Models of Abnormality
Freud’s Psychodynamic Model
Freud believed that three central forces shape the personality—instinctual needs, rational thinking, and moral standards. All these forces operate at the unconscious level, unavailable to immediate awareness; and he believed them to be dynamic, or interactive. Freud called the forces the id, ego, and superego.
Freud used the term id to denote instinctual needs, drives, and impulses. The id operates in accordance with the pleasure principle; that is, it always seeks gratification. Freud also believed that all id instincts tend to be sexual, noting that from the very earliest stages of life a child’s pleasure is obtained from nursing, defecating, masturbating, or engaging in other activities that he considered to have sexual links. He further suggested that a person’s libido, or sexual energy, fuels the id.
During our early years we come to recognize that our environment will not meet every instinctual need. Our mother, for example, is not always available to do our bidding. A part of the id separates off and becomes the ego. Like the id, the ego unconsciously seeks gratification, but it does so in accordance with the reality principle, the knowledge we acquire through experience that it can be unacceptable to express our id impulses outright. The ego, employing reason, guides us to know when we can and cannot express those impulses.
The ego develops basic strategies, called ego defense mechanisms, to control unacceptable id impulses and avoid or reduce the anxiety they arouse. The most basic defense mechanism, repression, prevents unacceptable impulses from ever reaching consciousness. There are many other ego defense mechanisms, and each of us tends to favor some over others (see Table 2-1).
The superego grows from the ego, just as the ego grows out of the id. As we learn from our parents that many of our id impulses are unacceptable, we unconsciously adopt our parents’ values. Judging ourselves by their standards, we feel good when we uphold their values; conversely, when we go against them, we feel guilty. In short, we develop a conscience.
According to Freud, these three parts of the personality—the id, the ego, and the superego—are often in some degree of conflict. A healthy personality is one in which an effective working relationship, an acceptable compromise, has formed among the three forces. If the id, ego, and superego are in excessive conflict, the person’s behavior may show signs of dysfunction.
Freudians would therefore view Philip Berman as someone whose personality forces have a poor working relationship. His ego and superego are unable to control his id impulses, which lead him repeatedly to act in impulsive and often dangerous ways—suicide gestures, jealous rages, job resignations, outbursts of temper, frequent arguments.
Freud proposed that at each stage of development, from infancy to maturity, new events and pressures challenge individuals and require adjustments in their id, ego, and superego. If the adjustments are successful, they lead to personal growth. If not, the person may become fixated, or entrapped, at an early stage of development. Then all subsequent development suffers, and the individual may well be headed for abnormal functioning in the future. Because parents are the key figures during one’s early years of life, they are often seen as the cause of improper development.
Freud named each stage of development after the body area that he considered most important to the child at that time. For example, he referred to the first 18 months of life as the oral stage. During this stage, children fear that the mother who feeds and comforts them will disappear. Children whose mothers consistently fail to gratify their oral needs may become fixated at the oral stage and display an “oral character” throughout their lives, marked by extreme dependence or extreme mistrust. Such persons are particularly prone to develop depression. As we shall see in later chapters, Freud linked fixations at the other stages of development—anal (18 months to 3 years of age), phallic (3 to 5 years), latency (5 to 12 years), and genital (12 years to adulthood)—to yet other kinds of psychological dysfunction.
Other Psychodynamic Explanations
Personal and professional differences between Freud and his colleagues led to a split in the Vienna Psychoanalytic Society early in the twentieth century. Carl Jung, Alfred Adler, and others developed new theories. Although the new theories departed from Freud’s ideas in important ways, each held on to Freud’s belief that human functioning is shaped by interacting psychological forces. Thus all such theories, including Freud’s, are referred to as psychodynamic.
Three of today’s most influential psychodynamic theories are ego theory, self theory, and object relations theory. Ego theorists emphasize the role of the ego and consider it a more independent and powerful force than Freud did. Self theorists, in contrast, give greatest attention to the role of the self—the unified personality—and believe that the basic human motive is to strengthen the wholeness of the self. Object relations theorists propose that people are motivated mainly by a need to have relationships with others and that severe problems in the relationships between children and their caregivers may lead to abnormal development.
Psychodynamic therapies range from Freudian psychoanalysis to modern therapies based on self theory or object relations theory. All seek to uncover past traumas and the inner conflicts that have resulted from them. All try to help clients resolve, or settle, those conflicts and to resume personal development.
According to most psychodynamic therapists, therapists must subtly and slowly guide the explorations so that the patients discover their underlying problems for themselves. To aid in the process, the therapists rely on such techniques as free association, therapist interpretation, catharsis, and working through.
Free Association In psychodynamic therapies, the patient is responsible for starting and leading each discussion. The therapist tells the patient to describe any thought, feeling, or image that comes to mind, even if it seems unimportant. This practice is known as free association. The therapist expects that the patient’s associations will eventually uncover unconscious events and underlying dynamics. Notice how free association helps this New Yorker to discover threatening impulses and conflicts within herself:
Therapist Interpretation Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative conclusions, and sharing interpretations when they think the patient is ready to hear them. Interpretations of three phenomena are particularly important—resistance, transference, and dreams.
