaroid photo that she grasped tightly in her fi st. It was the picture of a jubilant 22-year-old Rebecca on the day of her graduation from an Ivy L eague university. She stood beside her parents and her older sister, everyone gleaming with pride about all that she had accomplished and fi lled with the greatest of expec- tations about all that would lie ahead for her. I later learned that she was planning to attend one of the most prominent law schools in the country, where she would pursue a special- ization in maritime law. Everyone, in- cluding Rebecca, assumed that a life of happiness and personal fulfi llment would lie ahead. Before telling you the rest of Rebecca’s story, let me tell you more about my initial encounter with her. It was the Tuesday morn- ing following Labor Day weekend. The summer was over, and I was returning from a restful vacation, burdened somewhat by the pros- pects of the correspondence, the messages, and the new responsi- bilities that awaited me. I had arrived early that morning, even before the recepti onist, with the hope of getting a head start on my work. As I approached the clinic’s entrance, I was shocked, however, to fi nd a di- sheveled woman lying up against the locked door . Her hair was dirty and knotted, her clothes torn and stained. She looked up at me with piercing eyes and spoke my name. Who was this woman? How did she know my name? The sight of countless home- less people on the streets of the city every day had made me numb to the power of their despair, but I was suddenly startled to have one of them call me by name. After unlocking the door, I asked her to come in and take a seat in the waiting room. As she emerged from a state of seeming incoherence, this woman told me that her name was “Rebecca Hasbrouck.” She explained that an old college friend whom she had phoned had given her my name and address. Rebecca’s friend apparently recognized the serious- ness of her condition and urged he r to get some professional help. I asked Rebecca to tell me how I could be of assistance. With tears streaming down her face, she whis- pered that she needed to “return to the world” from which she had fl ed 3 years earlier. I asked her to tell me what that “world” was. The story that unfolded seemed unbelievable. She explained that just a few ye ars earlier she was living a comfortable life in an upper-middle-class suburb. Both she and her husband were very successful attorneys, and their two sons were bright, attractive, and athletically gifted. Oddly, Rebecca stopped there, as if that were the end of her story. Naturally, I asked her what happened then. On hear ing my question, her eyes glazed over as she drifted into a detached state of apparent fantasy. I continued to speak to her, but she did not seem to hear my words. Several minutes went by, and she returned to our dialogue. Rebecca proceeded to tell me the story of her journey into depres- sion, despair, and poverty. Interest- ingly, the turning point in Rebecca’ s life was almost 3 years to the day of our encounter. As she and her fam- ily were returning from a vacation in the mountains, a large truck vio – lently rammed their car, causing the car, which Rebecca was driving, to careen off the road and roll over several times. Rebecca was not sure how her body was propelled from the wreckage, but she does recall lying near the burning vehicle as fi re consumed the three most important people in her life. For the weeks that she spent in the hospital, recovering from her own serious injuries, i nclud- ing brain trauma, she wand ered in and out of consciousness, covinced all the while that her experience was merely a bad dream from which she would soon awaken. On her release from the hospital, she returned to her empty home but was tormented relentlessly by the voices and memories of her sons and husband. Realizing that she was in emotional turmoil, she turned to her mother for support and assistance. Sadly, Rebecca’s mother was strug- gling with one of her recurring epi- sodes of severe depression and was u nable to help Rebecca in her time of need. In fact, her mother sternly told Rebecca never to call again, because she did not want to be “burdened by” Rebecca’s diffi – culties. Adding to Rebecca’s dismay was the fact that she received a similar distancing response from the parents of her deceased husband, who told Rebecca that it was too painful for them to interact with the woman who had “killed” their son and grandchildren. Feeling that she had no one to whom she could turn for help, Rebecca set out in search of her lost family members. In the middle of a cold October night, she walked out the front door of her home, dressed only in a nightgown and slippers. Walking the 4-mile distance into the center of town, she called out the names of these three “ghosts” and searched for them in familiar places. At one point, she went to the fr ont door of the police chief’s home and screamed at the top of her lungs that she wanted her sons and husband “released from prison.” A police car was summoned, and she was taken to a psychiatric emergency room. However, during the process of her admission, she cleverly slipped away and set out on a path to reunite with her family members, who were “calling out” to her. During the 3 years that followed this tragic episode, Rebecca had fallen into a life of homelessness, losing all contact with her former world. Sarah Tobin, PhD Case Report Rebecca Hasbrouck haL7069X_ch01_002-035.indd Page 3 11/10/08 8:38:20 PM user-s174 haL7069X_ch01_002-035.indd Page 3 11/10/08 8:38:20 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 4 Chapter 1 Understanding Abnormality I n each chapter of this book, you will read a case study written in the words of Dr. Sarah Tobin, who is a com- posite of many of the qualities found in a good clinical psychologist. At the beginning of each chapter, Dr. Tobin tells us about her initial encounter with a client who has a problem pertinent to the content of that chapter. At the end of the chapter, after you have developed a better understand- ing about the client’s disorder, we will return to Dr. Tobin’s detailed discussion of the case. We believe that you will fi nd each case to be an exciting opportunity to hear the thoughts of a clinician and you will develop an appreciation for the complexity and challenges involved in the diagnosis and treatment of psychological disorders. The fi eld of abnormal psychology is fi lled with countless fascinating stories of people who suffer from psychological disorders. In this chapter, we will try to give you some sense of the reality that psychological disturbance is certain to touch everyone, to some extent, at some point in life. As you progress through this course, you will almost certainly develop a sense of the pain and stigma associated with psychological problems. You will fi nd yourself drawn into the many ways that mental health problems affect the lives of individuals, their families, and society. In addition to becoming more personally exposed to the emotional aspects of abnormal psychology, you will learn about the scientifi c and theoretical basis for understanding and treating the people who suffer from psychological disorders. What Is Abnormal Behavior? Think about how you would feel if you were to see someone like Rebecca walking around your neighborhood. You might be shocked, upset, or afraid, or you might even laugh. Why would you respond in this manner? Perhaps Rebecca would seem abnormal to you. But think further about this. On what basis would you judge Rebecca to be abnormal? Is it her dress, the fact that she is mumbling to herself, that she sounds paranoid, or that she is psychologically unstable? And what would account for your emotional responses to seeing this woman? Why should it bother you to see Rebecca behaving in this way? Do you imagine that she will hurt you? Are you upset because she seems so helpless and out of con- trol? Do you laugh because she seems so ridiculous, or is there something about her that makes you nervous? Perhaps you speculate on the causes of Rebecca’s bizarre behavior. Is she physically ill, intoxicated, or psychologically disturbed? And, if she is psychologically disturbed, how could her dis- turbance be explained? You might also feel concerned about Rebecca’s welfare and wonder how she might be helped. Should you call the police to take her to a hospital? Or should you just leave her alone, because she presents no real danger to anyone? You may not have experienced a situa- tion involving someone exactly like Rebecca, but you have certainly encountered some people in your life whom you regard as abnormal, and your reactions to these people probably have included the range of feelings you would experience if you were to see Rebecca. Conditions like Rebecca’s are likely to touch you in a very personal way. Perhaps you have already been touched by the distressing effects of psychological disorders. Perhaps you have been unusually depressed, fearful, or anxious, or maybe the emotional distress has been a step removed from you: Your father struggles with alcoholism, or your mother has been hospitalized for severe depression; a sister has an eating disorder, or your brother has an irrational fear. If you have not encountered a psychological disorder within your immediate family, you have very likely encountered one in your extended family and circle of friends. You may not have known the formal psychiatric diagnosis for the problem, and you may not have understood its nature or cause. But you knew that something was wrong and that professional help was needed. Until they are forced to face such problems, most peo- ple believe that “bad things” happen only to other people. Other people have car accidents, other people get cancer, and other people become severely depressed. We hope that reading this textbook will help you go beyond this “other people” syndrome. Psychological disorders are part of the This woman claims that her telephone conversations are being recorded by someone who wants to harm her. If you were her friend, how would you go about assessing whether her concerns are legiti- mate or whether her thinking is disturbed? haL7069X_ch01_002-035.indd Page 4 11/25/08 11:27:05 AM user-s174 haL7069X_ch01_002-035.indd Page 4 11/25/08 11:27:05 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 human experience, touching the life—either directly or indirectly—of every person. As you read about these dis- orders and the people who suffer with them, you will fi nd that most of these problems are treatable, and many are preventable. What is abnormal behavior? You may have read this word in the title of the book without giving it much thought. Perhaps you told a friend that you were taking a course in abnormal psychology. Think about what you had in mind when you read or used the word abnormal as applied to human behavior. How would you defi ne abnormal behavior? Read the following examples. Which of these behaviors do you regard as abnormal? ■ Finding a “lucky” seat in an exam ■ Being unable to sleep, eat, study, or talk to anyone else for days after a lover says, “It’s over between us” ■ Breaking into a cold sweat at the thought of being trapped in an elevator ■ Swearing, throwing pillows, and pounding fi sts on the wall in the middle of an argument with a roommate ■ Refusing to eat solid food for days at a time in order to stay thin ■ Having to engage in a thorough hand-washing after coming home from a ride on a bus ■ Believing that the government has agents who are lis-tening in on telephone conversations ■ Drinking a six-pack of beer a day in order to be “soci- able” with friends after work What is your basis for deciding between normal and abnor- mal? As you can see from this exercise, this distinction is often diffi cult to make. It may even seem arbitrary, yet it is essential that you arrive at a clear understanding of this term to guide you in your study of the many varieties of human behavior discussed in this book. Defi ning Abnormality Let’s take a look at four important ways in which we will be discussing abnormality throughout the remainder of this book. These criteria are based on the current diagnostic pro- cedures used in the mental health community. Abnormality could also be defi ned in terms of infrequency (such as left- handedness) or deviation from the average (such as extremes in height). In abnormal psychology, such statistical criteria typically are not considered relevant. Distress The story of Rebecca is that of a woman whose life was thrown into emotional chaos following a traumatic event in which she witnessed the death of her husband and sons. The horror of this image propelled her into a state of profound psychological turmoil, as she looked for ways to cope with the loss of the most important people in her life. Distress, the experience of emotional or physical pain, is common in life. At times, the level of pain becomes so great that an individual fi nds it diffi cult to function. As you will see in many of the conditions discussed in this book, psy- chological pain, such as deep depression or intense anxiety, may be so great that some people cannot get through the tasks of daily life. Impairment In many instances, intense distress leads to a reduction in a person’s ability to function, but there are also instances in which a person’s functioning is defi cient but he or she does not feel particularly upset. Impairment involves a reduction in a person’s ability to function at an optimal or even an average level. For example, when a man consumes an excessive amount of alcohol, his perceptual and cognitive functioning is impaired, and he would be a danger behind the wheel of a car. He might not describe himself as feeling distressed, however; on the contrary, he may boast about how great he feels. For some of the conditions that you will read about, people feel fi ne and describe themselves with positive terms; however, others would regard them as func- tioning inadequately in primary spheres of life, such as at work or within their families. In the case of Rebecca, we see a woman who is both distressed and impaired. Risk to Self or Other People Sometimes people act in ways that cause risk to themselves or others. In this context, risk refers to danger or threat to the well-being of a person. For example, we would describe a severely depressed woman, such as Rebecca, as being at risk of committing suicide. In other situations, an individual’s thoughts or behaviors are threatening to the physical or psychological welfare of other people. Thus, people who abuse children or exploit other people create a risk in society that is considered unacceptable and abnormal. Rebecca Hasbrouck certainly engaged in be- havior that put her at risk, as she lived a life of a homeless person; out of contact with reality and loved ones, she What Is Abnormal Behavior? 5 The anxiety about public speaking experienced by this woman may cause such a high level of tension that she becomes unable to con- tinue her presentation. haL7069X_ch01_002-035.indd Page 5 11/10/08 8:38:25 PM user-s174 haL7069X_ch01_002-035.indd Page 5 11/10/08 8:38:25 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 6 Chapter 1 Understanding Abnormality roamed the streets, looking for the family members who had been killed. Socially and Culturally Unacceptable Behavior Our fi nal criterion for abnormality is behavior that is outside the norms of the social and cultural context within which it takes place. For example, it wouldn’t be odd to see people with painted faces and bizarre outfi ts cheering inside a college basketball arena, but such behavior would be abnormal in a college classroom. In this example, the social context calls for, and permits, very different kinds of behavior; people who deviate from the expected norms are regarded as abnormal. Some behavior that is regarded as odd within a given culture, society, or subgroup may be quite common elsewhere. For example, some people from Mediterranean cultures believe in a phenomenon called mal de ojo, or evil eye, in which, they contend, the ill will of other people can affect them in profound ways. As a result, they may experience various bodily symptoms, such as fi tful sleep, stomach distress, and fever. People expressing such beliefs in contemporary Amer- ican culture might be regarded as odd, possibly a bit para- noid, or overly emotional. Returning to the case of Rebecca, her attempts to contact deceased loved ones would be con- sidered bizarre in the United States but would not be con- sidered unusual in other cultures where communication with the dead is an accepted cultural norm. As you can see, the context within which a behavior takes place is a critical determinant of whether it is regarded as abnormal. Although any one of the above four criteria could serve as the basis for defi ning abnormality, often there is an interaction. For example, a deeply distressed person will customarily be im- paired and may even be a risk to self or others. Challenges Involved in Characterizing Abnormal Behavior The four criteria just discussed might lead you to imagine that defi ning abnormality is a fairly straightforward process. However, you will learn as you read this book and study about various conditions that there is rarely a clear delinea- tion between what is normal and what is abnormal. Even experienced clinicians and researchers disagree about what constitutes a psychological disorder, as we will discuss in more depth in the next chapter. The complexity of diagnosing abnormal psychological conditions was highlighted in a classic study conducted by David Rosenhan in 1973, the conclusions of which continue to resonate in the mental health fi eld. Rosenhan reported the fi ndings of a study in which eight people successfully fooled the staffs of 12 psychiatric hospitals located across the United States. These people were all sane and were employed in a variety of mostly professional occupations. They each presented themselves at a hospital’s admissions offi ce, com- plaining that they had been hearing voices that said, “ Empty,” “Hollow,” and “Thud.” The kind of existential psychosis that these symptoms were supposed to represent had never been reported in the psychiatric literature, which is why those symp- toms were chosen. No other details about the lives of the pseu- dopatients (except their names and employment) were changed when they described themselves; consequently, their histories and current behaviors outside of their symptoms could not be considered abnormal in any way. All the hospitals accepted the pseudopatients for treatment. Once admitted to the hospitals, the pseudopatients stopped fabricating any symptoms at all. None of the staff in any of the hospitals detected the sanity of the pseudopatients and, instead, interpreted the ordinary activities of the pseudopatients on the hospital wards as fur- ther evidence of their abnormality. One of the most troubling experiences for the pseudopatients was a feeling of dehuman- ization, as they felt that no one on the staff cared about their personal issues and needs. Further, despite their efforts to con- vince the staff that they were normal, no one believed them, with the interesting exception of some of the real patients who guessed that they might be either reporters or researchers try- ing to get an inside look at mental hospitals. It took from 7 to 52 days for the pseudopatients to be released from the hospitals. By the time they left, each had been given a diagnosis of “schizophrenia in remission”; in other words, their symptoms were no longer evident, at least for the time being. Rosenhan (1973) concluded that the misattribution of abnormality was due to a general bias among hospital staff to call a healthy person sick: “better to err on the side of cau- tion, to suspect illness even among the healthy” (p. 251). Rosenhan’s study was criticized on both ethical and methodological grounds. Ethical concerns were raised about Do you think that wearing such unusual headgear to run in the Boston marathon is normal or abnormal behavior? haL7069X_ch01_002-035.indd Page 6 11/10/08 8:38:26 PM user-s174 haL7069X_ch01_002-035.indd Page 6 11/10/08 8:38:26 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 the fact that the study involved the deception of the mental health professionals whose job it was to diagnose and treat the pseudopatients. Methodological questions were raised by the fact that no attempt was made to exercise the usual exper- imental controls on a study of this nature, such as having a comparison group (Spitzer, 1975). Other criticisms pertained to diagnostic issues. The pseudopatients were reporting seri- ous symptoms (hallucinations) that would understandably lead most clinicians to a provisional diagnosis of a serious psychological condition such as schizophrenia. At the point of discharge, the fact that the pseudopatients were labeled as being in remission implied that they were symptom-free. Technically, the staff probably felt reluctant to label these individuals as normal in light of the fact that the pseudo- patients had previously complained of schizophrenia-like symptoms (Farber, 1975). Despite these criticisms, Rosenhan’s results and the debates that followed in the study’s aftermath were part of the momentum in the late 1960s and early 1970s to change attitudes toward institutionalization of psychologically dis- turbed individuals. At the same time, mental health profes- sionals were in the process of changing the system for diagnosing many disorders, including schizophrenia. The point of the study, however, is still pertinent today. When a patient in a psychiatric hospital claims to be “the sane one in an insane place,” would anyone believe the patient? In the decades since Rosenhan conducted this controver- sial study, much has changed in the mental health fi eld. The pendulum seems to have swung to the other extreme—many people with diagnosable forms of psychosis are fi nding it diffi cult to gain admission to mental health facilities. Scrib- ner (2001) studied the experience of seven people with long, well-documented