Patients are showing resistance, an unconscious refusal to participate fully in therapy, when they suddenly cannot free associate or when they change a subject to avoid a painful discussion. They demonstrate transference when they act and feel toward the therapist as they did or do toward important persons in their lives, especially their parents, siblings, and spouses. Consider again the woman who walked in Central Park. As she continues talking, the therapist helps her to explore her transference:
Finally, many psychodynamic therapists try to help patients interpret their dreams. Freud (1924) called dreams the “royal road to the unconscious.” He believed that repression and other defense mechanisms operate less completely during sleep and that dreams, correctly interpreted, can reveal unconscious instincts, needs, and wishes. Freud identified two kinds of dream content, manifest and latent. Manifest content is the consciously remembered dream; latent content is its symbolic meaning. To interpret a dream, therapists must translate its manifest content into its latent content.
Catharsis Insight must be an emotional as well as intellectual process. Psychodynamic therapists believe that patients must experience catharsis, a reliving of past repressed feelings, if they are to settle internal conflicts and overcome their problems.
Working Through A single episode of interpretation and catharsis will not change a person. The patient and therapist must examine the same issues over and over in the course of many sessions, each time with greater clarity. This process, called working through, usually takes a long time, often years.
Short-Term Psychodynamic Therapies In several short versions of psychodynamic therapy, developed over the past few decades, patients choose a single problem—a dynamic focus—to work on, such as difficulty getting along with other people. The therapist and patient focus on this problem throughout the treatment and work only on the psychodynamic issues that relate to it (such as unresolved oral needs). Only a limited number of studies have tested the effectiveness of these short-term psychodynamic therapies, but their findings do suggest that the approaches are sometimes quite helpful to patients.
Assessing the Psychodynamic Model
Freud and his followers have helped change the way abnormal functioning is understood. Largely because of their work, a wide range of theorists today look for answers and explanations outside biological processes. Psychodynamic theorists have also helped us to understand that abnormal functioning may be rooted in the same processes as normal functioning. Psychological conflict is a common experience; it leads to abnormal functioning only if the conflict becomes excessive.
Freud and his many followers have also had a monumental impact on treatment. They were the first to apply theory and techniques systematically to treatment. They were also the first to demonstrate the potential of psychological, as opposed to biological, treatment, and their ideas have served as starting points for many other psychological treatments.
At the same time, the psychodynamic model has shortcomings. Its concepts are hard to define and to research. Because processes such as id drives, ego defenses, and fixation are abstract and supposedly operate at an unconscious level, there is no way of knowing for certain if they are occurring. Not surprisingly, then, psychodynamic explanations and treatments have received limited research support, and psychodynamic theorists have been forced to rely largely on evidence provided by individual case studies. Nevertheless, 19 percent of today’s clinical psychologists identify themselves as psychodynamic therapists.
The Behavioral Model
Like psychodynamic theorists, behavioral theorists believe that our actions are determined largely by our experiences in life. However, the behavioral model concentrates entirely on behaviors, the responses an organism makes to its environment. Behaviors can be external (going to work, say) or internal (having a feeling or thought). In turn, behavioral theorists base their explanations and treatments on principles of learning, the processes by which behaviors change in response to the environment.
Many learned behaviors help people to cope with daily challenges and to lead happy, productive lives. However, abnormal behaviors also can be learned. Behaviorists who try to explain Philip Berman’s problems might view him as a man who has received improper training: he has learned behaviors that offend others and repeatedly work against him.
Whereas the psychodynamic model had its beginnings in the clinical work of physicians, the behavioral model began in laboratories where psychologists were running experiments on conditioning, simple forms of learning. The researchers manipulated stimuli and rewards, then observed how their manipulations affected their subjects’ responses.
During the 1950s, many clinicians became frustrated with what they viewed as the vagueness and slowness of the psychodynamic model. Some of them began to apply the principles of learning to the study and treatment of psychological problems. Their
efforts gave rise to the behavioral model of abnormality.
Behavioral Explanation for Abnormal Behavior
Learning theorists have identified several forms of conditioning, and each may produce abnormal behavior as well as normal behavior. In operant conditioning, for example, humans and animals learn to behave in certain ways as a result of receiving rewards—any satisfying consequences— whenever they do so. In modeling, individuals learn responses simply by observing other individuals and repeating their behaviors.
In a third form of conditioning, classical conditioning, learning occurs by temporal association. When two events repeatedly occur close together in time, they become fused in a person’s mind, and before long the person responds in the same way to both events. If one event produces a response of joy, the other brings joy as well; if one event brings feelings of relief, so does the other. A closer look at this form of conditioning illustrates how the behavioral model can account for abnormal functioning.
Abnormal behaviors, too, can be acquired by classical conditioning. Consider a young boy who is repeatedly frightened by a neighbor’s large German shepherd dog. Whenever the child walks past the neighbor’s front yard, the dog barks loudly and lunges at him, stopped only by a rope tied to the porch. In this situation, the boy’s parents are not surprised to discover that he develops a fear of dogs. They are stumped, however, by another intense fear the child displays, a fear of sand. They cannot understand why he cries whenever they take him to the beach and screams if sand even touches his skin.