histories of chronic schizophrenia, each of whom was in the midst of an acute episode of symptoms. When they presented themselves for admission, six of the seven people were denied treatment. Scribner concluded that would-be consumers of mental health services now face many bureaucratic impediments to receiving care. To test out the extent to which things may have changed in the fi eld of psychiatry in the four decades since Rosenhan’s study, author-psychologist Lauren Slater (2004) made several attempts to replicate the experience of Rosenhan’s pseudo- patients. She went to emergency rooms with the complaint that she was hearing a voice saying “thud” but had no other symptoms. In every instance she was denied admission. Most commonly, she was diagnosed as having depression with psychotic symptoms and then prescribed medication and sent on her way. Slater contrasts her experiences with those of Rosenhan’s pseudopatients by noting that, although she was mislabeled, she was not “locked up.” She also notes another experience that differed from that of the pseudo- patients in that she was treated with “palpable kindness” by every medical professional, and she never felt diminished by their diagnoses. Although there are many methodological and ethical debates related to research involving pseudopatients, the re- search by David Rosenhan served to initiate dialogue that has lasted for decades about what constitutes abnormal be- havior, and how mental health clinicians should and actually do respond to people presenting symptoms outside of normal experience. What Causes Abnormality? Now that we have discussed criteria for defi ning abnormal- ity, we can turn our attention to its causes. In trying to under- stand why people act and feel in ways that are regarded as abnormal, social scientists look at three dimensions: biologi- cal, psychological, and sociocultural. In other words, abnor- mal behavior arises from a complex set of determinants in the body, the mind, and the social context of the individual. Throughout this book, you will see that all three of these domains have relevance to the understanding and treatment of psychological disorders. In Chapter 4, we will discuss in much greater depth the theoretical approaches associated with these general causal categories. Biological Causes In their efforts to understand the causes of abnormal behavior, mental health experts carefully evaluate what is going on in a person’s body that can be attributed to genetic inheritance or disturbances in physical functioning. As a routine component of every evaluation, Dr. Tobin assesses the extent to which a problem that seems to be emotionally caused can be explained in terms of biological determinants. Understanding the important causal role of biology also alerts Dr. Tobin to the fact that she may need to incorporate biolog- ical components, such as medication, into her intervention. As is the case with many medical disorders, various psy- chological disorders run in families. Major depressive disor- der is one of these disorders. The odds of a son or daughter of a depressed parent developing depression are statistically greater than they are for offspring of nondepressed parents. In the case of Rebecca Hasbrouck, Dr. Tobin would attend to the fact that Rebecca’s mother suffers from recurring epi- sodes of depression. Might Rebecca carry within her body a genetic vulnerability to developing a similar mood disorder? In addition to considering the role of genetics, clinicians also consider the possibility that abnormal behavior may be the result of disturbances in physical functioning. Such dis- turbances can arise from various sources, such as medical conditions, brain damage, or exposure to certain kinds of environmental stimuli. Many medical conditions can cause a person to feel and act in ways that are abnormal. For example, a medical abnormality in the thyroid gland can cause wide variations in mood and emotionality. Brain damage resulting from a head trauma, even a slight one, can result in bizarre behavior and intense emotionality. Similarly, the ingestion of substances, either illicit drugs or prescribed medications, can result in emotional and behavioral changes that mimic a psy- chological disorder. Even exposure to environmental stimuli, such as toxic substances or allergens, can cause a person to experience disturbing emotional changes and behavior. What Is Abnormal Behavior? 7 haL7069X_ch01_002-035.indd Page 7 11/10/08 8:38:27 PM user-s174 haL7069X_ch01_002-035.indd Page 7 11/10/08 8:38:27 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 8 Chapter 1 Understanding Abnormality REAL STORIES KELSEY GRAMMER: RECOVERING FROM TRAUMA T he case of Rebecca Hasbrouck, which opens this chapter, tells the story of a woman who has survived a trauma that changed her life. Witness- ing the death of her beloved sons and husband provoked such havoc in her mind that Rebecca lost touch with reality. The enduring effects of traumatic experi- ences have been discussed in recent years by people, some quite famous, who have stepped forward to share their stories chronicling the residual effects of these intensely disturbing experi- ences. The life of actor Kelsey Grammer, who is known throughout the world for his television role as Dr. Frasier Crane on the sitcom Frasier, is an example of how intensely troubling family experi- ences can impair one’s functioning in life for years. Grammer’s bouts with tragedy began very early in his life. When Grammer was 12, his father was shot and killed by a man who was found not guilty by reason of insanity. Even though he had not been close to his father during his childhood, this trauma left him feeling vulnerable in many ways; in particular, he came to feel that life could not be trusted. Eight years after the murder of his father, Grammer’s sister was ab- ducted, raped, and murdered. It was Grammer’s task to identify her body. The nightmare continued when, at the age of 25, Grammer found himself once again mourning family members— his two half-brothers had died in a scuba diving accident. Like so many people devastated by profound personal losses and hurts, Grammer sought ways to relieve his pain and became involved in substance abuse and troubled intimate relationships. In 1988 he was arrested for drunken driving and cocaine possession. In 1990 he was arrested again and sentenced to 30 days in jail when he failed to appear in court. In 1996, he fl ipped his sports car in an alcohol- related incident, after which he sought professional help for his substance-a buse problems at the Betty Ford Center. The story of Grammer’s intimate rela- tionships mirrored the internal chaos with which he was struggling, as he became involved with women he describes in negative terms. His fi rst marriage, to a woman named Doreen, was short-lived, as Grammer became increasingly dissat- isfi ed. He moved on to involvement with Agnes, a woman who made several sui- cide attempts, and later he entered a re- lationship with another volatile woman, Cerlette. Subsequently, he married Leigh- Anne, a woman who Grammer asserts abused him verbally and physically until he fi nally ended the marriage. In his autobiographical book, So Far . . . , Grammer uses emotionally charged words to recount his experi- ences following the death of his father. The truth is, life at home was awful. It seemed that my grandmother and my mother, and even my sister at times, were members of a bizarre conspiracy, its sole purpose to ensure that I fulfi ll their needs. No matter what I was doing, they could call at any time and make me stop. Not because there was a big problem, but maybe just because they were having a fi ght. I was the glue, the man of the family. In describing his reaction to his sister’s murder, Grammer writes, I walked back to the house in a kind of daze. Karen was dead. I had trouble letting that sink in. It was too much to comprehend. Murdered. I stood searching helplessly for an appropriate response. I should be crying, I thought. I entered the kitchen and went back to cooking. Yes, I thought, I should be crying, and so I tried. But it didn’t work. Something strange was going on. It was as if I were split in two, and one half of me was watching the other. One a victim, and the other an observer, noting from the dis- tance like a stranger what was hap- pening to me. It’s diffi cult to explain what I was going through. The one who was watching said, What the hell is wrong with you? Your sister’s dead. Why aren’t you crying? Didn’t you love your sister? Of course I did, the other said, feeling guilty the tears would just not come, and fearing if they did the watching one would say that they weren’t real. (p. 80) Source: Excerpted from So Far . . . by Kelsey Grammer. Copyright ©1995 by Kelsey Grammer. Used by permission of Dutton, a division of Penguin Group (USA) Inc. Kelsey Grammer haL7069X_ch01_002-035.indd Page 8 11/25/08 11:27:27 AM user-s174 haL7069X_ch01_002-035.indd Page 8 11/25/08 11:27:27 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 Psychological Causes If biology could provide all the an- swers, then we would regard mental disorders as medical diseases. Obviously, there is more to the story. Disturbance commonly arises as a result of troubling life experiences. Perhaps an event an hour ago, last year, or in the early days of a person’s life has left its mark in ways that cause drama- tic changes in feelings or behavior. For example, a demean- ing comment from a professor can leave a student feeling hurt and depressed for days. A disappointment in an inti- mate relationship can evoke intense emotionality that lasts for months. A trauma that took place many years ago may continue to affect a person’s thoughts, behavior, and even dreams. Life experiences may also contribute to psychologi- cal disorder by causing the individual to form negative asso- ciations to certain stimuli. For example, an irrational fear of small spaces may arise from being trapped in an elevator. The trauma experienced by Rebecca Hasbrouck was so intense that her life was thrown into chaos and profound disturbance that would last for years. For Dr. Tobin to under- stand the natur e of Rebecca’s disorder , it would be important that she have a grasp of the extent of the trauma; such an understanding would also inform the treatment plan that she would develop to help Rebecca. Thus, in evaluating psychological causes for abnormal- ity, social scientists and clinicians consider a person’s experi- ences. Most experiences are interpersonal—events that take place in interactions with other people. But people also have intrapsychic experiences, those that take place within thoughts and feelings. As you will see later in the text, emo- tional problems can arise from distorted perceptions and faulty ways of thinking. Take the case of a college student, Matt, who inferred that his girlfriend was angry with him because she failed to return his phone call. For more than a day he was affected by feelings of anger, which led to feelings of depression. He later found out that his answering machine had malfunctioned when his girlfriend called back. After discussing the situation with his roommate, he realized that his response had been irrational. As he thought about it, he realized that his reaction was probably related to a long his- tory of disappointments with his parents, who had hurt him countless times with their unreliability. Having internalized the notion that important people tend to disappoint, Matt now expected this to happen, even when the facts did not support his conclusion. Just as biology can lead to the devel- opment of abnormality, so can the psychologically signifi – cant events in a person’s life. Sociocultural Causes Much of who we are is determined by interpersonal interactions that take place in the concentric circles of our lives. The term sociocultural refers to the vari- ous circles of social infl uence in the lives of people. The most immediate circle comprises those people with whom we inter- act on the most local level. For the typical college student, this would be a roommate, co-workers, and classmates who are seen regularly. Moving beyond the immediate circle are those people who inhabit the extended circle of relationships, such as family members back home or friends from high school. A third circle comprises the people in our environ- ments with whom we interact minimally, and rarely by name, perhaps residents of our community or campus, whose stan- dards, expectations, and behaviors infl uence our lives. A fourth social circle is the much wider culture in which we live, such as American society. Abnormality can be caused by events in any or all of these social contexts. Troubled relationships with a roommate or family member can cause a person to feel deeply distressed. A failed relationship with a lover might lead to suicidal de- pression. Involvement in an abusive relationship may initiate an interpersonal style in which an abused person becomes repeatedly caught up with people who are hurtful and dam- aging. Being raised by a sadistic parent may cause a person to establish a pattern of close relationships characterized by control and emotional hurt. Political turmoil, even on a rela- tively local level, can evoke emotions ranging from disturbing anxiety to incapacitating fear. For some people, the cause of abnormality is much broader, perhaps cultural or societal. For example, the experience of discrimination has profound impact on a person who is part of a minority group, whether involving race, culture, sexual orientation, or disability. Some social critics have taken an unorthodox stand in pointing out ways in which they believe that society can be at the roots of what is regarded and labeled as abnormal. Noted British psychiatrist R. D. Laing (1964) stirred up a debate that has lasted several decades by contending that modern society dehumanizes the individual, and that people who refuse to abide by the norms of this society are psychologically health- ier than those who blindly accept and live by such restrictive social norms. Along similar lines, American psychiatrist Thomas Szasz (1961) argued that the concept of mental illness is a “myth” created by modern society and put into practice by the mental health profession. Szasz proposed that a better way to describe people who cannot fi t into society’s norms is that they have “problems in living.” Such terminology avoids labeling people as “sick” and, instead, indicates that their dif- fi culties stem from a mismatch between their personal needs and society’s ability to meet those needs. Criticisms of the mental health establishment, such as those raised by Laing and Szasz, became more credible when researcher David Rosenhan conducted a radical study, dis- cussed earlier, that caused many people in the scientifi c com- munity to take a second look at institutionalization. Although most mental health professionals now regard the ideas of Laing and Szasz as simplistic and the Rosenhan study as methodologically fl awed, their ideas have caused mental health professionals to weigh the issues that these theorists have raised. The mental health community as a whole seems more sensitive today than in decades past to the need to avoid labeling people with psychological disor- ders as socially deviant. Such views also help promote social acceptance of people with emotional problems. Returning to the case of Rebecca, there are two ways in which sociocultural infl uences can be seen as playing a role What Is Abnormal Behavior? 9 haL7069X_ch01_002-035.indd Page 9 11/10/08 8:38:29 PM user-s174 haL7069X_ch01_002-035.indd Page 9 11/10/08 8:38:29 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 10 Chapter 1 Understanding Abnormality in her depression. First, as the child of a depressed mother, Rebecca grew up in a family in which maternal impairment may have left its mark on her. Second, following the acci- dent, Rebecca was profoundly affected by the decision of her mother and in-laws to distance themselves from her. Although these signifi cant people in her life did not directly cause Rebecca’s symptoms, they played a role in aggravating her impairment because of their emotional distancing. Abnormality: A Biopsychosocial Perspective The three categories of the causes of abnormality are sum- marized in Table 1.1 . Disturbances in any of these areas of human functioning can contribute to the development of a psychological disorder. However, the causes of abnormality cannot be so neatly divided. There is often considerable interaction among the three sets of infl uences. Social scien- tists use the term biopsychosocial to refer to the interaction in which biological, psychological, and sociocultural factors play a role in the development of the individual. As you will see when reading about the conditions in this textbook, the degree of infl uence of each of these variables differs from disorder to disorder. For some disorders, such as schizophre- nia, biology plays a dominant role. For other disorders, such as stress reactions, psychological factors predominate. For other conditions, such as post-traumatic stress disorder, that are often associated with experiences under a terrorist regime, the cause is primarily sociocultural. Related to the biopsychosocial model is a very important concept that sheds light on the biopsychosocial approach. Many research articles and scholarly writings are based on the diathesis-stress model , according to which people are born with a diathesis (or predisposition) that places them at risk for developing a psychological disorder. Presumably, this vul- nerability is genetic, although some theorists have proposed that the vulnerability may also be acquired due to early life events, such as traumas, diseases, birth complications, and even family experiences (Meehl, 1962; Zubin & Spring, 1977). When stress enters the picture, the person who carries such vulnerability is at considerable risk of developing the disorder to which he or she is prone. Rebecca Hasbrouck is a woman with a diathesis in the form of a genetic vulner- ability to the development of a mood disorder. However, it was only following the experience of an intense life stress, the accident and family deaths, that the depression emerged. When we turn to the discussion of schizophrenia, you will read about the fascinating fi nding that this disorder, with a prominent genetic loading, cannot be fully explained by genetics. For example, in identical twin pairs, one twin may have the disorder while the other does not, even in instances involving a clear family history. As you will see, scientists believe that the affected twin must have been exposed to a stressor not encountered by the unaffected twin. The bottom line, of course, is that psychological disorders arise from complex interactions involving biological, psycho- logical, and sociocultural factors. Special kinds of vulnerabil- ity, such as genetic vulnerability, increase the likelihood of developing given disorders. However, certain life experiences can protect people from developing conditions to which they are vulnerable. Protective factors, such as loving caregivers, adequate health care, and early life successes, reduce vulner- ability considerably. In contrast, low vulnerability can be heightened when people receive inadequate health care, engage in risky behaviors (such as using drugs), and get involved in dysfunctional relationships. Some researchers provide quanti- tative estimates of the relative contributions of genes and environment to the development of a psychological disorder. When we talk later in this book about specifi c disorders, such as schizophrenia, we will summarize the theories that scien- tists propose to explain the roles of diathesis and stress in the development of each disorder. TABLE 1.1 Causes of Abnormality Biological Genetic inheritance Medical conditions Brain damage Exposure to environmental stimuli Psychological Traumatic life experiences Learned associations Distorted perceptions Faulty ways of thinking Sociocultural Disturbances in intimate relationships Problems in extended relationships Political or social unrest Discrimination toward one’s social group REVIEW QUESTIONS 1. What are the four kinds of criteria that characterize abnormal behavior? 2. On what psychological factor in Rebecca Hasbrouck’s case did Dr. Tobin focus? 