Where did this fear of sand come from? Classical conditioning. It turns out that a big sandbox is set up in the neighbor’s front yard for the dog to play in. Every time the dog barks and lunges at the boy, the sandbox is there too. After repeated pairings of this kind, the child comes to fear sand as much as he fears the dog.
Behavioral therapy aims to identify the behaviors that are causing a person’s problems and then tries to replace them with more appropriate ones, by applying the principles of classical conditioning, operant conditioning, or modeling. The therapist’s attitude toward the client is that of teacher rather than healer. A person’s early life matters only for the clues it can provide to current conditioning processes.
Classical conditioning treatments, for example, may be used to change abnormal reactions to particular stimuli. Systematic desensitization is one such method, often applied in cases of phobia—a specific and unreasonable fear. In this step-by-step procedure, clients learn to react calmly instead of with fear to the objects or situations they dread. First, they are taught the skill of relaxation over the course of several sessions. Next, they construct a fear hierarchy, a list of feared objects or situations, starting with those that are less feared and ending with the ones that are most dreaded. Here is the hierarchy developed by a man who was afraid of criticism, especially about his mental stability:
1. Friend on the street: “Hi, how are you?”
2. Friend on the street: “How are you feeling these days?”
3. Sister: “You’ve got to be careful so they don’t put you in the hospital.”
4. Wife: “You shouldn’t drink beer while you are taking medicine.”
5. Mother: “What’s the matter, don’t you feel good?”
6. Wife: “It’s just you yourself, it’s all in your head.”
7. Service station attendant: “What are you shaking for?”
8. Neighbor borrows rake: “Is there something wrong with your leg? Your knees are shaking.”
9. Friend on the job: “Is your blood pressure okay?”
10. Service station attendant: “You are pretty shaky, are you crazy or something?”
Desensitization therapists next have their clients either imagine or actually confront each item on the hierarchy while in a state of relaxation. In step-by-step pairings of feared items and relaxation, clients move up the hierarchy until at last they can face every one of the items without experiencing fear. As we shall see in Chapter 4, research has shown systematic desensitization and other classical conditioning techniques to be effective in treating phobias.
Assessing the Behavioral Model
The number of behavioral clinicians has grown steadily since the 1950s, and the behavioral model has become a powerful force in the clinical field. Various behavioral theories have been proposed over the years, and many treatment techniques have been developed. Approximately 13 percent of today’s clinical psychologists report that their approach is mainly behavioral.
Perhaps the greatest appeal of the behavioral model is that it can be tested in the laboratory, whereas psychodynamic theories generally cannot. The behaviorists’ basic concepts—stimulus, response, and reward—can be observed and measured. Experimenters have in fact successfully used the principles of learning to create clinical symptoms in laboratory subjects, suggesting that psychological disorders may indeed develop in the same way. In addition, research has found that behavioral treatments can be helpful to people with specific fears, compulsive behavior, social deficits, mental retardation, and other problems.
At the same time, research has also revealed weaknesses in the model. Certainly behavioral researchers have produced specific symptoms in subjects. But are these symptoms ordinarily acquired in this way? There is still no indisputable evidence that most people with psychological disorders are victims of improper conditioning. Similarly, behavioral therapies have limitations. The improvements noted in the therapist’s office do not always extend to real life. Nor do they necessarily last without continued therapy.
Finally, some critics hold that the behavioral view is too simplistic, that its concepts fail to account for the complexity of human behavior. In 1977 the behaviorist Albert Bandura argued that in order to feel happy and function effectively people must develop a positive sense of self-efficacy. That is, they must have confidence that they can master and perform needed behaviors whenever necessary. Other behaviorists of the 1960s and 1970s similarly recognized that human beings engage in cognitive behaviors, such as anticipating or interpreting—ways of thinking that until then had been largely ignored in behavioral theory and therapy. These individuals developed cognitive-behavioral theories that took cognitive behaviors into greater account.
Cognitive-behavioral theorists bridge the behavioral model and the cognitive model, the view we turn to next. On the one hand, their explanations are based squarely on learning principles. They believe, for example, that cognitive processes are learned by classical conditioning, operant conditioning, and modeling. On the other hand, cognitive-behavioral theorists share with other kinds of cognitive theorists a belief that the ability to think is the most important aspect of human functioning.
The Cognitive Model
Philip Berman, like the rest of us, has cognitive abilities—special intellectual capacities to think, remember, and anticipate. These abilities can certainly help him in life. Yet they can also work against him. As he thinks about his experiences, Philip may misinterpret experiences in ways that lead to poor decisions, maladaptive responses, and painful emotions.
In the early 1960s two clinicians, Albert Ellis (1962) and Aaron Beck (1967), proposed that cognitive processes are at the center of behavior, thought, and emotions and that we can best understand abnormal functioning by looking to cognition—a perspective known as the cognitive model. Ellis and Beck claimed that clinicians must ask questions about the assumptions and attitudes that color a client’s perceptions, the thoughts running through that person’s mind, and the conclusions they are leading to. Other theorists and therapists soon embraced and expanded their ideas and techniques.
Cognitive Explanation of Abnormal Behavior
To cognitive theorists, we are all artists. We reproduce and create the world in our
minds as we try to understand the events going on around us. If we are effective
artists, our cognitions tend to be accurate (they agree with the perceptions of others).