3. To what does diathesis refer? Abnormal Psychology Throughout History Now that you know about the complexities of defi ning and understanding abnormality, you can appreciate how very dif- fi cult it is to understand its causes. The greatest thinkers of the world, from Plato to the present day, have struggled to explain the oddities of human behavior. In this section, we will look at how the mental health fi eld has arrived at current haL7069X_ch01_002-035.indd Page 10 11/25/08 11:27:28 AM user-s174 haL7069X_ch01_002-035.indd Page 10 11/25/08 11:27:28 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 understandings of the causes and treatments of psychological disorders. You will see how ideas about psychological disor- ders have taken a variety of twists and turns throughout recorded history. There is every reason to expect that these concepts will continue to evolve. Three prominent themes in explaining psychological dis- orders recur throughout history: the mystical, the scientifi c, and the humanitarian. Mystical explanations of psychologi- cal disorders regard abnormal behavior as the product of possession by evil or demonic spirits. The scientifi c explana- tion looks for natural causes, such as biological imbalances, faulty l earning processes, or emotional stressors. Humanitar- ian explanations view psychological disorders as the result of cruelty, nonacceptance, or poor living conditions. Tension among these three themes has existed throughout history; at times, one or another has dominated, but all three have coex- isted for centuries. Even in today’s scientifi c world, the hu- manitarian and mystical approaches have their advocates. As you read about the historical trends in understanding and treating psychological disorders, see if you can identify which theme is most prevalent at each stage. Prehistoric Times: Abnormal Behavior as Demonic Possession There is no written record of ideas regarding psychological disorders in prehistoric times, but there is mysterious arche- ological evidence dating back to 8000 B.C. during the Stone Age: skulls with holes drilled in them. Furthermore, there is evidence that the bone healed near these holes, which is taken to indicate that the procedure was surgical and that people survived it (Piek et al., 1999). Why would prehistoric people perform such bizarre surgery? Anthropologists have wondered whether this kind of surgery, called trephining , was performed as a way of treating psychological disorders. Some theorize that prehistoric peo- ple thought that evil spirits that were trapped inside the head caused abnormal behavior and that releasing the evil spirits would cause the person to return to normal. Another inter- pretation is that trephining was used to treat medical prob- lems. For all we know, the procedure might have been an effective treatment for some psychological disturbances caused by physiological imbalances or abnormalities. In any case, the skulls are the only evidence we have from that period of history, and we can only speculate about their meaning (Maher & Maher, 1985). Surprisingly enough, the practice of trephining did not end in the Stone Age (Gross, 1999). It was practiced all over the world from ancient times through the eighteenth century, for various purposes from the magical to the medical. Evidence of trephining has been found from many countries and cultures, including the Far and Middle East, the Celtic tribes in Britain, ancient and recent China, India, and various peoples of North and South America, including the Mayans, Aztecs, Incas, and Brazilian Indians. The procedure is still in use among certain tribes in Africa for the relief of head wounds. Another practice that was used in ancient times was the driving away of evil spirits through the ritual of exorcism. Although intended as a cure through the conjuring of spirits, the procedures involved in exorcism seem more like torture to our contemporary eyes. The possessed person might be starved, whipped, beaten, and treated in other extreme ways, with the intention of driving the evil spirits away. Some were forced to eat or drink foul-tasting and disgusting concoc- tions, which included blood, wine, and sheep dung. Some were executed, because they were considered a burden and a threat to their neighbors. These practices were carried out by a shaman, priest, or medicine man—a person thought by the community to possess magical powers. Although these practices are associated with early civilizations, variants of shamanism have appeared throughout history. The Greeks sought advice from oracles believed to be in contact with the gods. The Chinese practiced magic as a protection against demons. In India, shamanism fl ourished for centuries, and it still persists in Central Asia. Had Rebecca lived at a time or in a culture in which exorcism was practiced, her symptoms might have been inter- preted as signs of demonic possession. The voices she heard could have been devils speaking to her. Her bizarre behavior would have been perceived as evidence that she was under the control of a supernatural force. Frightened and disturbed by behaviors they could not understand, her neighbors might have sent her to a shaman, who would carry out the rites of exorcism. As you will see, such ideas played a prominent role in the understanding and treatment of psychological disor- ders for centuries to follow. Ancient Greece and Rome: The Emergence of the Scientifi c Model Even though their theories now may seem strange, early Greek philosophers established the foundation for a system- atic approach to psychological disorders. Hippocrates ( ca. 460–377 B.C. ), whom many people consider the founder of modern medicine, was concerned not only with physical dis- eases but with psychological problems as well. He believed that there were four important bodily fl uids that infl uenced physical and mental health: black bile, yellow bile, phlegm, and blood. An excess of any of these fl uids could account for changes in an individual’s personality and behavior. For example, an excess of black bile would make a person depressed (melancholic), and an excess of yellow bile would cause a person to be anxious and irritable (cho- leric). Too much phlegm would result in a calm disposition bordering perhaps on indifference (phlegmatic). An over- abundance of blood would cause a person to experience unstable mood shifts (sanguine). Treatment of a psycho- logical disorder, then, involved ridding the body of the excess fl uid through such methods as bleeding, purging (forced excretion), and administering emetics (nausea-producing substances) and establishing a healthier balance through proper nutrition. Abnormal Psychology Throughout History 11 haL7069X_ch01_002-035.indd Page 11 11/25/08 11:27:29 AM user-s174 haL7069X_ch01_002-035.indd Page 11 11/25/08 11:27:29 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 12 Chapter 1 Understanding Abnormality As unlikely as it sounds, Hippocrates’ classifi cation of four types of fl uid imbalances resurfaced in modern explana tions of personality types. The classifi cation proposed by Hans Eysenck (1967), shown in Figure 1.1 , is based on a psychological test that provides scores on various personality dispositions. The two dimensions of neurotic–normal and introvert–extrovert interact to produce four personality types. The resurfacing of ancient ideas in the form of a modern psychological theory suggests that, despite the very different philosophies that underlie these systems, there might be some- thing to the notion that there are some enduring dimensions of personality. The views of Hippocrates dominated medical thinking on the topic of psychological disorders for 500 years. However, these views were countered by the more popular belief in spiritual possession and the cruel treatment of psychologically disturbed people. The next signifi cant advances in the medical approach were made by two Greek physicians living in Rome, separated by 200 years, who introduced new and more hu- mane ideas about psychological disorders. In the fi rst century B.C. , Aesclepiades rebelled against the Hippocratic belief that the imbalance of bodily substances caused psychological disorders. Instead, he recognized that emotional disturbances could result in psychological problems. Two hundred years later, Claudius Galen ( A.D. 130–200) de – veloped a system of medical knowledge that revolutionized previous thinking about psychological as well as physical disorders. Rather than rely on philosophical speculation, Galen studied anatomy to discover answers to questions about the workings of the human body and mind. Unfortu- nately, although Galen made important advances in medi- cine, he essentially maintained Hippocrates’ beliefs that abnormality was the result of an imbalance of bodily sub- stances. Nevertheless, the writings of Hippocrates and Galen formed the basis for the scientifi c model of abnormal behav- ior. These views were to be buried under the cloud of the Middle Ages and the return to superstition and spiritual explanations of abnormality. The Middle Ages and Renaissance: The Re-emergence of Spiritual Explanations The Middle Ages are sometimes referred to as the “Dark Ages.” In terms of the approaches to psychological disor- ders, this was indeed a dark period. No scientifi c or medical advances occurred beyond those of Hippocrates and Galen. In the rare cases in which people with psychological disor- ders sought medical treatment, the physician could offer little beyond the barbaric methods of purging and bleeding, ineffectual attempts to manipulate diet, or the prescription of useless drugs. During the Middle Ages, there was a resurgence of prim- itive beliefs regarding spiritual possession. People turned to superstition, astrology, and alchemy to explain many natural Quickly aroused Anxious CHOLERIC CHOLERIC PHLEGMATIC PHLEGMATIC Worried Unhappy Suspicious Serious Thoughtful ReasonableHigh-principled ControlledPersistent Calm Egocentric Exhibitionist HotheadedHistrionic Playful Easygoing Sociable Carefree Hopeful Contented Neurotic (emotional) MELANCHOLIC MELANCHOLIC Introvert (unchangeable) Normal (nonemotional) SANGUINE SANGUINE Extrovert (changeable) Dimensional Classification FIGURE 1.1 Four temperaments An illustration of Eysenck’s explanation of per- sonality types. The two dimensions of neurotic– normal and introvert–extrovert in teract to produce the four types described by Hippocrates. haL7069X_ch01_002-035.indd Page 12 11/12/08 5:31:00 AM user-s173 haL7069X_ch01_002-035.indd Page 12 11/12/08 5:31:00 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 phenomena, including psychological and physical illnesses. Magical rituals, exorcism, and folk medicines were widely practiced. Beliefs in demonic possession were also used to account for abnormal behavior, and people who sought help from the clergy were treated as sinners, witches, or embodi- ments of the devil. The punishment and execution of people accused of being witches became more widespread toward the end of the Middle Ages, especially during the Renaissance. The dominance of religious thinking in the Middle Ages had both positive and negative effects on the care of psycho- logically disturbed individuals. Beliefs in spiritual possession and the treatment of people as sinners had harmful effects. In contrast, ideas about Christian charity and the need to help poor and sick people formed the basis for more hu – manitarian approaches to treatment. Monasteries began to open their doors to give these people a place to stay and receive whatever primitive treatments the monks could offer. Poorhouses, or homes for people who could not pay their living expenses, were built all over Europe. Many of them sheltered people who were emotionally disturbed. Later, the poorhouses became known as asylums . One of the most famous of these asylums was the Hospital of St. Mary of Bethlehem in London. Originally founded as a hospital for poor people in 1247, by 1403 it began to house people referred to at the time as “lunatics.” In the centuries to follow, the term bedlam, a derivative of the hospital’s name, became synonymous with the chaotic and inhumane housing of psychologically disturbed people who languished unat- tended for years (MacDonald, 1981). As the hospital became more crowded and its occupants increasingly unruly, the hos- pital workers resorted to chains and other punishments to keep the inhabitants under control. Similar conditions prevailed in other asylums as they became more and more crowded. Unfor- tunately, the original intention of enlisting clergy to treat psy- chologically disturbed individuals with humanitarian methods had disastrous consequences. Not until several centuries later were the humanitarian ideals reinstated. In contrast to what you might learn in a history class about the Renaissance as a period of enlightenment, this period was far from enlightened with regard to psychological disorders. There were virtually no scientifi c or humanitarian advances during this entire period, and demonic possession remained the prevalent explanation for abnormal behavior of any kind. Some historical accounts have proposed that witch hunts, conducted on a wide scale throughout Europe and later in North America, were directed at people with psychological disturbances. These acts were seen as justifi ed by the publication of the Malleus Malifi carum, an indictment of witches written by two Dominican monks in Germany in 1486, in which witches were denounced as heretics and devils who must be destroyed in the interest of preserving Christianity. The “treatments” it recommended were deporta- tion, t orture, and burning at the stake. Women, particularly old women, as well as midwives, were the main targets of Abnormal Psychology Throughout History 13 Hieronymous Bosch’s Removal of the Stone of Folly depicted a medi- eval “doctor” cutting out the presumed source of madness from a patient’s skull. The prevailing belief was that spiritual possession was the cause of psychological disorder. The inhumane treatment at the Hospital of St. Mary of Bethlehem in London is shown in William Hogarth’s The Madhouse. haL7069X_ch01_002-035.indd Page 13 12/4/08 5:48:39 PM user-s174 haL7069X_ch01_002-035.indd Page 13 12/4/08 5:48:39 PM user-s174 /Users/user-s174/Desktop/MHSF107-01 /Users/user-s174/Desktop/MHSF107-01 14 Chapter 1 Understanding Abnormality persecution. Once a woman was labeled a witch by the Church, there was no escape for her. Were Rebecca to be treated during this era, she might have been regarded as a witch, especially if she were heard to refer to the devil or any other supernatural force. How- ever, if she were lucky, someone might consult a medical practitioner. In the midst of the witch hunt frenzy, some voices of reason were starting to be heard, and, in the 1500s, the idea began to spread that people who showed signs of demonic possession might be psychologically disturbed. In 1563, a physician named Johann Weyer (1515–1588) wrote an important book called The Deception of Demons, in which he tried to debunk the myth that psychologically dis- turbed people were possessed by the devil. Although Weyer did not abandon the notion of demonic possession, his book represented the fi rst major advance since the time of Galen in the description and classifi cation of forms of abnormal behavior. Weyer’s approach also formed the basis for what later became a renewal of the humanitarian approach to psychologically disturbed people. However, at the time of his writing, Weyer was severely criticized and ridiculed for challenging the vie ws held by the powerful and infl uential religious and political leaders of the time. However, in another part of Europe, Weyer’s radical ideas were being echoed by an Englishman, Reginald Scot (1538–1599), who deviated even further from the prevalent ideologies by deny- ing the very existence of demons. Europe and the United States in the 1700s: The Reform Movement The eighteenth century was a time of massive political and social reform throughout Europe. By this point, public insti- tutions housing individuals with psychological disorders had become like dungeons, where people were not even given the care that would be accorded an animal. The living condi- tions for poor people were miserable, but to be both psycho- logically disturbed and poor was a horrible fate. People with psychological disorders lived in dark, cold cells with dirt fl oors and were often chained to straw beds and surrounded by their excrement. It was widely believed that psychologi- cally disturbed people were insensitive to extremes of heat and cold or to the cleanliness of their surroundings. The “treatment” given to these people involved bleeding, forced vomiting, and purging. It took a few courageous people, who recognized the inhumanity of the existing practices, to bring about sweeping reforms. The leader of the reform movement was Vincenzo Chiarugi ( 1759–1820). Fresh from medical school, at age 26, he was given the responsibility of heading Ospitdale di Bon- ifacio, the newly built mental hospital in Florence. Within a year of taking charge of the hospital, he instituted a set of revolutionary standards for the care of mental patients. These standards were a landmark in creating general principles for care of the mentally ill, including a detailed history for each patient, high hygiene standards, recreational facilities, occu- pational therapies, minimal use of restraints, and respect for individual dignity. In 1793–1794, Chiarugi published a major work on the causes and classifi cation of insanity, which he regarded as due to impairment of the brain. Thus, Chiarugi made important contributions to both the humanitarian and scientifi c models of abnormality. More attention was given, however, to the reforms of Philippe Pinel (1745–1826) in La Bicêtre, a hospital in Paris If Rebecca were living in New England during the height of the Salem witch trials, she might have suffered the fate of the woman shown here being arrested. This painting shows Philippe Pinel having the irons removed from the inmates at La Salpêtrière Hospital. It was actually Pinel’s employer, Jean-Baptiste Pussin, who performed this liberating gesture. haL7069X_ch01_002-035.indd Page 14 11/12/08 5:31:33 AM user-s173 haL7069X_ch01_002-035.indd Page 14 11/12/08 5:31:33 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 with conditions like those faced by Chiarugi. On his appoint- ment as a hospital physician in 1792, a hospital worker, Jean-Baptiste Pussin, who had begun the process of reform, infl uenced Pinel. Together, they made changes to improve the living conditions of the patients. When Pinel left La Bicêtre 2 years later, Pussin stayed behind. It was then that Pussin made the bold gesture of freeing patients from their chains, an act for which Pinel is mistakenly given credit. After leaving La Bicêtre, Pinel became director of La Salpêtrière Hospital, where he and Pussin continued to spread these reforms. England was the third country to see major reforms in its treatment of psychologically disturbed individuals. In 1792, an English Quaker named William Tuke established the York Retreat, an institution based on the religious hu- manitarian p rinciples of the Quakers. Tuke’s work was carried on by succeeding generations of his family. Their methods became known as moral treatment and were based on the philosophy that the mentally ill deserved to be treated with humanity. Underlying this approach was the philosophy that, with the proper care, people can develop self-control over their disturbed behaviors. Restraints were used only if absolutely necessary, and even in those cases the patient’s comfort came fi rst. At the time of Europe’s revolutionary reforms, similar changes in the care of psychologically disturbed people were being initiated in the United States. Benjamin Rush (1745–1813) became known as the founder of American psy- chiatry for his rekindling of interest in the scientifi c approach to psychological disorders. His text, Observations and Inquiries upon the Diseases of the Mind, written in 1812, was the fi rst psychiatric textbook printed in the United States. Rush, who was one of the signers of the Declaration of Independence, achieved fame outside psychiatry as well. He was a politician, statesman, surgeon general, and writer in many diverse fi elds, ranging from philosophy to meteorology. Because of his pres- tigious role in American society, he was able to infl uence the institution of reforms in the mental health fi eld. In 1783, he joined the medical staff of Pennsylvania Hospital. Rush was appalled by the poor conditions in the hospital and by the fact that psychologically disturbed patients were placed on wards with the physically ill. He spoke out for changes that were considered radical at the time, such as placing psycho- logically disturbed patients in separate wards, giving them occupational therapy, and prohibiting visits from curiosity seekers who frequented the hospital for entertainment. In evaluating Rush’s contributions, we must also men- tion that he advocated some of what we now regard as bar- baric interventions that were accepted conventions at the time. For example, Rush supported the use of bloodletting and purging in the treatment of psychological disorders. Some of his methods were unusual and seem sadistic now— such as the “tranquilizer” chair, to which a patient was tied. The chair was intended to reduce stimulating blood fl ow to the brain by binding the patient’s head and limbs. Rush also recommended that patients be submerged in cold shower baths and frightened with threats that they would be killed. Other physicians at the time used similar techniques, such as surprise immersions into tubs of cold water and the “well- cure,” in which a patient was placed at the bottom of a well as water was slowly poured into it. Rush and his contempo- raries thought that the fright induced by these methods would counteract the overexcitement responsible for their patients’ violent and bizarre behavior (Deutsch, 1949). It is ironic that, in the spirit of reform, methods just as primitive as those of the Middle Ages continued to be developed. Despite the more humane changes Rush advocated, con- ditions in asylums worsened over the next 30 years with con- tinued overcrowding. The psychologically disturbed patients were often forced to live in poorhouses and jails, where con- ditions were even less conducive to treatment than in the asy- lums. By 1841, when a Boston schoolteacher named Dorothea Dix (1802–1887) made her fi rst venture into these institu- tions, conditions had become ripe for another round of major reforms. She was shocked and repulsed by scenes that were reminiscent of the horrifying conditions that European re- formers had faced in the previous century. Her fi rst encoun- ter was with the prison system, in which many psychologi- cally disturbed people were incarcerated. Inmates were chained to the walls, no heat was provided for them, and they were forced to live in fi lth. Viewing these conditions was enough to set Dix off onto an investigative path. She traveled throughout Massachusetts, visiting jails and poorhouses and chronicling the horrors she witnessed. Two years later, Dix presented her fi ndings to the Massachusetts Legislature, with the demand that more state-funded public hospitals be built to care specifi cally for the psychologically disturbed. Dix be- lieved, furthermore, that the proper care involved the appli- cation of moral treatment. From Massachusetts, Dix spread her message throughout North America, and even to Europe. She spent the next 40 years campaigning for the proper treat- ment of psychologically disturbed people. She was an effective champion of this cause, and her efforts resulted in the growth of the state hospital movement. Benjamin Rush’s methods