If we are ineffective artists, we may create a cognitive inner world that is
painful and harmful to ourselves.
Abnormal functioning can result from several kinds of cognitive problems. Some people may make assumptions and adopt attitudes that are disturbing and inaccurate. Philip Berman, for example, often seems to assume that his past history has locked him in his present situation. He believes that he was victimized by his parents and that he is now forever doomed by his past. He seems to approach all new experiences and relationships with expectations of failure and disaster.
Illogical thinking processes are another source of abnormal functioning, according to cognitive theorists. Beck, for example, has found that some people consistently think in illogical ways and keep arriving at self-defeating conclusions. As we shall see in Chapter 7, he has identified a number of illogical thought processes regularly found in depression, such as overgeneralization, the drawing of broad negative conclusions on the basis of a single insignificant event. One depressed student couldn’t remember the date of Columbus’s third voyage to America during a history class. Overgeneralizing, she spent the rest of the day in despair over her general ignorance.
According to cognitive therapists, people with psychological disorders can overcome their problems by developing new, more functional ways of thinking. Because different forms of abnormality may involve different kinds of cognitive dysfunctioning, cognitive therapists have developed a number of strategies. Beck, for example, has developed an approach that is widely used in cases of depression.
In Beck’s approach, called simply cognitive therapy, therapists help clients recognize the negative thoughts, biased interpretations, and errors in logic that dominate their thinking and, according to Beck, cause them to feel depressed. Therapists also guide clients to challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply the new ways of thinking in their daily lives. As we shall see in Chapter 7, people with depression who are treated with Beck’s approach improve much more than those who receive no treatment.
In the excerpt that follows, a cognitive therapist guides a 26-year-old graduate student who is experiencing depression to see the tie between the way she interprets her experiences and the way she feels and to begin questioning the accuracy of her interpretations:
Assessing the Cognitive Model
The cognitive model has had broad appeal. In addition to the behaviorists who now include cognitive concepts in their theories about learning, there are many clinicians who believe that thinking processes are in fact much more than conditioned reactions. Cognitive theory, research, and treatments have developed in so many interesting ways that the model is now viewed as separate from the behavioral school that gave birth to it.
Approximately 24 percent of today’s clinical psychologists identify their approach as cognitive. There are several reasons for the model’s popularity. First, it focuses on a process unique to human beings—the process of human thought—and many theorists from varied backgrounds find themselves drawn to a model that sees this unique process as the primary cause of normal and abnormal behavior.
Cognitive theories also lend themselves to research. Investigators have found that people with psychological disorders often make the kinds of assumptions and errors in thinking the theorists claim. Yet another reason for the popularity of this model is the impressive performance of cognitive therapies. They have proved very effective for treating depression, panic disorder, and sexual dysfunctions, for example.
Nevertheless, the cognitive model, too, has its drawbacks. First, although disturbed cognitive processes are found in many forms of abnormality, their precise role has yet to be determined. The cognitions seen in psychologically troubled people could well be a result rather than a cause of their difficulties. Second, although cognitive therapies are clearly of help to many people, they do not help everyone. Is it enough to change the cognitive habits of a person with a serious psychological dysfunction? Can such specific changes make a lasting difference in the way the person feels and behaves?
Furthermore, like the other models we have examined, the cognitive model is narrow in certain ways. Although cognition is a very special human dimension, it is still only one part of human functioning. Aren’t human beings more than the sum total of their thoughts, emotions, and behaviors? Shouldn’t explanations of human functioning also consider broader issues such as how people approach life, what value they get from it, and how they deal with the question of life’s meaning? This is the position of the humanistic-existential perspective.
The Humanistic-Existential Model
Philip Berman is more than the sum of his psychological conflicts, learned behaviors, or cognitions. Being human, he also has the ability to pursue philosophical goals such as self-awareness, strong values, a sense of meaning in life, and freedom of choice. According to humanistic and existential theorists, Philip’s problems can be understood only in the light of such complex goals. Humanistic and existential theorists are usually grouped together—in an approach known as the humanistic-existential model—because of their common focus on these broader dimensions of human existence. At the same time, there are important differences between them.
Humanists, the more optimistic of the two groups, believe that human beings are born with a natural tendency to be friendly, cooperative, and constructive. People, these theorists propose, are driven to self-actualize—that is, to fulfill this potential for goodness and growth. They can do so, however, only if they honestly recognize and accept their weaknesses as well as their strengths and establish satisfying personal values to live by. Humanists further suggest that self-actualization leads naturally to a concern for the welfare of others and to behavior that is loving, courageous, spontaneous, and independent.
Existentialists agree that human beings must have an accurate awareness of themselves and live meaningful—they say “authentic”—lives in order to be psychologically well adjusted. These theorists do not believe, however, that people are naturally inclined to live positively. They believe that from birth we have total freedom, either to face up to our existence and give meaning to our lives or to shrink from that responsibility. Those who decide to “hide” from responsibility and choice will view themselves as helpless and weak and may live empty, inauthentic, and dysfunctional lives as a result.
The humanistic and existential views of abnormality both date back to the 1940s. At that time Carl Rogers, often considered the pioneer of the humanistic perspective, developed client-centered therapy, a warm and supportive approach that contrasted sharply with the psychodynamic techniques of the day. He also proposed a theory of personality that paid little attention to irrational instincts and conflicts.