of treatment, based on what he thought were scientifi c principles, would be considered barbaric by today’s standards. Abnormal Psychology Throughout History 15 haL7069X_ch01_002-035.indd Page 15 11/12/08 5:31:47 AM user-s173 haL7069X_ch01_002-035.indd Page 15 11/12/08 5:31:47 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 16 Chapter 1 Understanding Abnormality In the century to follow, scores of state hospitals were built throughout the United States. Once again, as in the Middle Ages, the best intentions of the mental health reform- ers became lost and ultimately backfi red. These new state hospitals became so overcrowded and understaffed that treat- ment conditions deteriorated. The wards in these hospitals overfl owed with people whose symptoms included violent and destructive behaviors. Under these circumstances, there was no way to fulfi ll Dix’s goal of providing moral therapy. Instead, the staff resorted to the use of physical restraints and other measures that moral therapy was intended to replace. However, there were some reforms, such as allowing patients to work on the hospital grounds and to participate in various forms of recreation. At the same time, though, these institutions became custodial facilities where people spent their entire lives, an outcome that Dix had not antici- pated. It simply was not possible to cure people of these serious disorders by providing them with the well-intentioned but ineffective interventions proposed by moral therapy. Furthermore, over the course of several decades, the emphasis of this form of treatment had shifted almost solely toward disciplinary enforcement of the institution’s rules and away from the more humane spirit of the original idea. Even though moral therapy was a failure, the humani- tarian goals that Dix advocated had a lasting infl uence on the mental health system. Her work was carried forward into the 1900s by advocates of the mental hygiene movement— most notably, Clifford Beers. In 1908, Beers wrote the auto- biographical A Mind That Found Itself, which recounted in alarming detail his own harsh treatment in psychiatric institutions. Beers had become so enraged by the inhumane treatments that he established the National Committee for Mental Hygiene, a group of people who worked to improve the treatment of those in psychiatric institutions. The 1800s to the 1900s: Development of Alternative Models for Abnormal Behavior While Dix was engaged in her reform campaign, the super- intendents of existing state mental hospitals were also trying to develop better ways to manage patients. In 1844, a group of 13 mental hospital administrators formed the Association of Medical Superintendents of American Institutions for the Insane. The name of this organization was eventually changed to the American Psychiatric Association. The founding of this organization gave rise to the medical model , the view that abnormal behaviors result from physical problems and should be treated medically. The goals of the American Psychiatric Association were furthered by the publication in 1845 of a book on the pathol- ogy and treatment of psychological disorders by William Greisinger, a German psychiatrist. Greisinger focused on the role of the brain, rather than spirit possession, in abnormal behavior. Another German psychiatrist, Emil Kraepelin, was also infl uential in the development of the American psychi- atric movement. Kraepelin carried further Greisinger’s ideas that brain malfunction caused psychological disorder. He is perhaps better known, however, for his efforts to improve the way that psychological disorders were classifi ed. Kraepelin’s ideas continue to be infl uential even today, and some of the distinctions he introduced are refl ected in contemporary sys- tems of psychiatric diagnosis. For example, Kraepelin’s con- cept of manic depression was a precursor to what is now called bipolar disorder; his concept of dementia praecox (pre- mature degeneration) is now known as schizophrenia. At the same time that the medical model was evolving, a very different approach to understanding psychological prob- lems was also taking root. The psychoanalytic model , which seeks explanations of abnormal behavior in the workings of unconscious psychological processes, had its origins in the con- troversial techniques developed by Anton Mesmer (1734–1815), a Viennese physician. Mesmer gained notoriety for his dra- matic interventions involving hypnotic techniques. Expelled from Vienna for what were regarded as false claims of cure, Mesmer traveled to Paris, where the same misfortune befell him. Wherever he went, the medical establishment regarded him as a fraud because of his unbelievable assertions and ques- tionable practices. In 1766, Mesmer published a book called The Infl uence of the Planets, which promoted the idea that magnetic fl uid fi lled the universe and, therefore, was in the bodies of all living creatures. He maintained that physical and psychological disturbances were the result of an imbalance in this magnetic fl uid, called animal magnetism. These distur- bances could be corrected by a device Mesmer invented called a magnetizer. So many people became interested in this cure that Mesmer began to treat them in groups. Mesmer’s patients held hands around a baquet, a large oak tub containing Dorothea Dix worked throughout the late 1800s to move psycho- logically disturbed people from jails and poorhouses to state-funded hospitals where they could receive more humane treatment. haL7069X_ch01_002-035.indd Page 16 11/10/08 8:38:35 PM user-s174 haL7069X_ch01_002-035.indd Page 16 11/10/08 8:38:35 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 water, iron fi lings, and glass particles, while he walked around them, stroking them with a magnetic wand. This practice be- came exceptionally popular in Paris because of reports of benefi cial effects. Hundreds of sick individuals, particularly women, went to Mesmer’s clinic. The medical establishment decided to investigate Mesmer’s practices, which aroused sus- picion due to their questionable scientifi c basis. In 1784, the French government invited Benjamin Franklin to head a com- mission to investigate animal magnetism. The investigation lasted 7 years and concluded that the effects of magnetism were due to “excitement of the imagination” (Baker, 1990). An English physician, James Braid (1795–1860), was intrigued by what he heard about magnetism’s popularity in France and decided to investigate how such a questionable method could actually produce such dramatic benefi ts. Braid became convinced that whatever positive effects occurred were unrelated to animal magnetism. Instead, Braid proposed that changes took place in people’s minds, outside their con- scious awareness, that could explain the cures attributed to mesmerism. In 1842, Braid introduced the term hypnotism t o describe the process of being put into a trance, which he believed to be the cause of Mesmer’s ability to effect changes in the minds of his subjects. He reasoned that some people treated by Mesmer’s method improved because they were in a hypnotic state and were open to suggestions that could result in the removal of their symptoms. The term mesmerized , in fact, refers to this state of heightened suggestibility brought about by the words and actions of a charismatic individual. Braid’s explanation of hypnosis played an important role in leading practitioners to realize how powerful the mind can be in causing and removing symptoms. Two decades later, Ambrose-Auguste Liébault (1823–1904), a French doctor, began to experiment with mesmerism. Many of Liébault’s patients were poor farmers, whom Liébault treated in his clinic in Nancy, France. Liébault discovered that he could use hypnotic sleep induction as a substitute for drugs. Liébault’s clinic eventually became well known for innovative treatments. In 1882, another physician, Hippolyte- Marie Bernheim (1837–1919), who became one of the major proponents of hypnotism in Europe, visited Liébault. Bernheim was seeking Liébault’s help in treating a patient with severe back pains for whom other forms of therapy were unsuccess- ful. Liébault’s cure of this patient convinced Bernheim that hypnosis was the wave of the future. From their work at the Nancy clinic, Bernheim and Liébault gained international attention for advances in the use of hypnosis as a treatment for nervous and psychological dis- orders. At the same time, an esteemed neurologist in Paris, Jean-Martin Charcot (1825–1893), was testing similar tech- niques in La Salpêtrière Hospital. However, Charcot’s Sal- pêtrière “school” of hypnosis differed sharply in its explana- tion of how hypnosis worked. Charcot believed that hypno- tizability w as actually a symptom of a neurological disorder and that only people who suffered from this disorder could be treated by hypnosis. You can see how Charcot’s notion that hypnosis involved physical changes in the nervous system was a radical departure from the Nancy school’s position. The weight of evidence, however, was in favor of the Nancy school, and eventually Charcot adopted its position. Hypnosis was clearly understood as a psychological process that could be very instrumental in resolving certain kinds of disorders. In particular, hypnosis became the treatment of choice for hysteria , a disorder in which psychological problems become expressed in physical form. A girl whom Mesmer “cured” of her blindness was probably suffering from hysteria; in other words, a psychological confl ict was converted into an appar- ent sensory defi cit. Other forms of hysteria became widely known in the medical establishment, including various forms of paralysis, pain disorders, and a wide range of sensory def- icits, such as blindness and hearing loss. The development of hypnosis went on to play a central role in the evolution of psychological methods for treating psy- chological disorders. In fact, Sigmund Freud (1856–1939) was heavily infl uenced by both Charcot and Bernheim in his early work with hysterical patients. Freud originally studied medicine French neurologist Jean-Martin Charcot is shown demonstrating a hypnotic technique during a medical lecture. Abnormal Psychology Throughout History 17 Anton Mesmer claimed that by redistributing the magnetic fl uids in the patient’s body he could cure psychological disorders. Mesmer, sitting in the left side of the room, is holding a wand while his patien ts hold metal rods. haL7069X_ch01_002-035.indd Page 17 11/25/08 11:27:29 AM user-s174 haL7069X_ch01_002-035.indd Page 17 11/25/08 11:27:29 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 18 Chapter 1 Understanding Abnormality in Vienna, where he trained as a neurologist. After graduating from the University of Vienna, Freud traveled to France to learn about hypnosis, a method of treatment that fascinated him. In Studies in Hysteria (Breuer & Freud, 1895/1982), written with his colleague, Josef Breuer (1842–1925), Freud analyzed the famous case of “Anna O.” and other women suf- fering from hysteria. Freud and Breuer described how Anna O. was cured of her many and varied hysterical symptoms by the use of hypnosis. In addition, however, Anna O. urged Breuer, who was actually the one treating her, to allow her to engage in “chimney sweeping,” which she also called the “talking cure.” When she was allowed simply to talk about her problems, she felt better, and her symptoms disappeared. Freud and Breuer called this the cathartic method, a cleansing of the mind’s emotional confl icts through talking about them. The cathartic method was the forerunner of psychotherapy , the treatment of abnormal behavior through psychological techniques. This discovery eventually led Freud to develop psychoanalysis , a theory and system of practice that relied heavily on the concepts of the unconscious mind, inhibited sexual impulses, and early development, as well as the use of free association and dream analysis. In the early 1900s, Freud attracted a variety of brilliant minds and courageous practitioners from across the Atlantic Ocean and all over Europe, who came to work with him at his home in Vienna. Although many of these people eventu- ally broke ranks and went on to develop their own theories and training schools, Freud’s legacy continues to maintain an important position throughout the world. At the same time as these developments were taking place in Vienna, the Russian physiologist Ivan Pavlov (1849–1936) discovered principles of classical conditioning in his experi- ments on salivation in dogs. Some of his experiments included studies of learned neurotic behavior in dogs and provided a model of the learning of abnormal behavior through control of environmental conditions. Pavlov’s approach became the basis for the behaviorist movement begun in the United States by John B. Watson (1878–1958), who applied principles of classical conditioning to the learning of abnormal behavior in humans. Watson became best known in this country for the advice he gave to parents on childrearing. At around the same time, Edward L. Thorndike (1874–1949) developed the law of effect, which proposed that organisms will repeat behavior that produces satisfying consequences; this was the basis for operant conditioning. Building on this work, B. F. Skinner (1904–1990) formulated a systematic approach to operant con- ditioning, specifying the types and nature of reinforcement as a way to modify behavior. Classical and operant conditioning models are now incorporated into many forms of therapeutic interventions. Throughout the twentieth century, there emerged alterna- tive models of abnormal behavior based on various experi- mental approaches. The most prominent among these were the social learning theory of Albert Bandura (1925–), the cog- nitive model of Aaron Beck (1921–), and the rational-emotive therapy approach developed by Albert Ellis (1913–2007). In Chapter 4, we will go into greater depth in the discussion of these theories and their use in treatment. The Twenty-First Century: The Challenge of Providing Humane and Effective Treatment When fi rst encountering the various historical approaches to understanding and treating psychological disorders, you may wonder how it could be possible for people to have such extreme beliefs as demonic possession and to propose such seemingly naive treatments as moral therapy and the use of mechanical devices as cures. However, if you look around at the popular media and perhaps even in your local bookstore, you can readily fi nd examples of spiritual, mystical, or New Age approaches to physical and psychological treatment. For the most part, mainstream contemporary society takes a more scientifi c approach to understanding and treating psychological disorders. The scientifi c approach, rooted in the ideas of ancient Greek philosophers and physicians, began to be applied systematically in the mid-1900s and is now the predominant view in Western culture. In the 1950s, scientists introduced medications that con- trolled some of the debilitating symptoms of severe psycho- logical disturbance. Because of the many reports of dramatic reduction in symptoms, these medicines were quickly incor- porated into the treatment regimens of mental hospitals. They were seen as an easy solution to the centuries-old prob- lem of how to control the harmful and bizarre behaviors of psychologically disturbed people and possibly even to cure them. The initial hopes for these miracle drugs were naive and simplistic. No one realized that these medications could have harmful physical side effects, some of which could cause irreversible neurological damage. Swept away by early enthusiasm, mental health professionals often became caught up in the indiscriminate and unselective use of large doses of powerful drugs. An extreme overemphasis on the medical model also had the unanticipated effect of inattention to the other mental health needs of these patients. Until the 1970s, despite the growing body of knowledge about the causes of abnormal behavior, the actual practices used in the day-to-day care of psychologically disturbed peo- ple were sometimes as barbaric as those used in the Middle Ages. Even people suffering from the least severe psycho- logical disorders were often housed in what were known as the “back wards” of large and impersonal state institutions, without adequate or appropriate care. Although patients were not chained to the walls of their cells, they were fre- quently severely restrained by the use of powerful tranquil- izing drugs and straitjackets, coats with sleeves long enough to wrap around the patient’s torso. Even more radical was the indiscriminate use of behavior-altering brain surgery or the application of electrical shocks—so-called treatments that were often used as punishments intended to control unruly patients (see more on these procedures in Chapter 2). haL7069X_ch01_002-035.indd Page 18 11/12/08 5:32:29 AM user-s173 haL7069X_ch01_002-035.indd Page 18 11/12/08 5:32:29 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 Public outrage over these abuses in mental hospitals fi nally led to a more widespread realization that dramatic changes were needed in the provision of mental health ser- vices. The federal government took emphatic action in 1963 with the passage of groundbreaking legislation. The Mental Retardation Facilities and Community Mental Health Cen- ter Construction Act of that year initiated a series of changes that would affect mental health services for decades to come. Legislators began to promote policies designed to move people out of institutions and into less restrictive programs in the community, such as vocational rehabilitation facilities, day hospitals, and psychiatric clinics. People were placed in halfway houses after their discharge from the hospital, which provided a supportive environment in which they could learn the social skills needed to re-enter the community. By the mid-1970s, the state mental hospitals, which had once been overfl owing with patients, were practically deserted ( Figure 1.2 ). Hundreds of thousands of people who had been confi ned to dreary institutions were freed, to begin living with greater dignity and autonomy. This process, known as the deinstitu- tionalization movement , promoted the release of psychiatric patients into community treatment sites. Unfortunately, like all other supposed breakthroughs in the treatment of psychologically disturbed people, the deinsti- tutionalization movement did not completely fulfi ll the dreams of its originators. Rather than abolishing inhumane treatment, deinstitutionalization created another set of woes. Many of the promises and programs hailed as alternatives to institutional- ization ultimately failed to come through because of inade- quate planning and insuffi cient funds. Patients were often shuttled back and forth between hospitals, halfway houses, and shabby boarding homes, never having a sense of stability or respect. Some social critics have questioned whether the almost indiscriminate release of psychologically disturbed people was too radical a step that took place too rapidly. Although the intention of releasing patients from psychiatric hospitals was to free people who had been deprived of basic human rights, the result may not have been as liberating as many had hoped. In contemporary American society, many people who would have been found in psychiatric hospitals four decades ago are being moved through a circuit of shelters, rehabilitation pro- grams, jails, and prisons, with a disturbing number of these 1980 1990 1995 2000 2005 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 Patients in psychiatric hospitals (in thousands) Year FIGURE 1.2 The number of patients in psychiatric hos- pitals, 1980–2005 This fi gure shows the number (in thousands) of patients in long-term psychiatric hospitals in the United States of July 1 of each of the years shown on the graph. Source: U.S. Bureau of the Census, 2007. Abnormal Psychology Throughout History 19 Although deinstitutionalization was designed to enhance the quality of life for people who had been held for years in public psychiatric hospitals, many individuals left institutions only to fi nd a life of poverty and neglect on the outside. haL7069X_ch01_002-035.indd Page 19 11/12/08 5:32:49 AM user-s173 haL7069X_ch01_002-035.indd Page 19 11/12/08 5:32:49 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 20 Chapter 1 Understanding Abnormality individuals spending long periods of time as homeless and marginalized members of society. If a community program is to succeed, support must be provided to help seriously disturbed people cope with psycho- logical disorders. Recovery from psychological disorders can be viewed as comparable to recovery from physical conditions. In both cases, there is a difference between cure and recovery. Even though people who have suffered an affl iction may con- tinue to have symptoms, they can develop coping strategies that help them adapt and move on with their lives. An important component of this approach is the notion that people can re- cover without professional intervention. Presumably, mental health professionals facilitate the recovery of a person with a psychological disorder, but it is really up to the client, the con- sumer in this model, to take the steps toward recovery, usually by reaching out to others. Essential to recovery is the avail- ability of people who are concerned about and supportive of the struggling individual, especially in times of active symp- toms or intense stress. Self-help can be derived through contact with relatives, friends, groups, and churches. Although the recov- ery m odel rests on some lofty ideals, infl uential changes have emerged from this framewor k, along with recommendations for new ways of responding to the needs of psychologically troubled people in the years to come. In the early 1970s, deinstitutionalization was promoted by advocacy groups such as the Judge David L. Bazelon Center for Mental Health Law in Washington, D.C. The center was named for the late Chief Judge of the U.S. Court of Appeals for the District of Columbia Circuit. Bazelon was a principal spokesperson for mental health law in the United States. The Bazelon Center pr omotes legislation sensitive to the needs of people with mental illness and mental retardation and provides advocacy through litigation, legislative policy reform, and com- munity education. One community model endorsed by the Bazelon Center is known as Assertive Community Treatment (ACT). ACT involves a team of professionals from psychiatry, psychology, nursing, and social work who reach out to clients in their homes and workplaces. Their goal is to help clients comply with medical recommendations, manage their fi nances, obtain adequate health care, and deal with crises. The premise is that it is better to bring care to clients than to wait for them to come to a facility for help (Mueser et al., 2003). Based on a similar philosophy of engagement in the community are pro- grams in which individuals are taught ways to improve cognitive skills such as attention, concentration, learning and memory, and decision making (McGurk, 2007). Although deinstitutionalization has had a profound effect on the delivery of mental health services to severely disturbed people, most communities have not yet resolved the dilemma of how to deal with those who are unable to care for them- selves and may indeed be in danger of perishing from inade- quate self-care. Some communities rely on procedures involving mandatory outpatient commitment of such people, yet this app- roach is quite controversial and engenders lively debate about social policy, legal, and philosophical issues ( Vandevooren, Miller, & O’Reilly, 2007). Some experts contend that involun- tary outpatient commitment is an effective and necessary response in high-risk situations (Swartz & Swanson, 2004), but others argue that personal rights can easily be infringed on in situations in which a person’s autonomy is restricted. You can imagine how complex such issues are, as society faces the chal- lenges of assessing the extent to which some people are able to care for themselves and providing necessary help even in instances in which help is ardently rejected. Group therapy provides a context for clients to share their stories with others and, in doing so, obtain support while going through diffi cult experiences, such as grief over the loss of someone close. haL7069X_ch01_002-035.indd Page 20 11/25/08 11:27:30 AM user-s174 haL7069X_ch01_002-035.indd Page 20 11/25/08 11:27:30 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 In recent years, changes in the insurance industry have had a tremendous effect on the provision of mental health care. Managed health care has become the standard by which third-party payers, such as insurance companies, oversee reim- bursement for health services. In a managed care system, all medical and mental health procedures are evaluated to ensure that they provide the best therapeutic value at the least fi nan- cial cost. For example, if you need a dental fi lling for a cavity, a dental managed care company will reimburse your dentist for a routine fi lling, but it would be unwilling to pay for monthly cleanings, because they would be viewed as unneces- sary. In the fi eld of mental health care, insurers also want to be certain that the care provided to clients is effective, inex- pensive, and limited to what is absolutely necessary. The rationale of managed care rests on the notion that everyone involved saves money when excessive costs are con- tained. Unfortunately, many practitioners feel that the ideals on which health maintenance organizations and related pro- vider systems were developed some 30 years ago have been compromised by changes aimed at short-term cost savings with little foresight about the long-term effects on clients and society. For example, 20 years ago, a seriously depressed client might have remained in the hospital for several weeks of treatment, but today the client might be released after a few days, because an insurance company would regard ex- tended inpatient treatment as unnecessary and too expen- sive. What does this mean for the many individuals who suffer from chronic psychological disorders? In the worst- case scenario, they are released to the community, where they may be at risk of neglect and deterioration. In a survey of nearly 16,000 licensed psychologists, 4 out of every 5 respondents reported that managed car e was neg- atively affecting their clinical practice (Phelps, Eisman, & Kohout, 1998). Of particular concern are the ethical dilem- mas raised by working within a managed care system (Braun & Cox, 2005). For example, clinicians are concerned about the compromise of confi dentiality standards, as can happen when they must submit detailed personal information about their patients to seemingly anonymous utilization staff at the managed care company’s central offi ce. Clinicians also com- plain that managed care decisions commonly lead to the provision of inadequate care or inappropriate treatment— decisions that are based on cost rather than clinical need. Also in recent years, consumers have joined with provid- ers in expressing their alarm about inadequacies in the health care system, and some promising changes have taken place. Federal and state legislatures have responded to public con- cern by enacting laws that regulate managed care practices and decisions. For more than a decade, the U.S. Congress debated the issue of mental health parity , a standard that would require health insurers to provide equal levels of cover- age for physical and mental illnesses. Mental health parity leg- islation would require group health plans that already offer benefi ts for mental health and addiction to offer coverage that is comparable to that provided for medical conditions. In 2008, the United States Senate and the House of Representatives passed legislation to equalize the treatment of physical and mental illness. Under this legislation, insurers could not dif- ferentiate between mental and physical illness in terms of hospital stays, offi ce visits, co-payments, co-insurance, or deductibles. As states move toward mandatory universal health care coverage, mental health services should also be- come available to more people who previously lacked access to professional treatment. In the decades to come, experts and laypeople will con- tinue to struggle to fi nd the proper balance between providing asylum for those in need and incarcerating people in institu- tions beyond the point at which they are helped. At the same time, scientifi c researchers will continue to search for the causes of abnormal behavior and the most effective forms of treat- ment. In the next section, we will examine research methods used by scientists to deal with these crucial issues. REVIEW QUESTIONS 1. According to Hippocrates, what were the four bodily fl uid imbalances that infl uence mental and physical health? 2. What was the name of the treatment for psychological disorder recommended by Dorothea Dix and other reformers in the nineteenth century? 3. What was the process that promoted the release of psy- chiatric patients into community treatment sites in the second half of the twentieth century? Research Methods in Abnormal Psychology 21 Research Methods in Abnormal Psychology Psychological disorders are such a fascinating and mysteri- ous aspect of human behavior that people feel compelled to offer explanations, even without adequate support. Popular books claiming that psychological problems are due to every- thing from diet to radioactivity are frequently published. You can pick up almost any newspaper and read simplistic specula- tions about the profi le of a murderer or a person who has committed suicide. Such easy explanations can be misleading, because they lack a grounding in psychological theory and scientifi c data. The Scientifi c Method Claims about the cause and treatment of abnormal behavior must be made on the basis of solid, scientifi c research rather than speculation. We will explain briefl y the essentials of sci- entifi c methods as applied to abnormal psychology. In the process, we will discuss topics that you may have learned in introductory psychology or in a psychological methods course. Our review of this topic will explain the aspects of research methods that apply specifi cally to the study of abnormal psy- chology. This review will equip you to read reports in news- papers and magazines with an eye for scientifi c standards. An haL7069X_ch01_002-035.indd Page 21 11/25/08 11:27:31 AM user-s174 haL7069X_ch01_002-035.indd Page 21 11/25/08 11:27:31 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 22 Chapter 1 Understanding Abnormality TABLE 1.2 Research Methods in Abnormal Psychology Type of Method Application to Studying Depression Experimental The effectiveness of an antidepressant drug is evaluated by comparing the scores on a test of depression of people who receive the drug with those of people who do not. Purpose: To establish whether the drug works better than no drug. Advantages: If the group receiving the drug improves and the other group does not, the experimenter can conclude quite confi dently that the drug had a therapeutic effect. Disadvantages: It can be diffi cult to withhold treatment from people who are depressed. Quasi-experimental People who differ in the number of friends they have are compared on a m easure of depression. Purpose: To determine whether groups that differ in number of friends differ in level of depression. Advantages: It is useful when people are being compared on characteristi cs that cannot be manipulated. Disadvantages: Since people were not assigned randomly to groups, the ex perimenter cannot be sure that they actually were similar on all but the relevant variable. Correlational People who become depressed are tested on self-esteem to see if they hav e negative views about themselves. Purpose: To study the relationship of depression with other psychological states. Advantages: The experimenter can determine what other psychological qualities characterize depressed people. Disadvantages: The experimenter cannot determine whether depression causes people to have low self-esteem or whether low self-esteem is a cause of depression. Survey Anonymous questionnaires are sent to thousands of people, asking them to indicate whether they have symptoms of depression. Purpose: To obtain responses from a representative sample so that fi ndings can be generalized to the population. Advantages: The responses of large samples of people can be obtained at relatively low cost. Disadvantages: Questions asked of respondents tend to be limited in dept h. Case study A person with a history of depression is described in detail with particular emphasis on this person’s development of the disorder. Purpose: To provide an in-depth analysis of one person to gain unique insight into the particular disorder. Advantages: Many circumstances in the person’s life and psychological status can be explored in an attempt to gain a thorough understanding of that individual. Disadvantages: What characterizes one individual may not characterize ot hers with depression. Single-subject design A depressed person is given a trial run of a treatment and is tested aft er this treatment to measure its effectiveness. Then the treatment is discontinued, and depression is measured again. This cycle is repeated one or more times. Purpose: To use one case for studying the effects of alterations in conditions on behavior. Advantages: By comparing the person receiving the treatment with himself or herself rather than with other individuals, differences between people in their life histories or curre nt circumstances can be ruled out. Disadvantages: It can be emotionally draining for the individual to be r un through a cycle of on- again, off-again treatments. Later treatments may be infl uenced by the outcome of earlier ones. overview of research methods in abnormal psychology is pro- vided in Table 1.2 . The essence of the scientifi c method is objectivity, the process of testing ideas about the nature of psychological phenomena without bias before accepting these ideas as adequate explanations. Taking a farfetched example, let’s say you suspect that people who live on the East Coast are more stable psychologically than people who live on the West Coast (or, vice versa, if you live on the West Coast). You should test this suspicion systematically before accepting it as fact. As you set about the testing process, you would certainly want to hold open the possibility that your initial hunch was in error. The potential to discard an erroneous idea is an essential ingredient of the scientifi c method. The underlying logic of the scientifi c method involves three concepts: observation, hypothesis formation, and the ruling out of competing explanations through proper con- trols. You have probably already used the scientifi c method yourself without referring to it in these terms. You may have found, for example, that it seems that every time you have a caffeinated drink, such as coffee, after 6 P.M. you have trouble falling asleep. What would you need to do to test this pos- sibility? You might go through the observation process , in which you mentally keep track of the differences between haL7069X_ch01_002-035.indd Page 22 11/10/08 8:38:46 PM user-s174 haL7069X_ch01_002-035.indd Page 22 11/10/08 8:38:46 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 the nights you drink coffee and the nights you do not. The hypothesis formation process would be the step of predicting that drinking coffee causes you to stay awake at night. To test this hypothesis, you could try experimenting with drink- ing coffee on some nights but not on others. Next, try ruling out competing explanations. You must be careful not to drink coffee on a night when you have just watched a scary television program, for example. Otherwise, you would have no way of knowing whether your sleep problems were due to the coffee or to the anxiety created by the program. Although the coffee-drinking example may seem rather simple, it highlights the basic issues involved in most of the research we will encounter in this book. Researchers in ab- normal psychology begin by observing a phenomenon of interest, form hypotheses to explain it, and then design ways to eliminate as many competing explanations as possible. This last step often is the most diffi cult, because abnormal behavior is such a multifaceted phenomenon. To help make these important decisions, researchers rely on statistical procedures in which probability is a central con- cept. Probability refers to the odds, or likelihood, that an event will happen. The probability of a coin toss turning up heads is .5; that is, if a coin is tossed 100 times, it should show heads 50 times because there are only two possibilities. All conclu- sions about the correctness of hypotheses are framed in terms of probability, because it is almost impossible to study every individual whose responses might be relevant to the question under study. For example, if you are studying people with serious depression, you cannot obtain data from every person in the world who is depressed. You can study only some peo- ple from this very large group. In other words, you would choose a sample , or selection, from the population , or entire group, of depressed people. After you have studied the sam- ple, you would proceed to draw conclusions about the larger population. For example, you might fi nd that, in your sample of 50 depressed people, most of them have a disturbance in their appetite. You could then infer that appetite disturbance is a common feature of serious depression. However, you would have to be careful to state this inference in terms of probabilities. After all, you did not sample every depressed person in the population. Assuming your results were statisti- cally signifi cant, there would be at most a 5 percent prob- ability that y our results were due to chance factors. All statistics rely on some important assumptions about the samples on which the results are based—namely, that the sample is representative of the whole population and that it was randomly selected. Representativeness is the idea that your sample adequately refl ects the characteristics of the population from which it is drawn. For example, if you inter- view only 50 men, you cannot draw conclusions about men and women. Random selection increases the likelihood that your sample will not be contaminated by a selective factor. Ideally, every person who is representative of the population of depressed people should have an equal likelihood of being selected for the sample. Let’s say you have identifi ed 1,000 potential participants for your study who are representative of the population of depressed people. Of these 1,000, you have resources to interview only 50. To ensure that your fi nal sample is randomly selected you need to use a method such as drawing names out of a hat. You can see how it would be a mistake to select your fi nal sample by choosing the fi rst 50 people who responded to your initial request for partici- pants. These people might be unusually compulsive or des- perate in pursuit of relief from their depression. Either of these attributes might bias your sample so that it no longer represents the full spectrum of people with depression. The Experimental Method The purpose of psychological research is to develop an under- standing of how and why people differ in their behavior. The dimensions along which people, things, or events differ are called variables . For example, depression is a variable. Some people are more depressed than others; if given a test of depres- sion, some people would receive high scores and others would receive low scores. The purpose of research on depression is to fi nd out what accounts for these differences among people. The experimental method is one approach to discovering the source of differences among people on psychological vari- ables. The experimental method involves altering or changing the conditions to which participants are exposed and observ- ing the effects of this manipulation on the behavior of the participants. In research involving this method, the experi- menter attempts to determine whether there is a cause–effect relationship between two kinds of variables. The experimenter adjusts the level of one variable, called the independent vari- able , and observes the effect of this manipulation on the sec- ond variable, called the dependent variable . In our example about the effects of coffee on sleep patterns, the independent variable would be the caffeine in the coffee, and the dependent variable would be ease of falling asleep. In depression research, the independent variable would be a factor the researcher has hypothesized causes depression. For example, a current hypoth- esis is that some people in northern climates become more depressed in the winter, when the daylight hours are shorter and the light is less intense. To test this hypothesis, you would need to create an artifi cial situation in which you could manipulate light exposure (independent variable) for at least several days and observe the effect on depression scores (dependent variable) in your participants. The experimental method usually involves making com- parisons between groups exposed to varying levels of the inde- pendent v ariables. The simplest experimental design has two groups: an experimental and a control group. In this design, the experimental group receives the treatment thought to infl uence the behavior under study and the control group does not. Returning to the coffee example, you would test the hypothesis that caffeine causes sleeplessness by designing an experiment in which the experimental group is given caffeine a nd the control group is not given caffeine. By com- paring sleep patterns in the two groups, you would be able to determine whether caffeine causes sleeplessness. Research Methods in Abnormal Psychology 23 haL7069X_ch01_002-035.indd Page 23 11/12/08 5:33:52 AM user-s173 haL7069X_ch01_002-035.indd Page 23 11/12/08 5:33:52 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 24 Chapter 1 Understanding Abnormality Many studies involve a special kind of control group— a placebo condition. In the placebo condition , people are given an inert substance or treatment that is similar in all other ways to the experimental treatment. Thus, to test the caffeine hypothesis, you might give one group of participants a sugar pill that has no caffeine in it but looks identical to the caffeine pill you give the experimental participants. What is the purpose of the placebo condition? Think about your own experience in taking pills or in exposing yourself to other treatments that supposedly affect your behavior or health. Sometimes you feel better (or, perhaps, worse) just knowing that you have taken a substance that you think might affect you. The purpose of a placebo is to eliminate the possibility that a participant will experience a change that could be attributed to his or her expectations about the outcome of a treatment. Again, in the case of the caffeine example, if you wanted to test the effects of coffee (as op- posed to caf feine), you might give the experimental group a cup of caffeinated coffee and the placebo group a cup of decaffeinated coffee. That way, people in both groups would be drinking a hot, brown beverage. You might compare their sleeping patterns, then, with those of the no-treatment con- trol group, who drink nothing before going to sleep. In abnormal psychology, studies on the effectiveness of various therapeutic treatments should, ideally, include a pla- cebo condition. For example, researchers who are investigating whether a new medication will be effective in treating a certain psychological disorder must include a group receiving a placebo to ensure that any therapeutic benefi t in the treatment group can be attributed to the active ingredients in the medication. If the medication was found to be an effective treatment or if the researcher was interested in establishing further control, the researcher might