The existential view of personality and abnormality appeared during this same period. Many of its principles came from the ideas of nineteenth-century European existential philosophers who held that human beings are constantly defining and so giving meaning to their existence through their actions. In the late 1950s a book titled Existence described a number of major existential ideas and treatment approaches and helped them gain recognition.
The humanistic and existential theories and their uplifting implications were extremely popular during the 1960s and 1970s, years of considerable soul-searching and social upheaval in Western society. They have since lost some of their popularity, but they continue to influence the ideas and work of many clinicians.
Rogers’s Humanistic Theory and Therapy
According to Carl Rogers, the road to dysfunction begins in infancy. We all have a basic need to receive positive regard from the important people in our lives (primarily our parents). Those who receive unconditional (nonjudgmental) positive regard early in life are likely to develop unconditional self-regard. That is, they come to recognize their worth as persons, even while recognizing that they are not perfect. Such people are in a good position to actualize their positive potential.
Unfortunately, some children are repeatedly made to feel that they are not worthy of positive regard. As a result, they acquire conditions of worth, standards that tell them they are lovable only when they conform to certain guidelines. In order to maintain positive self-regard, these people have to look at themselves very selectively, denying or distorting thoughts and actions that do not measure up to their conditions of worth. They thus acquire a distorted view of themselves and their experiences. They do not know what they are truly feeling, what they genuinely need, or what values and goals would be meaningful for them. Problems in functioning are then inevitable.
Rogers might view Philip Berman as a man who has gone astray. Rather than striving to fulfill his positive human potential, he drifts from job to job and relationship to relationship. In every interaction he is defending himself, trying to interpret events in ways he can live with, usually blaming his problems on other people. Nevertheless, his basic negative self-image continually reveals itself. Rogers would probably link this problem to the critical ways Philip was treated by his mother throughout his childhood.
Clinicians who practice Rogers’s client-centered therapy try to create a supportive climate in which clients feel able to look at themselves honestly and acceptingly. The therapist must display three important qualities throughout the therapy—unconditional positive regard (full and warm acceptance of the client), accurate empathy (skillful listening and restatements), and genuineness (sincere communication). The following interaction shows the therapist using these three qualities to move the client toward greater self-awareness:
In such an atmosphere, persons are expected to feel accepted by their therapists. They then may be able to look at themselves with honesty and acceptance—a process called experiencing. That is, they begin to value their own emotions, thoughts, and behaviors, and so they are freed from the insecurities and doubts that prevent self-actualization.
Client-centered therapy has not fared very well in research. Although some studies show that people who receive this therapy improve more than control subjects, many other studies have failed to find any such advantage. All the same, Rogers’s therapy has had a positive influence on clinical practice. It was one of the first major alternatives to psychodynamic therapy, and it helped open up the field to new approaches. Rogers also helped pave the way for psychologists to practice psychotherapy; it had previously been considered the territory of psychiatrists. And his commitment to clinical research helped promote the systematic study of treatment. Approximately 1 percent of today’s clinical psychologists, 2 percent of social workers, and 4 percent of counseling psychologists report that they employ the client-centered approach.
Gestalt Theory and Therapy
Gestalt therapy, another humanistic approach, was developed in the 1950s by a charismatic clinician named Frederick (Fritz) Perls (1893–1970). Gestalt therapists, like client-centered therapists, guide their clients toward self-recognition and self-acceptance. But unlike client-centered therapists, they often try to achieve this goal by challenging and even frustrating their clients. Some of Perls’s favorite techniques were skillful frustration, role-playing, and numerous rules and exercises.
In the technique of skillful frustration, gestalt therapists refuse to meet their clients’ expectations or demands. This use of frustration is meant to help people see how often they try to manipulate others into meeting their needs. In the technique of role-playing, the therapists instruct clients to act out various roles. A person may be told to be another person, an object, an alternative self, or even a part of the body. Role-playing can become intense, as individuals are encouraged to fully express emotions. Many cry out, scream, kick, or pound. Through this experience they may come to “own” (accept) feelings that previously made them uncomfortable.
Perls also developed a list of rules to ensure that clients will look at themselves more closely. In some versions of gestalt therapy, for example, clients may be required to use “I” language rather than “it” language. They must say, “I am frightened” rather than “The situation is frightening.” Yet another common rule requires clients to stay in the here and now. They have needs now, are hiding their needs now, and must observe them now.
Approximately 1 percent of clinical psychologists and other kinds of clinicians describe themselves as gestalt therapists. Because they believe that subjective experiences and self-awareness cannot be measured objectively, controlled research has not often been done on the gestalt approach.
Spiritual Views and Interventions
For most of the twentieth century, clinical scientists viewed religion as a negative—or at best neutral—factor in mental health. In the early 1900s, for example, Freud argued that religious beliefs were defense mechanisms, “born from man’s need to make his helplessness tolerable” (1961, p. 23). Subsequently, clinical theorists proposed that people with strong religious beliefs were more suspicious, irrational, guilt-ridden, and unstable than others, and less able to cope with life’s difficulties. Correspondingly, spiritual principles and issues were considered a taboo topic in most forms of therapy.
The division between the clinical field and religion now seems to be ending. During the past decade, many articles and books linking spiritual issues to clinical treatment have been published, and the ethical codes of psychologists, psychiatrists, and counselors now state that religion is a type of diversity that mental health professionals are obligated to respect. Researchers have learned that spirituality can, in fact, be of psychological benefit to people. In particular, studies have examined the mental health of people who are devout and who view God as warm, caring, helpful, and dependable. Repeatedly, these persons are found to be less lonely, pessimistic, depressed, or anxious than people without any religious beliefs or those who view God as cold and unresponsive. Such individuals also seem to cope better with major life stresses—from illness to war—and to attempt suicide less often. In addition, they are less likely to abuse drugs.
In line with such findings, many therapists now make a point of focusing on spiritual issues when treating religious clients. At the very least, they try to respect how religious beliefs and values are affecting their clients’ psychological functioning and to include such beliefs in their therapy discussions. Some therapists further encourage clients to use their spiritual resources to help them cope with current stresses.
Existential Theories and Therapy
Like humanists, existentialists believe that psychological dysfunctioning is caused by self-deception; but existentialists are talking about a kind of self-deception in which people hide from life’s responsibilities and fail to recognize that it is up to them to give meaning to their lives. According to existentialists, many people become overwhelmed by the pressures of present-day society and so look to others for guidance and authority. They overlook their personal freedom of choice and avoid responsibility for their lives and decisions. Such people are left with empty, inauthentic lives. Their dominant emotions are anxiety, frustration, boredom, alienation, and depression.
Existentialists might view Philip Berman as a man who feels overwhelmed by the forces of society. He sees his parents as “rich, powerful, and selfish,” and he perceives teachers, acquaintances, and employers as abusive and oppressing. He fails to appreciate his choices in life and his capacity for finding meaning and direction. Quitting becomes a habit with him—he leaves job after job, ends every romantic relationship, and flees difficult situations.
In existential therapy people are encouraged to accept responsibility for their lives and for their problems. They are helped to recognize their freedom so that they may choose a different course and live with greater meaning. For the most part, existential therapists care more about the goals of therapy than the use of specific techniques; methods vary greatly from clinician to clinician. At the same time, most do place great emphasis on the relationship between therapist and client and try to create an atmosphere of candor, hard work, and shared learning and growth.
Existential therapists do not believe that experimental methods can adequately test the effectiveness of their treatments. To them, research dehumanizes individuals by reducing them to test measures. Not surprisingly, then, very little controlled research has been devoted to the effectiveness of this approach. Nevertheless, around 3 percent of today’s therapists use an approach that is primarily existential.
Assessing the Humanistic-Existential Model
The humanistic-existential model appeals to many people in and out of the clinical field. In recognizing the special challenges of human existence, humanistic and existential theorists tap into an aspect of psychological life that is typically missing from the other models. Moreover, the factors that they say are critical to effective functioning—self-acceptance and personal values, meaning, and choice—are certainly lacking in many people with psychological disturbances.
The optimistic tone of the humanistic-existential model is also an attraction. Proponents of these principles offer great hope when they claim that despite past and present events, we can make our own choices, determine our own destiny, and accomplish much. Still another attractive feature of the model is its emphasis on health. Unlike clinicians from some of the other models who see individuals as patients with psychological illnesses, humanists and existentialists view them simply as people whose special potential has yet to be fulfilled.
At the same time, the humanistic-existential focus on abstract issues of human fulfillment gives rise to a major problem from a scientific point of view: such issues are difficult to research. In fact, with the notable exception of Rogers, who tried to carefully investigate his clinical methods, humanists and existentialists have traditionally rejected the use of empirical research. This anti-research position is just now beginning to change. Humanistic researchers have conducted several recent studies that use appropriate control groups and statistical analyses, and they have found that such therapies can be beneficial in some cases. This newfound interest in humanistic research and the clinical field’s growing concern with religious issues should lead to important insights about this model in the coming years.
The Sociocultural Model
Philip Berman is also a social being. He is surrounded by people and by institutions, he is a member of a family and a society, and he takes part in both social and professional relationships. Thus social forces are always operating upon Philip, setting rules and expectations that guide or pressure him, helping to shape his behavior, thoughts, and emotions.
According to the sociocultural model, abnormal behavior is best understood in light of the social and cultural forces that influence an individual. What are the norms of the society? What roles does the person play in the social environment? What kind of cultural background or family structure is the person a part of? And how do other people view and react to him or her?
Sociocultural Explanation of Abnormal Behavior
Because behavior is shaped by social forces, sociocultural theorists hold, we must examine a person’s social and cultural surroundings if we are to understand abnormal behavior. Sociocultural explanations focus on family structure and communication, cultural influences, social networks, societal conditions, and societal labels and roles.
Family Structure and Communication According to family systems theory, the family is a system of interacting parts—the family members—who relate to one another in consistent ways and follow rules unique to each family. Family systems theorists believe that the structure and communication patterns of some families actually force individual members to behave in a way that otherwise seems abnormal. If the members were to behave normally, they would severely strain the family’s usual manner of operation and would actually increase their own and their family’s turmoil.