then make medication available to the people in the placebo and other control conditions and test the effect of the intervention at that point. Comparable procedures would be carried out in investigating the effects of certain kinds of psychotherapy. In these cases, however, the task of providing a placebo treatment is much more complicated than in the case of medication studies. What would a placebo treatment be for psychotherapy? Ideally, the researchers would want the placebo participants to receive treatments of the same frequen cy and duration as the experimental group participants who are receiv- ing psychotherapy. As you might imagine, this would provide a real challenge for the researchers, who would be faced with trying to devise a method in which the people in the placebo condition would be meeting with a “therapist” but not par- ticipating in a “therapeutic interaction.” Perhaps they would talk about the weather or politics, but even such apparently neutral conversations might have some therapeutic effect. Researchers in the fi eld of abnormal psychology must also make allowances for the demand characteristics of the experimental situation. People in an experiment have certain expectations about what is going to happen to them and about the proper way they should respond, particularly when these people suspect that the research may reveal something very personal about themselves. For example, if you know that you will be given caffeine, you might anticipate diffi culty falling asleep that night. Similarly, if the experimenter knows that you have been given caffeine, he or she might make com- ments that could further infl uence how easily you fall asleep. The demand in this situation is the pull toward responding in ways based not on the actual effects of caffeine but on how you or the experimenters think the caffeine will affect you. Imagine how seriously the demand characteristics could bias an experiment on the effects of an antianxiety medica- tion. An experimenter administers a drug and tells partici- pants that they will feel relaxed in a little while. The chances are that they will feel more relaxed, but there is no way of knowing whether this is the result of the experimenter’s lead- ing comments or a true response to the medication. Or per- haps a participant notices labeling on the bottle, indicating that the pill is an antianxiety drug. This alone might have some infl uence on how the participant feels. To control for demand characteristics on both sides, most researchers use a double-blind technique , in which neither the person giving the treatment nor the person receiving the treatment knows whether the participant is in the experimental This woman is participating in an experimental study on the therapeu- tic effects of light therapy for alleviating depression. She is a participant in the treatment group, which receives exposure from a light source. haL7069X_ch01_002-035.indd Page 24 11/25/08 11:27:32 AM user-s174 haL7069X_ch01_002-035.indd Page 24 11/25/08 11:27:32 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 or the control group. Even if this technique cannot be applied, as in the case of research on the effects of psycho- therapy on depression, a minimal requirement for method- ologically sound research is that neither the experimenter nor the participant knows the study’s hypotheses. Otherwise, they will behave in ways that fulfi ll the expectations of the research. In all of these cases, it is essential that the experimenter assign participants to conditions in a totally random man- ner. You would not want to put all the people with sleep problems in the coffee-drinking group, or vice versa. Instead, the researcher would place people in groups according to a predetermined method of random assignment. The experimental method can be a powerful way to de- termine cause–effect relationships. However, it is not al- ways possible to manipulate a variable in an experiment by assigning participants randomly to conditions. For instance, you cannot use “number of friends” as an independent vari- able, because there is no practical way you can control how many friends someone has. In this case, you would use a quasi-experimental design , one that looks a bit like an ex- perimental design but lacks the key ingredient of random assignment (Cook & Campbell, 1979; Cook, Campbell, & Peracchio, 1990). You would choose groups that appear to be as similar as possible, except on the characteristic of num- ber of friends, and then compare them on the dependent variable of interest. The problem with this method is that, because people are not assigned randomly to groups, you cannot be sure that they actually are similar on all but the relevant variable. Any pre-existing differences between the groups may affect the outcome of the study. For instance, the group with few friends may have poor social skills, com- pared with the group with many friends. If the dependent variable is depression, it may be differences in social skills rather than number of friends that account for differences in their depression scores. Despite these problems, it is neces- sary to use a quasi-experimental design in research compar- ing groups whose characteristics have been predetermined. For example, comparisons of males versus females, older versus younger individuals, or people of different ethnicities would all involve this type of quasi-experimental design. Similarly, when participants in a research study choose one of the treatment conditions rather than being randomly assigned to a group, a quasi-experimental method is the only available design. Many studies on psychotherapy use quasi- experimental designs to enable clients to select the interven- tion they want. However, it is possible to develop statistical methods of controlling for this design problem in studies of the effectiveness of psychotherapy (Shadish, Matt, Navarro, & Phillips, 2000). The Correlational Method It is not always possible or desirable to frame a research problem in experimental or even quasi-experimental terms. In such cases, researchers use the correlational method. A correlation is an association, or co-relation, between two variables. The relationship described in the previous section between depression and number of friends is a perfect ex- ample of a correlation. The advantage of using a correla- tional procedur e is that the researcher can study areas that are not easily tested by the experimental method. For example, it is theorized that people who have depressive disorders think very negatively about themselves and have very low levels of self-esteem. The most direct way to test this theory is to mea- sure the levels of depression and self-esteem in people and see if the scores are correlated, or related to each other. The correlation statistic is expressed in terms of a number between 11 and 2 1. Positive numbers represent positive correlations—meaning that, as scores on one variable increase, scores on the second variable increase. For example, because one aspect of depression is that it causes a disturbance in normal sleep patterns, you would expect, then, that scores on a measure of depression would be positively correlated with scores on a measure of sleep disturbances. Conversely, nega- tive correlations indicate that, as scores on one variable in- crease, scores on the second variable decrease. An example of a negative correlation is the relationship between depression and self-esteem. The more depressed people are, the lower their scores are on a measure of self-esteem. In many cases, there is no correlation between two variables. In other words, two variables show no systematic relationship with each other. For example, depression is unrelated to height. Just knowing that there is a correlation between two vari- ables does not tell you whether one variable causes the other. The correlation simply tells you that the two variables are asso- ciated with each other in a particular way. Sleep disturbance might cause a higher score on a measure of depression, just as a high degree of depression might cause more disturbed sleep patterns. Or, a third variable that you have not measured could account for the correlation between the two variables that you have studied. Both depression and sleep disturbance could be due to an unmeasured physical problem, such as a biochemical imbalance. People who use correlational methods in their research are always on guard for the potential existence of unmeasured variables infl uencing the observed results. Fur- thermore, new methods involving complex correlational analy- ses with multiple variables are leading to improved and better-controlled correlational designs in research on abnormal psychology. For example, researchers have assessed the relative contributions of genetics, personality, and attitudes to the development of alcohol abuse (Finn, Sharkansky, Brandt, & Trucotte, 2000). The Survey Method Almost every day you can pick up a newspaper or magazine and read the results of the most recent survey report on any aspect of human behavior. It might be nationwide surveys of people’s attitudes toward the guilt or innocence of a major fi gure in the news, a campuswide survey about satisfaction with dormitory food, or a report in a newsmagazine comparing Research Methods in Abnormal Psychology 25 haL7069X_ch01_002-035.indd Page 25 11/12/08 5:34:29 AM user-s173 haL7069X_ch01_002-035.indd Page 25 11/12/08 5:34:29 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 26 Chapter 1 Understanding Abnormality sexual practices in America with those in Europe. The survey method is a research tool used to gather information from a sample of people considered representative of a particular population. The reason so many surveys are published in the news is that people are interested in what other people think and do. Sometimes the most interesting surveys are the ones that do not seem to fi t with what you might expect, or the ones that pertain to a particular issue that is on people’s minds. Surveys vary, of course, in their scope and relevance, with some pertaining more to political attitudes and others to the general health and well-being of a large segment of the population. Although they have the advantage that they can be administered to thousands of people, they tend to be limited in depth, especially when they rely on the self-reports of respondents. In abnormal psychology, the surveys that have the most relevance are those that focus on the mental health of the population, reporting the frequency of various psychological disorders. Other aspects of human behavior are also of inter- est, such as the frequency of drug use, sexual experiences, and child abuse and the use of mental health services. In the pages to follow, you will read many statistics about the frequency of psychological disorders. Researchers gather information about these disorders by conducting sur- veys. The statistics they obtain fall into two categories: inci- dence and prevalence. The incidence of a disorder is the frequency of new cases within a given time period. For ex- ample, the public health commissioner in a large city may be interested in the number of newly reported cases of AIDS during the month of January. This number would represent the 1-month incidence of AIDS cases for the population of that city. In other cases, incidence may be based on a 1-year period, so that the number represents all new cases reported during that 12-month period. Sometimes researchers do not have access to the entire population in attempting to deter- mine the number of people who develop the disorder in a given time period. In this case, incidence rates are based on a sample that is assumed to be representative of the entire population. For example, researchers interested in estimating the incidence of depression in a 1-month period may base their fi gures on interviews in which they ask people if they have begun to experience symptoms of depression within the past month. The prevalence of a disorder is the number of people who have ever had the disorder at a given time or over a specifi ed period. The time period could be the day of the survey (the point prevalence), the month preceding the study, or the entire life of the respondent. The period of time on which the prevalence rate is based is important to specify. Lifetime prevalence rates are higher than point prevalence rates, because the chances of a person developing a disorder increase with age. People in their fi fties, for example, are more likely to have a higher lifetime prevalence rate of alco- hol dependence, because they have lived longer than people in their twenties. Interestingly, the incidence rate for the dis- order might actually be higher for the 20-year-olds than for the 50-year-olds, even though the lifetime prevalence might be lower. New cases of alcohol dependence are more likely to arise in the younger group. The Case Study Method Sometimes a researcher is interested in studying a condition that is very rare but has compelling features that make it worth investigating. For example, transsexualism is a disorder in which people feel that they are trapped in the body of the wrong gender. This disorder affects a fraction of 1 percent of the population, so researchers would not have access to suffi – cient numbers to conduct a statistically rigorous study. Instead, they would perform a case study. The case study method allows the researcher to describe a single case in detail. For example, a therapist treating a transsexual client would describe the client’s developmental history, psychological functioning, and response to interventions. Other clinicians and researchers reading about this case would have the opportunity to learn about a rare phenomenon to which they might otherwise not have access. Furthermore, case studies can be particularly use- ful in helping others develop hypotheses about either psycho- logical disorders or treatment. In response to criticisms that case studies are commonly unsystematic and possibly biased reports, some experts (Fishman, 1999, 2001; Fishman & Messer, 2004) have proposed the pragmatic case study method, an organized approach for the development and accumulation of case study material that focuses on practical results. The pragmatic case study has a specifi ed structure that fosters systematic, refl ective processing of taped sessions or extensive progress notes and the collection of quantitative feedback from client questionnaires. The com- mon framework for case write-ups facilitates the development of a cumulative science of cases. Such a collection of cases would enable scholars and clinicians to organize case studies with similar presenting problems and intervention approaches into searchable databases (Fishman & Messer, 2004). Researchers gain a better understanding of psychological disorders, such as depression, through surveys in which they assess the preva- lence of the condition in certain segments of the population. haL7069X_ch01_002-035.indd Page 26 11/10/08 8:38:48 PM user-s174 haL7069X_ch01_002-035.indd Page 26 11/10/08 8:38:48 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 Single-Subject Design A single-subject design adds an experimental component to the study of the individual. In this type of research, one person at a time is studied in both the experimental and control condi- tions. Often, this method is used in research in which the focus is really on treatment. For example, suppose a school psychol- ogist wants to assess the effectiveness of a particular approach to treating a kindergartner named Bruce for aggressive out- bursts. She could use a four-phase variant of the single-subject design called the “A-B-A-B” method. The “A” phase is the baseline, the fi xed period of time in which Bruce is observed but given no treatment. During phase “B,” the treatment is administered. In Bruce’s case, this might consist of giving Bruce positive attention when he is quiet. The baseline and treatment conditions are repeated at least once to provide greater assurance that improvements in behavior during treatment were due to the intervention and not other, chance factors. Throughout this period, the frequency of Bruce’s ag- gressive outbursts is monitored. If the treatment is effective, the number of aggressive incidents should be less frequent in the “B” periods than in the “A.” You can see from the graph in Figure 1.3 how an A-B-A-B design would look. Sometimes the withdrawal of treatment in the A-B-A-B design would be considered unethical. In Bruce’s case, this would be true if Bruce were physically harming himself or other children. The psychologist would not want to suspend treatment that was regarded as effective. As an alternative, the psychologist could use a multiple baseline approach . This method involves observing different dependent variables in the same person over the course of treatment. The interven- tion would be introduced at different times and its impact evaluated on multiple dependent variables. In Bruce’s case, a baseline would be established for verbal outbursts, the treat- ment introduced, then his number of verbal outbursts mea- sured. Another baseline would be established at a different point for another type of aggressive behavior, such as punch- ing with his fi sts. Positive attention would be introduced and the frequency of punching measured. A similar process would be repeated for another type of aggressive behavior, such as kicking. If the positive attention is working, then it should result in reduced frequency of all three dependent variables. Single-subject designs are most appropriate for studying behaviors that are easily observed and measured and are particularly useful in evaluating the effects of therapeutic interventions (Morgan & Morgan, 2001). The emotional state associated with stress would be diffi cult to study using this procedure, but specifi c behaviors, such as the amount of alcohol consumed when a person feels stressed, can be stud- ied in this manner (Tennen, Affl eck, Armeli, & Carney, 2000). One advantage of this method is that it allows the investigator to make precise manipulations whose effect can be carefully measured. The disadvantage is that the study is carried out on only one individual, thus limiting its general- izability. To avoid this problem, some researchers report the results of several single-subject designs in one study. Studies of Genetic Infl uence So far, we have been discussing psychological methods of re- search. Although psychological research provides valuable information about the causes and treatment of abnormal behavior, it cannot answer all the questions. In fact, there has been a great deal of excitement over the past decade as researchers have plunged into new areas of inquiry that focus on the genetic transmission of behavioral characteristics. We all know that we inherit many physical characteristics from our parents, but, as researchers discover more about genetics, it is becoming apparent that behavioral characteristics have a strong genetic component as well. In the chapters to follow, you will see that many psychological disorders are being examined from a genetic perspective. Depression, schizophre- nia, alcoholism, and panic disorder are just a few that genet- icists and psychologists are actively researching. Most researchers begin the search for genetic causes of a disorder by establishing that the disorder shows a distinct pat- tern of family inheritance. This process requires obtaining com- plete family histories from people who are identifi ed as having symptoms of the disorder. Their genealogy must be traced in order to calculate the prevalence of the disorder among blood relatives. Another way to trace inherited causes of psychologi- cal disorders is to compare the concordance rate , or agreement ratios, between people diagnosed as having the disorder and their relatives. For example, a researcher may observe that out of a sample of 10 twin pairs, in 6 pairs each member has the same diagnosed psychological disorder. This would mean that, among this sample, there is a concordance rate of .60 (6 out of 10). An inherited disorder would be expected to have the highest concordance between monozygotic , or identical, twins (whose genes are the same), with somewhat lower rates between siblings and dizygotic , or fraternal, twins (who are no more alike genetically than siblings of different ages), and even lower rates among more distant relatives. Research Methods in Abnormal Psychology 27 Number of aggressive incidents Baseline Baseline FTR (20s) FTR (20s) Ten minute sessions 100 80 60 40 200 Thinning (to 90s) FIGURE 1.3 An example of an A-B-A-B design This graph shows the frequency of aggressive incidents recorded during observation of a child in a classroom. Note: FTR 5 fi xed-time reinforcement; 20s 5 20 seconds; Thinning 5 longer interval. Source: From Rasmussen, K., & O’Neill, R. E. (2006), The effects of fi xed-time rein- forcement s chedules on problem behavior of children with emotional and behavioral disorders in a day-treatment classroom setting. Journal of Applied Behavioral Analysis, 39(4), 453–457, Figure 1, “Chad,” p. 455. Reprinted by Permission. haL7069X_ch01_002-035.indd Page 27 11/25/08 3:57:44 PM user-s205 haL7069X_ch01_002-035.indd Page 27 11/25/08 3:57:44 PM user-s205 /Users/user-s205/Desktop/TEMPWORK/NOV_2008/SAN.25:11:08/MHSF107/working_ files… /Users/user-s205/Desktop/TEMPWORK/NOV_2008/SAN.25:11:08/MHSF107/working_ files… 28 Chapter 1 Understanding Abnormality A more powerful way to determine whether a disorder has a genetic basis is the study of families in which an adoption has taken place. The most extensive evidence gathered from these studies comes from the Scandinavian countries, where the governments maintain complete records for the population. Two types of adoptions are studied in this research. In the fi rst, simply called an adoption study , researchers look at children whose biological parents have diagnosed psychological disor- ders but whose adoptive parents do not. In the second and rarer kind of adoption situation, called a crossfostering study , researchers look at children who are adopted by parents with psychological disorders but whose biological parents are psy- chologically healthy. These kinds of studies enable researchers to draw strong inferences about the relative contributions of biology and family environment to the development of psychological dis- orders. Take the example of a boy who is born to two seri- ously depressed parents but who is adopted by two parents with no diagnosed psychological disorder. If this child also develops serious depression later in life, it makes sense to infer that he is genetically pr edisposed. Conversely, consider the case of a girl born to parents with no diagnosed psycho- logical disorder who is adopted and whose adoptive parents later become psychologically disturbed. If she develops the adoptive parents’ psychological disorder, family environment would be one logical cause. When researchers study many dozens of people in similar situations and observe a height- ened prevalence rate of psychological disorders among these children, they are able to draw conclusions with a high degree of certainty. Researchers trying to understand the specifi c mecha- nisms involved in models of genetic transmission have found it helpful to study measurable characteristics whose family patterns parallel the pattern of a disorder’s inheritance, called biological markers . For example, hair color would be a biological marker if a certain hair color always appeared in people within a family who have the same disorder. Other marker studies involve genetic mapping , a process researchers currently use in studying a variety of diseases thought to have a hereditary basis. Using this method, in the early spring of 2001 a team of genetic researchers mapped the entire sequence of genes in humans. In the chapters to fol- low, we will explore many of the important discoveries about a variety of psychological disorders that have been made using these methods. REVIEW QUESTIONS 1. In an experimental study, the _________ variable is what the experimenter controls and the ____________ variable is what the experimenter observes. 