Family systems theory holds that certain family systems are particularly likely to produce abnormal functioning in individual members. Some families, for example, have an enmeshed structure in which the members are grossly overinvolved in each other’s activities, thoughts, and feelings. Children from this kind of family may have great difficulty becoming independent in life. Some families display disengagement, which is marked by very rigid boundaries between the members. Children from these families may find it hard to function in a group or to give or request support.
In the sociocultural model, Philip Berman’s angry and impulsive personal style might be seen as the product of a disturbed family structure. According to family systems theorists, the whole family—mother, father, Philip, and his brother Arnold—relate in such a way as to maintain Philip’s behavior. Family theorists might be particularly interested in the conflict between Philip’s mother and father and the imbalance between their parental roles. They might see Philip’s behavior as both a reaction to and stimulus for his parents’ behaviors. With Philip acting out the role of the misbehaving child, or scapegoat, his parents may have little time to question their own relationship.
Family systems theorists would also seek to clarify the precise nature of Philip’s relationship with each parent. Is he enmeshed with his mother and/or disengaged from his father? They would look too at the rules governing the sibling relationship in the family, the relationship between the parents and Philip’s brother, and the nature of parent–child relationships in previous generations of the family.
Culture “Culture” refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next. During the past two decades, sociocultural researchers have greatly increased their focus on possible ties between culture and abnormal behavior. They have learned that some of the disorders we shall be coming across in this textbook—anorexia nervosa, for example—are much less common in non-Western countries. It may be that key Western values—such as favoring a thin appearance —help set the stage for such disorders.
Social Networks and Supports Sociocultural theorists are also concerned with the social networks in which people operate, including their social and professional relationships. How well do they communicate with others? What kind of signals do they send to or receive from others? Researchers have often found ties between deficiencies in social networks and a person’s functioning. They have noted, for example, that people who are isolated and lack social support or intimacy in their lives are more likely to become depressed when under stress and to remain depressed longer than are people with supportive spouses or warm friendships.
Societal Conditions Wide-ranging societal conditions may create special stresses and increase the likelihood of abnormal functioning in some members. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is more common in the lower socioeconomic classes than in the higher ones. Perhaps the special pressures of lower-class life explain this relationship. That is, the higher rates of crime, unemployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities of lower-class life may place great stress on members of these groups.
Sociocultural researchers have noted that racial and sexual prejudice may also contribute to certain forms of abnormal functioning. Women in Western society receive diagnoses of anxiety and depressive disorders at least twice as often as men. Similarly, African Americans experience unusually high rates of anxiety disorders. Hispanic persons, particularly young men, have higher rates of alcoholism than members of most other ethnic groups. And Native Americans display exceptionally high alcoholism and suicide rates. Although many factors may combine to produce these differences, racial and sexual prejudice and the problems they pose may contribute to abnormal patterns of tension, unhappiness, low self-esteem, and escape.
Societal Labels and Roles Sociocultural theorists also believe that abnormal functioning is influenced greatly by the labels and roles assigned to troubled people. When people stray from the norms of their society, the society calls them deviant and, in many cases, “mentally ill.” Such labels tend to stick. Moreover, when people are viewed in particular ways, reacted to as “crazy,” and perhaps even encouraged to act sick, they gradually learn to play the assigned role. Ultimately the label seems appropriate.
A famous study by the clinical investigator David Rosenhan (1973) supports this position. Eight normal people presented themselves at various mental hospitals, complaining that they had been hearing voices say the words “empty,” “hollow,”
and “thud.” On the basis of this complaint alone, each was diagnosed as having schizophrenia and admitted. As the sociocultural model would predict, the “pseudopatients” had a hard time convincing others that they were well once they had been given the diagnostic label. Their hospitalizations ranged from 7 to 52 days, even though they behaved normally as soon as they were admitted. In addition, the label kept influencing the way the staff viewed and dealt with them. For example, one pseudopatient who paced the corridor out of boredom was, in clinical notes, described as “nervous.” Overall, the pseudopatients came to feel powerless, invisible, and bored.
Sociocultural theories have helped spur the growth of several treatment approaches, including culture-sensitive therapy, group therapy, family and couple therapy, and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models. In such instances the therapy approach is not purely sociocultural. However, more and more of the clinicians who use these formats believe that psychological problems emerge in a social setting and are best treated in such a setting, and they include special sociocultural strategies in their work.
Culture-Sensitive Therapy A number of recent studies have found that many members of ethnic and racial minority groups improve less in clinical treatment than members of majority groups. Similarly, studies conducted throughout the world have found that minority clients use mental health services less often than members of majority groups. In some cases, cultural beliefs, a language barrier, or lack of information about available services may prevent minority individuals from seeking help; in other cases, such persons may not trust the establishment, relying instead on traditional remedies that are available in their immediate social environment.
Research also indicates that members of minority groups stop therapy sooner than persons from majority groups. In the United States, African Americans, Native Americans, Asian Americans, and Hispanic Americans all have higher therapy dropout rates than white Americans. Members of these groups may stop treatment because they do not feel they are benefiting from it or because ethnic and racial differences prevent the development of a strong rapport with their therapist.
How can clinicians be more helpful to people from minority groups? A number of studies suggest that two features of treatment can increase a therapist’s effectiveness with minority clients: (1) greater therapist sensitivity to cultural issues and (2) inclusion of cultural morals and models in treatment, especially in therapies for children and adolescents. Given such findings, clinicians have developed culture-sensitive therapies, approaches that seek to address the unique issues faced by members of minority groups. Similarly, some clinicians have developed therapies geared to the special pressures of being a woman in Western society, called gender-sensitive or feminist therapies.
Group Therapy Thousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. Indeed, one survey of clinical psychologists revealed that almost one-third of them devoted some portion of their practice to group therapy. Typically, members of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice. Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.
Research suggests that group therapy is of help to many clients, often as helpful as individual therapy. The group format has also been used for purposes that are educational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.
A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (bereavement, substance abuse, illness, unemployment, divorce) come together to help and support one another without the direct leadership of a professional clinician. According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by 3 to 4 percent of the population. Indeed, it is estimated that 25 million Americans will participate in self-help groups at some point in their lives. Self-help groups tend to offer more direct advice than is provided in group therapy and to encourage more exchange of information or “tips.”
Family Therapy Family therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change. Here the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:
Family therapists may follow any of the major theoretical models, but more and more of them are adopting the sociocultural principles of family systems theory. Today 4 percent of all clinical psychologists, 13 percent cent of social workers, and 1 percent of psychiatrists identify themselves mainly as family systems therapists.
As we observed earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, structural family therapy, therapists try to change the family power structure, the role each person plays, and the alliances between members. In another, conjoint family therapy, therapists try to help members change harmful patterns of communication.
Family therapies of various kinds are often helpful to individuals, although research has not yet clarified how helpful. Some studies have found that as many as 65 percent of individuals treated with family approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others.
Couple Therapy In couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns occurring in the relationship. A couple approach may also be used when a child’s psychological problems are traced to problems that may exist between the parents.
Although some degree of conflict exists in any long-term relationship, many adults in our society experience serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate. Many couples who live together without marrying apparently have similar levels of difficulty.
Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Behavioral couple therapy, for example, uses many techniques from the behavioral perspective. Therapists help spouses recognize and change problem behaviors largely by teaching specific problem-solving and communication skills. A broader, more sociocultural version, called integrative couple therapy, further helps partners accept behaviors that they cannot change and embrace the whole relationship nevertheless. Partners are asked to see such behaviors as an understandable result of basic differences between them.
Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who fail to receive treatment, but no one form of couple therapy stands out as superior to others. Although two-thirds of treated couples experience improved marital functioning by the end of therapy, fewer than half of those who are treated achieve “distress-free” or “happy” relationships. Moreover, one-third of successfully treated couples may relapse within two years after therapy. Couples who are younger, well adjusted, and less rigid in their gender roles tend to have the best results.
Community Treatment Following sociocultural principles, community mental health treatment programs allow clients, particularly those with severe psychological difficulties, to receive treatment in familiar surroundings as they try to recover. In 1963 President Kennedy called for such a “bold new approach” to the treatment of mental disorders—a community approach that would enable most people with psychological problems to receive services from nearby agencies rather than distant facilities or institutions. Congress passed the Community Mental Health Act soon after, launching the community mental health movement across the United States. A number of other countries have launched similar movements.
As we observed in Chapter 1, a key principle of community treatment is prevention. Here clinicians actively reach out to clients rather than wait for them to seek treatment. Research suggests that such efforts are often very successful. Community workers recognize three types of prevention, which they call primary, secondary, and tertiary.
Primary prevention consists of efforts to improve community attitudes and policies. Its goal is to prevent psychological disorders altogether. Community workers may lobby for better community recreational programs, consult with a local school board, or offer public workshops on stress reduction.
Secondary prevention consists of identifying and treating psychological disorders in the early stages, before they become serious. Community workers may work with schoolteachers, ministers, or police to help them recognize the early signs of psychological dysfunction and teach them how to help people find treatment.
The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Today community agencies across the United States do successfully offer tertiary care for millions of people with moderate psychological problems, but, as we observed in Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances. One of the reasons for this failure is lack of funding, an issue that we shall return to in later chapters .
Assessing the Sociocultural Model
The sociocultural model has added greatly to the understanding and treatment of abnormal functioning. Today most clinicians take family, cultural, social, and societal issues into account, factors that were overlooked just 30 years ago. In addition, clinicians have become more aware of the impact of clinical and social labels. Finally, as we have just observed, sociocultural treatment formats sometimes succeed where traditional approaches have failed.
At the same time, the sociocultural model, like the other models, has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Research may reveal a relationship between certain sociocultural factors and a particular disorder yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not necessarily mean that family dysfunction causes schizophrenia. It is equally possible that family functioning is disrupted by the tension created by the schizophrenic behavior of a family member.
Another limitation of the model is its inability to predict abnormality in specific individuals. For example, if societal conditions such as prejudice are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?
Given these limitations, most clinicians view sociocultural explanations as operating in conjunction with biological or psychological explanations. They agree that sociocultural factors may create a climate favorable to the development of certain disorders. They believe, however, that biological or psychological conditions or both must also be present in order for the disorders to spring forth.