2. What is the difference between incidence and prevalence? 3. What is the term used to describe the agreement ratio between people diagnosed as having a disorder and their relatives? The Human Experience of Psychological Disorders Today, we continue to face the prospect of many seriously disturbed people wandering homeless in the streets without adequate care and perhaps moving in and out of jails and shelters. Ironically, this situation is not unlike that which con- fronted Dorothea Dix in 1841. Like Dorothea Dix, some contemporary advocates have suggested new forms of com- passionate treatment for people who suffer from psychologi- cal disorders. In particular, methods of collaboration between the mental health establishment and consumers of services are being developed in which the consumers are encouraged to take an active role in choosing their treatment. The com- munity, in turn, can provide greater fi nancial and emotional support, so that those with psychological disorders can sur- vive more effectively outside the institution. In accord with these concerns, the U.S. government has set as an objective for the year 2010 improvements in care that will reduce homelessness among the mentally ill (SAMHSA, 2005). As researchers continue to make progress in understand- ing the causes of psychological disorders, interest and attention have become increasingly focused on the impact of these dis- orders on every level—the family, community, and society. The widespread distribution of information, such as research fi nd- ings, along with society’s increased openness to confronting the concerns of people with psychological disorders, has led to a dramatic increase in public awareness of how psychological disorders affect many aspects of life. Psychological problems touch on many facets of human experience. Not only is the individual with the problem deeply troubled; the family is dis- turbed, the community is moved, and society is affected. Impact on the Individual: Stigma and Distress One of your reactions to seeing people like Rebecca Has- brouck might be to consider them as very different from you. You may even feel a certain degree of contempt or disgust for them. Many people in our society would react to her in such disdainful ways, not fully realizing the powerful impact of their discriminatory response. Such reactions are com- mon, and they are the basis for the discrimination and stigma experienced by many people with severe psychological dis- turbance. A stigma is a label that causes certain people to be regarded as different, defective, and set apart from main- stream members of society. The phenomenon of stigma was brought to public attention in the writings of famous soci- ologist Erving Goffman in the 1960s, and, several decades later, stigma continues to be a major focus in publications and discussions pertaining to the rights and treatment of psychologically disturbed individuals. It is common for people with serious psychological dis- orders, especially those who have been hospitalized, to expe- rience profound and long-lasting emotional and social effects. These “survivors” commonly report feeling isolated and re- haL7069X_ch01_002-035.indd Page 28 11/25/08 11:27:33 AM user-s174 haL7069X_ch01_002-035.indd Page 28 11/25/08 11:27:33 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 jected by others. In time, they come to think less of them- selves, take less advantage of opportunities for growth and development, and actually come to believe in society’s myths and expectations for the mentally ill (Wright, Gronfein, & Owens, 2000) ( Table 1.3 ). Unfortunately, the popular media often perpetuate these myths with stereotyped portrayals of individuals with mental illness (Salter & Byrne, 2000). For example, when it is reported that a man with schizophrenia has attacked a stranger, the public is led to believe that most individuals with schizophrenia are prone to violent behavior. As a result, it is no surprise to fi nd that a large percentage of people in the United States are fearful of people with mental illness and do not wish to be associated with them (Link et al., 1999). Individuals with psychological disorders, especially severe conditions such as schizophrenia, often fi nd that other people resist living with them, socializing with them, renting to them, or giving them jobs (Corrigan & Penn, 1999; Penn & Martin, 1998). Although tremendous efforts have been undertaken to humanize the experiences of patients within psychiatric insti- tutions, for most people the process of hospitalization is deeply upsetting, and possibly traumatizing. A number of in- stitutional procedures are seen as dehumanizing and contrib- uting to stigma. For example, patients who are out of control may be physically restrained. Others may be forced to give up personal possessions or to limit their contact with loved ones, even by telephone. They are expected to participate in group activities, such as occupational or recreational ther- apy, and to share their private concerns in group therapy. While such structures are designed to be therapeutic, some individuals fi nd them too intrusive and controlling. Even clinic routines that require patients to wait for appointments can be dehumanizing, causing them to feel that they are less important than the staff. Loss of privacy, inadequate access to information about diagnosis and treatment, patronizing or infantilizing speech, offensive slang, and language with a medical orientation are additional objectionable practices that stigmatize individuals. Finally, being forced to accept a psychiatric label may be experienced as stigmatizing. The individual may be made to feel as though he or she cannot argue or dispute the diagnosis once it has been given. Most people would outwardly espouse an understanding and a tolerance for people with psychological disorders. Refl ected more subtly in their language, humor, and stereotypes, however, are usually some fairly negative attributions. Watch television for an hour, or listen to the everyday conversation of those around you, and you will probably encounter some comments about emotional illness. Colloquialisms relating to emotional illness abound in our language. Statements about being “nuts,” “crazy,” “mental,” “maniac,” “fl aky,” “off-the-wall,” “psycho,” “schizo,” or “retarded” are quite common. Popular humor is fi lled with jokes about “crazy people.” Imagine the response of a group of teenagers walking past Rebecca; they might make derogatory comments and jokes about her appearance and behavior. What toll do you think this would take on Rebecca’s already unstable sense of self ? The Human Experience of Psychological Disorders 29 TABLE 1.3 Goals for the Future of Mental Health The serious problem of stigma caught the attention of the federal government, which established a Commission on Mental Health. This Commission issued a report in 2003 spelling out six goals for the future of mental health: 1. Americans need to understand that mental health is essential to overall health: ■ many people with mental illnesses go untreated ■ stigma impedes people from getting the care they need ■ better coordination is needed between mental health care and primary health care 2. Mental health care needs to be consumer and family driven: ■ the complex mental health system overwhelms many consumers ■ consumers and families do not control their own care ■ consumers and families need community-based care 3. Disparities in mental health services should be eliminated: ■ minority populations are underserved ■ minorities face barriers to receiving appropriate care ■ rural America needs improved access to mental health services 4. Early mental health screening, assessment, and referral to services should be common practice: ■ early assessment and treatment are critical across the life span ■ if untreated, childhood disorders can lead to a down- ward spiral ■ schools can help address mental health problems 5. Excellent mental health care should be delivered and research should be accelerated: ■ the delay is too long before research reaches practice ■ too few benefi t from available treatment ■ reimbursement policies do not foster converting research to practice 6. Technology should be used to access mental health care and information: ■ access to care is a concern in rural and other under- served areas ■ information technology can now enhance medical records systems ■ consumers may not have access to reliable health information Source: http://www.mentalhealthcommission.gov/reports/Finalreport/downloads/ FinalReport.pdf haL7069X_ch01_002-035.indd Page 29 11/25/08 11:27:33 AM user-s174 haL7069X_ch01_002-035.indd Page 29 11/25/08 11:27:33 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 30 Chapter 1 Understanding Abnormality Considering the tremendous impact of psychological disorder on the individual, why are some people so cruel as to joke about a person’s distressed state? One reason might be that people often joke about issues that make them anx- ious. There is something very frightening about a psycho- logical disorder that makes people want to distance themselves from it as much as possible, perhaps feeling frightened about the prospect of losing control over their own behavior and thoughts. Consequently, they joke about oddities in other people’s behavior. A leading researcher on the topic of stigma, Patrick Corrigan (2004) contends that stigma is particularly problem- atic because it deters people in need of treatment from seek- ing or sticking with treatment. Corrigan frames the stigma process in terms of four social cognitive processes: (1) cues, (2) stereotypes, (3) prejudice, and (4) discrimination. Cues include four kinds of information that can fuel inferences about mental illness: (a) psychiatric symptoms (e.g., inappro- priate affect or bizarre behavior); (b) social skills defi cits (e.g., impaired understanding of socially appropriate behavior); (c) physical appearance (e.g., unkempt clothing or poor hy- giene); and (d) labels (e.g., being psychiatrically diagnosed, or even being seen coming out of a mental health clinic). According to Corrigan (2004), cues elicit stereotypes such as, “All people with mental illness are dangerous.” Stereotypes commonly yield prejudice such as, “People with mental illness are dangerous, and I am afraid of them.” The result of such thinking and behavior is discrimination, such as, “I do not want to be near them or hire them for a job.” The progression of public stigma from stereotype to prejudice to discrimina- tion has a parallel in the self-stigma of the individual with a psychological disorder. For example, a woman with a psycho- logical disorder may hold the stereotype that all people with mental illness are incompetent. Her prejudice is expressed in the thought, “I have a mental illness, so I must be incompe- tent,” and in the acceptance of discrimination: “Why should I even try to get a job if I’m just an incompetent mental patient?” What about your attitudes? Imagine the following sce- nario. An urgent message is waiting for you when you return to your room. It is from the mother of Jeremy, your best friend in high school. You call Jeremy’s mother, who says she wants you to meet her at the psychiatric hospital in your hometown as soon as possible. Jeremy has just been admitted there and says that he has to see you, because only you can understand what he is going through. You are puzzled and distressed by this news. You had no idea that he had any psychological problems. What will you say to him? Can you ask him what’s wrong? Can you ask him how he feels? Do you dare inquire about what his doctors have told him about his chances of getting better? What will it be like to see him in a psychiatric hospital? Do you think you could be friends with someone who has spent time in such a hospital? Now imagine the same scenario, but instead you receive news that Jeremy has just been hospitalized for treatment of a kidney dysfunction. As you imagine yourself going to visit him, you will probably not think twice about how you will respond to him. Of course, you will ask him how he feels, what exactly is wrong with him, and when he will be well again. Even though you might not like hospitals very much, at least you have a pretty good idea about what hospital patients are like. It does not seem peculiar to imagine Jeremy as a patient in this kind of hospital. Your friend’s physical illness would probably be much easier to understand and accept than his psychological disorder, and you would prob- ably not even consider whether you could be friends with him again after he is discharged. Apart from the distress created by stigma is the personal pain associated with the actual psychological disorder. Think about Rebecca and the dramatic turn that her life took as she was shaken from her successful and stable existence. Not only was she devastated by the trauma of losing her family, but she lost her own identity and sense of purpose as well. By the time she reached out for help, she no longer had even the remnants of her former self. Think about how you would feel if everything you had were suddenly gone in the course of a few weeks—your family, your home, your identity. For many people who develop a serious psychological disorder, whatever the cause, the symptoms themselves are painful and possibly terrifying. The sense of loss of control over one’s thoughts and behaviors adds to one’s torment. Of course, not all cases of psychological disorder are as severe as Rebecca’s, nor do they necessarily follow from an identifi able event. In the chapters to follow, you will read about a wide range of disorders involving mood, anxiety, substance abuse, sexuality, and thought disturbance. The case descriptions will give you a glimpse into the feelings and experiences of people who have these disorders, and you may fi nd that some of these individuals seem similar to you or to people you know. As you read about the disorders, put your- self in the place of the people who have these conditions. Consider how they feel and how they would like to be treated. We hope that you will realize that our discussion is not about disorders but about the people with these disorders. Impact on the Family Typically, even before a person with a psychological disorder has been seen by a professional, the family has been affected by the person’s behavior and distress. The degree of the im- pact depends in part on the nature of the problem and in part on the dynamics of the family. Most commonly, family members are touched by the pain of a relative who is wounded emotionally. For example, a mother loses sleep for many months as she struggles to understand what role she might have played in the develop- ment of her teenager’s suicidal depression. A father worries that his child might once again drink insecticide in response to visions of giant insects crawling down his throat. A wife feels anxious every time the phone rings, wondering whether it might be the police or an acquaintance calling to tell her haL7069X_ch01_002-035.indd Page 30 11/10/08 8:38:50 PM user-s174 haL7069X_ch01_002-035.indd Page 30 11/10/08 8:38:50 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 that her husband has passed out in a drunken stupor at the neighborhood bar. The stigma of a psychological disorder also taints the family. Many families speak of the shame and embarrass- ment they feel when neighbors, schoolmates, and co-workers discover that someone in the family is schizophrenic, de- pressed, addicted to drugs, or abusive. You can imagine how Rebecca’s relatives might have felt when news of her wan- dering and disruptive behavior with the police was broadcast on the local media. For much of the twentieth century, the mental health pro- fession in general was unsympathetic regarding the impact of psychological disorder on the family. Not only were families kept uninformed about treatment, but they were often blamed for the problem. Theories about the causes of many disorders, such as schizophrenia, depression, and sexual problems, typi- cally blamed families—usually mothers. Fam ilies found them- selves distressed by the turbulence caused by the problems of one of their relatives, hurt, and confused by what they heard as accusations from mental health professionals. Much of that has changed in recent years, as some prominent mental health professionals, such as psychiatrist E. Fuller Torrey, have rec- ognized the distress of these families and have written books specifi cally directed to them (Torrey, 2006), letting them know that they are not alone; in fact, their worries, concerns, and problems are similar to those experienced by millions of other Americans. Families also have banded together for support and mu- tual education. Across the country, families of people with serious psychological disorders have formed organizations, such as the National Alliance on Mental Illness (NAMI). These groups have helped many families better understand the nature of the problems they face, and the organizations have also served an important political function. Such family advocacy groups have played a crucial role in ensuring that psychiatrically hospitalized people are properly treated, that their legal rights are respected, and that adequate posthospi- talization care is planned. Impact on the Community and Society Anyone who has lived in a community where a state psychi- atric hospital is located knows that there are many challenges involved in accommodating the mental health care needs of psychologically disturbed people following their discharge from the hospital. As we discussed earlier, beginning in the 1970s, there has been a national movement toward relocating psychiatric inpatients from hospitals to less restrictive envi- ronments. It was commonplace in the mid-1970s for a state hospital to house several thousand patients. By the start of the twenty-fi rst century, those numbers had dwindled. (Review Figure 1.2 .) Many institutions had closed; others were left open but operated on a far smaller scale. Some of the dis- charged individuals moved back to their family homes, but most moved into community-based homes with several other deinstitutionalized people. In some programs and communi- ties, these people are adequately cared for; however, in many areas, particularly large cities, there are dozens, even hun- dreds of formerly institutionalized people who go without home, food, or health attention. A particularly disturbing fact associated with the lack of appropriate care and attention given to mentally ill indi- viduals is the alarming number who are winding up in jail or prison. Some experts contend that the rapid release of patients over the course of decades from mental hospitals, associated with inadequate follow-up , has resulted in a phe- nomenon in which approximately 16 per cent of inmates in the United States are identifi ed as mentally ill, a statistic that is considered an underestimate of the true number (Lamberg, 2004). Also striking is the fact that ethnic minority persons are unlikely to receive mental health services appropriate to their needs. Even those who have access to some mental health services have little guarantee that the services will be of high quality (Snowden & Yamada, 2005). In the report of the President’s New Freedom Commission on Mental Health (2003), conclusions highlighted access problems associated with racial, cultural, and ethnic variables. Various explana- tions for such disparities have been proposed over the years, including factors such as cultural mistrust, stigma, differences in the way symptoms are expressed and managed, insurance limitations, and even the preference of many people for alter- native interventions (e.g., acupressure, chiropractic care, tai chi). The fact remains, however, that there are striking ethnic and cultural disparities in the utilization of mental health services, and that continuing research is needed in order to understand such differences and to propose changes in the health care delivery system (Snowden & Yamada, 2005). In an attempt to tackle the question about why members of ethnic minority groups are less likely than middle-class whites to seek professional treatment for mental health prob- lems such as depression, one researcher (Karasz, 2005) noted that ethnic minority individuals, in this case South Asian immigrants, are likely to view symptoms of depression as social problems or emotional reactions to situations, while The Human Experience of Psychological Disorders 31 As a kickoff to National Mental Health Month, several thousand people joined in a Washington march to bring attention to the con- cerns of people with mental illness. haL7069X_ch01_002-035.indd Page 31 11/10/08 8:38:50 PM user-s174 haL7069X_ch01_002-035.indd Page 31 11/10/08 8:38:50 PM user-s174 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 /Users/user-s174/Desktop/TempWork/November/10-11-08/MHSF107_Helgin/MHSF1 07-01 32 Chapter 1 Understanding Abnormality European-American whites are more likely to view depression as some form of disease warranting professional treatment. Other researchers (Roberts, Alegria, Roberts, & Chen, 2005) have studied the different ways in which members of several ethnic groups view the problems of adolescents, and found that European-American youths and their caregivers are twice as likely as members of minority groups to defi ne problems in mental health terms or to seek help for such problems. The impact of psychological disorders on society is not easily measured, but there is agreement among mental health professionals and public health experts that psychological prob- lems exact a tremendous toll on society (Callahan, 1999). F o r example, adults with psychological disorders miss 1.3 billion days of work, school, or other productive activities every year, a statistic that exceeds loss of productivity due to phys- ical illnesses such as back and neck pain. Families are often torn apart and communities are divided. Once again, con- sider Rebecca’s story. The loss of her productivity and par- ticipation in the community can be considered costs to society. More directly measured are the actual fi nancial costs of her rehabilitation. Her treatment will require intensive therapy, inpatient hospitalization, relocation within the community, and follow-up support. The expenses of her treatment must be weighed against the human cost of the continued suffering she would experience if she were not able to receive proper care. When you think of the fact that there are hundreds of thousands of people like Rebecca on the streets of America, you can appreciate the tragedy of the unfulfi lled lives that takes its toll on society. Reducing Stigma Stigma is a phenomenon that adds to the burden of psycho- logically distressed people in several ways. In addition to increasing the burden for them and for their loved ones, stigma deters people from obtaining badly needed help, and thereby perpetuates a cycle in which many people in need become much worse. Corrigan (2004) discusses three approaches that may diminish aspects of public stigma experienced by such individuals: protest, education, and contact. When people protest againt inaccurate or hostile representations of mental illness, those delivering such representations are often forced to stop, listen, and revise. For example, when a company pro- duced a Valentine’s Day teddy bear clothed in a straitjacket, holding commitment papers, and emblazoned with the mes- sage “crazy for you,” the public outcry was tremendous. Educational efforts are also important in providing information to the public about the nature of psychological disorders and the effectiveness of mental health interven- tions. Articles in newspapers and magazines, programs on radio and television, and the vast store of information avail- able on the Internet serve important roles in enlightening the public about conditions and their treatments. Contact with people with mental health problems can be especially effective in changing attitudes and reducing stigma. When people become aware of the fact that life goes on for millions of people with serious psychological disor- ders and that it is possible to be successful in life even while contending with challenging problems, stigma diminishes. Various advocacy groups have worked tirelessly to change the way the public views mentally ill people and how they are dealt with in all settings of society. These groups include the National Alliance on Mental Illness, which we mentioned earlier, as well as the Mental Health Association, the Center to Address Discrimination and Stigma, and the Eliminate the Barriers Initiative. In recent years, the U.S. federal government has also become involved in antistigma programs as part of efforts to improve the delivery of mental health services through the President’s New Freedom Commission (Hogan, 2003). Certainly those who have been affected by serious psychological disorder, either directly or indirectly, will welcome efforts to under- stand and to assist those whose lives have been touched by mental illness. Bringing It All Together: Clinical Perspectives As you come to the close of this chapter, you now have an appreciation of the issues that are central to your understand- ing of abnormal psychology. We have tried to give you a sense of how complex it is to defi ne abnormality, and you will fi nd yourself returning to this issue as you read about many of the disorders in the chapters that follow. The historical perspective we have provided will be elaborated on in subsequent chapters as we look at theories of and treatments for specifi c disorders. Currently, developments are emerging in the fi eld of abnormal psychology at an unbelievable pace due to the efforts of researchers applying the techniques described here. You will learn more about some of these research methods in the con- text of discussions regarding specifi c disorders. You will also develop an understanding of how clinicians, such as Dr. Sarah Tobin, look at the range of psychological disorders that affect people throughout the life span. We will give particular atten- tion to explaining how disorders develop and how they are best treated. Our discussion of the impact of psychological disorders forms a central theme for this book, as we return time and again to consideration of the human experience of psychological disorders. REVIEW QUESTIONS 1. What is meant by stigma with regard to people with psy chological disorders? 2. To what does the term mental health parity refer? 3. According to the 2003 report of the U.S. Commission on Mental Health, w hat three social disparities must be addressed in the provision of mental health services? haL7069X_ch01_002-035.indd Page 32 12/4/08 5:48:52 PM user-s174 haL7069X_ch01_002-035.indd Page 32 12/4/08 5:48:52 PM user-s174 /Users/user-s174/Desktop/MHSF107-01 /Users/user-s174/Desktop/MHSF107-01 Case Report Rebecca Hasbrouck Course and Outcome My professional relationship with Rebecca provided a powerful glimpse into the mind and experiences of a woman who had been emotionally devastated by a personal trauma. Lit- tle did I expect that my encounter with her on that Tuesday morning in Sep- tember would be the start of psycho- therapy that would prove to be so instrumental in helping a troubled woman set on a new life course, nor did I anticipate the impact that this year-long therapy would have on my professional work with my other clients. Somehow , this relationship helped me increase my level of empa- thy and responsiveness to my clients. I often think back to the fi rst hour I spent with Rebecca and how I was called on to make some important decisions regarding her needs. Of immediate concern was Rebecca’ s physical health and comfort. I es- corted her to the admissions offi ce of the psychiatric unit, where a nurse welcomed her to the unit and as- sisted her in washing and dressing in clean clothes. I recall being startled, on returning to speak with Rebecca later in the day, to fi nd a woman who looked so dramatically different from the helpless fi gure I had encountered only a few hours earlier . Although she continued to have a look of n umb- ness, she seemed much more re- sponsive in her interactions with me. She asked me what would happen to her. At one point, she became agi- tated for a few moments, telling me that she really should be on her way . I asked her to be patient and to listen to my recommendations. Although she could not be retained in the hos- pital against her will, it made sense for her to rest and recuperate, so that a plan could be developed to return her to a “normal life.” I explained to Rebecca that I would be her therapi st during her stay in the hospital, which I expected to last approximately 2 weeks. During that time, I would collaborate with a social worker, Beverly Mullins, who would focus on helping Rebecca re- enter the world she had fl ed 3 years ago. Pract ical matters would be planned, such as where Rebecc a would live and how she would gain access to the fi nancial resources she had left behind. My task would be to help Rebecca understand what had happened to her emotionally—to re- turn to the trauma of the car accident and to develop a basic understanding of how this trauma and the loss of her husband and sons had precipitated a fl ight from reality. I would try to help her develop some of the psychologi- cal strength she would need to re- cover from her 3 years of torment. During the fi rst few days of Rebecca’s stay in the hospital, the medical staff conducted a compre- hensive assessment of her physical health. The list of her physical mala- dies was lengthy and included gas- trointestinal problems, skin infections, and head lice. I also requested a full neurological evaluation, particularly important in light of the fact that Re- becca had suffered a brain trauma in the car accident, which probably contributed to her dysfunction. By the end of the fi rst week, her medical needs were being treated, and she was on a nutritional regimen de- signed to address various defi cien- cies. Concurrent with attention to her physical condition, the clinical staff and I formulated a treatment plan to address her psychological state. During her 14 days in the hospital, Rebecca met with me six times and attended group therapy each day . She also met several times with Beverly Mullins, who contacted Rebecca’s sister and parents to in- volve them in developing a plan of action. I joined Bev Mullins for the initial meeting of Rebecca and her family members . The emotion that fi lled the room was overwhelming; Rebecca was greeted as a person “coming back from the grave.” In my own work with Rebecca in those six sessions during her inpa- tient stays, we reviewed in painful detail Rebecca’s memories of what had happened to her during the past 3 years. Much of this period was blotted out, perhaps in part due to neurological damage, but Rebecca did remember the accident and her psychological devastation in the weeks that followed. She recalled her desperate pursuit of her lost loved ones, and she spoke in disbe- lief about how she thought she had heard their voices calling out to her . The depth of her depression was so great that Rebecca had become im- mobilized after losing her children and husband. She spent nights and days for many months crying con- stantly and wandering the streets of the city. As strange as it came to seem to Rebecca, she found comfort in the community of other homeless people who befriended her. These people became her “family” and taught her the ways of the streets. Rebecca was never quite sure what prompted her to emerge from the dismal life she had come to live. Perhaps it was the anniversary of the car accident that caused her to think about what was happening to her life and to consider the possibil- ity of returning to the world fr om which she had tried to escape. Per – haps healing within her traumatized brain was taking place. The intensity of Rebecca’s con- nection with me was evident from our very fi rst sessions. As we p lanned her discharge from the hospital, she asked me if she could continue to see me until her functioning was more stable. I agreed. Bev Mullins was able to arrange a posthospital placement for Rebecca in a halfway house for women who were capable of working and gradu- ally assuming independent control of their lives. Although none of the other six clients in the halfway house had stories as dramatic as that of Rebec- ca’s, each had suffered a serious break with reality and was trying to return to an independent life in the community. Rebecca remained in the halfway house for a month. During that time, she worked out her fi nancial situa- tion with an attorney and took an apartment not far from her sister’s house so that she could be near a relative until she felt more comfort- able returning to a normal life. Both during her stay in the half- way house and for 11 months follow- ing her departure from the house, Rebecc a came to see me twice a RETURN TO THE CASE (continued) haL7069X_ch01_002-035.indd Page 33 11/25/08 11:27:34 AM user-s174 haL7069X_ch01_002-035.indd Page 33 11/25/08 11:27:34 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 Case Report Rebecca Hasbrouck week for outpatient therapy. Although dealing with her grief always re- mained a component of our work, in time we refocused our attention on tapping her talents and abilities so that she could return to work and so- cial involvement with other people. Rebecca felt that she had fallen out of touch with the practice of law, and she had little desire to retur n to that kind of work. She also continued to experience cognitive problems that impaired her attention, concentration, and memory. Because of a large in – surance settlement, she did not feel pressured to fi nd a high-paying posi- tion, but she realized that it was im- portant for her psychological health to be active and to work. Always having had an affi nity for writing, Rebecca decided to pursue a career as a free- lance writer of feature articles for popular magazines. This route seemed ideal for her, because it permitted her to work in a more private space, in which she would feel less burdened by having to interact with people who would inquire about her personal life. The success story that unfolded for Rebecca seemed to have a fairy- tale quality to it. Her writing was very well received, and she returned to a healthy psychological state over the course of a year, although mild cogni- tive dysfunction caused considerable frustration at times. In our work to- gether, she slowly reacquired a sense of her identity and learned to compart- mentalize her traumatic experience, so that it would be less intrusive in her day-to-day life. We also developed techniques aimed at compensating for her mild problems with memory. After a year of regular therapy sessions, Rebecca decided that she was ready to end therapy. I suggested that she might wish to gradually re- duce the frequency of sessions, a practice I have found useful with other long-term clients. Although Rebecca initially considered this pos- sibility, she decided against it, be- cause she felt it important to make a “clean break” in order to prove to herself that she could be truly inde- pendent. In the years that followed, I heard from Rebecca only once. About 4 years after we had terminated, I re- ceived an engraved announcement of her wedding on which she wrote, “Thanks for everything. I’ve now come back to the world.” Becau se there was no return address, I con- cluded that Rebecca did not need, or wish for, me to respond. Her note did mean a great deal to me, however. I was now able to have a sense of completion about our work, and, in contrast to many other cases with less-than-happy outcomes, I was able to feel a sense of comfort that my efforts with Rebecca were instru- mental in bringing her “back.” Sarah Tobin, PhD RETURN TO THE CASE (continued) 34 SUMMARY ■ We are defi ning abnormality in terms of four criteria: dis- tress, impairment, risk to self or others, and behavior that is outside the norms of the social and cultural context within which it takes place. ■ In trying to understand why people act and feel in ways that are regarded as abnormal, social scientists look at three dimensions—biological, psychological, and sociocultural— and use the term biopsychosocial to characterize the inter- actions among these three dimensions. Related to the biopsychosocial approach is the diathesis-stress model, according to which people are born with a diathesis (or predisposition) that places them at risk for developing a psychological disorder. ■ The history of understanding and treating people with psy- chological disorders can be considered in terms of three recurring themes: the mystical, the scientifi c, and the humanitarian. The mystical theme regards abnormality as due to demonic or spirit possession. This theme was preva- lent during prehistoric times and the Middle Ages. The sci- entifi c theme regards abnormality as due to psychological or physical disturbances within the person. This theme had its origins in ancient Greece and Rome, and it has predom- inated since the nineteenth century. The humanitarian theme regards abnormality as due to improper treatment by society; this theme predominated during the reform move- ments of the eighteenth century and is still evident in con- temporary society. ■ Researchers use various methods to study the causes and treatment of psychological disorders. The scientifi c method involves applying an objective set of methods for observing behavior, hypothesizing about the causes of behavior, setting up proper conditions for studying the hypothesis, and draw- ing conclusions about its validity. In the experimental method, the researcher alters the level of the independent variable and observes its effects on the dependent variable. The quasi-experimental method is a variant of this proce- dure and is used to compare groups that differ on a prede- termined characteristic. The correlational method studies associations, or co-relations, between variables. The survey method enables researchers to estimate the incidence and prevalence of psychological disorders. In the case study method, one individual is studied intensively, and a detailed and careful analysis of that individual is conducted. In the single-subject design, one person at a time is studied in both the experimental and control conditions, as treatment is ap- plied and removed in alternating phases. haL7069X_ch01_002-035.indd Page 34 11/12/08 5:35:07 AM user-s173 haL7069X_ch01_002-035.indd Page 34 11/12/08 5:35:07 AM user-s173 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 /Users/user-s173/Desktop/MHSF107:Helgin/MHSF107-01 INTERNET RESOURCE To get more information on the material covered in this chapter, visit our website at www.mhhe.com/halgin6e . There you will fi nd more information, resources, and links to topics of interest. ANSWERS TO REVIEW QUESTIONS What Is Abnormal Behavior? (p. 10) 1. Distress; impairment; risk to self or other people; socially and culturally unacceptable behavior 2 . The intense trauma that threw Rebecca into chaos and profound disturbance, which lasted for years 3 . A predisposition that places a person at risk of developing a disorder Abnormal Psychology Throughout History (p. 21) 1. Sanguine, melancholic, phlegmatic, and choleric 2. Moral treatment 3 . Deinstitutionalization movement Research Methods in Abnormal Psychology (p. 28) 1. Independent; dependent 2. Incidence is the frequency of new cases within a given period, and prevalence is to the number of people who have ever had the disorder at a given time or over a spec- ifi ed period. 3 . Concordance rate The Human Experience of Psychological Disorders (p. 32) 1. People with psychological disorders are often labeled as different, defective, and set apart from mainstream mem- bers of society. 2 . A standard that would require health insurers to pro- vide equal levels of coverage for physical and mental illnesses 3 . Underserving of minority populations; barriers faced by minority individuals to receiving appropriate care; and limited access to mental health care in rural America ■ Psychological disorders affect not only the people who suffer from them but also the family, community, and society. Indi- viduals with psychological disorders are stigmatized, which adds to their emotional problems. Family members are affected by the distress of their loved ones, and also share a sense of stigma. On a broader level, the social and fi nancial costs of mental health problems are inestimable. In this book, we will use a clinical perspective rooted within a life-span approach to gain an understanding of the range of psychological disorders and the methods used to treat people with these conditions. KEY TERMS Double-blind technique 24 Experimental group 23 Experimental method 23 Genetic mapping 28 Hypnotism 17 Hypothesis formation process 23 Hysteria 17 Incidence 26 Independent variable 23 Medical model 16 Mental health parity 21 Mesmerized 17 Monozygotic twins 27 Moral treatment 15 Multiple baseline approach 27 Observation process 22 See Glossary for defi nitions Adoption study 28 Asylums 13 Baseline 27 Biological markers 28 Biopsychosocial 10 Case study method 26 Concordance rate 27 Control group 23 Correlation 25 Crossfostering study 28 Deinstitutionalization movement 19 Demand characteristics 24 Dependent variable 23 Diathesis-stress model 10 Dizygotic twins 27 Placebo condition 24 Population 23 Pragmatic case study 26 Prevalence 26 Probability 23 Psychoanalysis 18 Psychoanalytic model 16 Psychotherapy 18 Quasi-experimental design 25 Representativeness 23 Sample 23 Single-subject design 27 Stigma 28 Survey method 26 Trephining 11 Variable 23 Internet Resource 35 haL7069X_ch01_002-035.indd Page 35 11/25/08 11:27:36 AM user-s174 haL7069X_ch01_002-035.indd Page 35 11/25/08 11:27:36 AM user-s174 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01 /Users/user-s174/Desktop/TempWork/21:11:08/MHSF107/working_files/MHSF107 -01


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