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The Scientific Method Ethics in Research Naturalistic Observation The Correlational Method The Experimental Method Epidemiological Studies Kinship Studies Case Studies SUMMING UP 32–
Asylums The Reform Movement and Moral Therapy A Step Backward The Community Mental Health Movement: The Exodus from State Hospitals Contemporary Perspectives on Abnormal Behavior RESEARCH METHODS IN ABNORMAL PSYCHOLOGY 18– Description, Explanation, Prediction, and Control: The Objectives of Science
C H A P TE R O UTLI N E
HOW DO WE DEFINE ABNORMAL BEHAVIOR? 6– Criteria for Determining Abnormality Cultural Bases of Abnormal Behavior HISTORICAL PERSPECTIVES ON ABNORMAL BEHAVIOR 10– The Demonological Model Origins of the Medical Model: In “Ill Humor” Medieval Times Witchcraft
Introduction and Methods
1 of Research
or F I C T I O N
T ❑ F ❑ Psychological disorders affect relatively few Americans. (p. 4) T ❑ F ❑ Although effective treatments exist for some psychological disorders, we still lack the means of effectively treating most types of psychological disorders. (p. 5) T ❑ F ❑ Unusual behavior is abnormal. (p. 6) T ❑ F ❑ Psychological problems like depression may be experienced differently by people in different cultures. (p. 9) T ❑ F ❑ A night’s entertainment in London a few hundred years ago might have included gaping at the inmates at the local asylum. (p. 12) T ❑ F ❑ Despite changing attitudes in society toward homosexuality, the psychiatric profession continues to classify homosexuality as a mental disorder. (p. 17) T ❑ F ❑ Recent evidence shows there are literally millions of genes in the nucleus of every cell in the body. (p. 26) T ❑ F ❑ Case studies have been conducted on dead people. (p. 28)
T R U T H or
I never thought I’d ever see a psychologist or someone like that, you know. I’m a police photographer and I’ve shot some pretty grisly stuff, corpses and all. Crime scenes are not like what you see on TV. They’re more grisly. I guess you kind of get used to it. It never bothered me, just maybe at first. Before I did this job, I worked on a TV news chopper. We would take shots of fires and rescues, you know. Now I get uptight sitting in the back seat of car or riding an elevator. I’ll avoid taking an elevator unless I really have no other choice. Forget flying anymore. It’s not just helicopters. I just won’t go in a plane, any kind of plane. I guess I was younger then and more daring when I was younger. Sometimes I would hang out of the helicopter to shoot pictures with no fear at all. Now, just thinking about flying makes my heart race. It’s not that I’m afraid the plane will crash. That’s the funny thing. Not ha-ha funny, but peculiar, you know. I just start trembling when I think of them closing that door, trapping us inside. I can’t tell you why.
—Phil, 42, a police photographer
Source: From the Author’s Files
“Pretty Grisly Stuff”
When I start going into a high, I no longer feel like an ordinary housewife. Instead I feel organized and accomplished and I begin to feel I am my most creative self. I can write poetry easily. I can compose melodies without effort. I can paint. My mind feels facile and absorbs everything. I have countless ideas about improving the conditions of mentally retarded children, of how a hospital for these children should be run, what they should have around them to keep them happy and calm and unafraid. I see myself as being able to accomplish a great deal for the good of people. I have countless ideas about how the environment prob- lem could inspire a crusade for the health and betterment of everyone. I feel able to accomplish a great deal for the good of my family and others. I feel pleasure, a sense of euphoria or elation. I want it to last forever. I don’t seem to need much sleep. I’ve lost weight and feel healthy and I like myself. I’ve just bought six new dresses, in fact, and they look quite good on me. I feel sexy and men stare at me. Maybe I’ll have an affair, or perhaps several. I feel capable of speaking and doing good in politics. I would like to help people with problems similar to mine so they won’t feel hopeless. It’s wonderful when you feel like this.... The feeling of exhilaration—the high mood—makes me feel light and full of the joy of living. However, when I go beyond this stage, I become manic, and the creativeness becomes so magnified I begin to see things in my mind that aren’t real. For instance, one night I created an entire movie, complete with cast, that I still think would be terrific. I saw the people as clearly as if watching them in real life. I also experienced complete terror, as if it were actually happening, when I knew that an assassination scene was about to take place. I cowered under the covers and became a complete shaking wreck.... My screams awakened my husband, who tried to reassure me that we were in our bedroom and everything was the same. There was nothing to be afraid of. Nevertheless, I was admitted to the hospital the next day. —A firsthand account of a 45-year-old woman with bipolar disorder Source: Fieve, 1975, pp. 27–
Cowering Under the Covers
Introduction and Methods of Research 5
Let us pause for a moment to raise an important distinction. Although the terms psychological disorder and mental disorder are often used interchangeably, we prefer using the term psychological disorder. The major reason is that the term psychological disorder puts the study of abnormal behavior squarely within the purview of the field of psychology. Moreover, the term mental disorder (also called mental illness ) is derived from the medical model perspective that views abnormal behavior patterns as symp- toms of underlying illness. Although the medical model is a major contemporary model for understanding abnormal behavior, we believe we need to take a broader view of abnormal behavior by incorporating psychological and sociocultural perspec- tives as well.
Surgeon General’s Report on Mental Health The U.S. Surgeon General issued a report at the turn of the new millennium that is still pertinent today in terms of focusing the nation’s attention on problems of mental health. Here are some key conclusions from the report (Satcher, 2000; USDHHS, 1999b):
- Mental health reflects the complex interaction of brain functioning and environmen- tal influences.
- Effective treatments exist for most mental disorders, including psychological interventions such as psychotherapy and counseling and psychopharmacologic or drug therapies. Treatment is often more effective when psychological and psychopharmacological treatments are combined.
- Progress in developing effective prevention programs in the mental health field has been slow because we do not know the causes of mental disorders or ways of altering known influences, such as genetic predispositions. Nonetheless, some effective preven- tion programs have been developed.
- Although 15% of American adults receive some form of help for mental health prob- lems each year, many who need help do not receive it.
Percentage with Disorders
50
40
30
20
10
0 Mood Disorders
Anxiety Disorders
Substance Use Disorders
Any Disorders
Past Year Lifetime
FIGURE 1.1 Lifetime and past-year prevalences of psychological disorders. This graph is based on a nationally representative sample of 9,282 English-speaking U.S. residents aged 18 and older. Here we see percentages of individuals with diagnosable psychological disorders either during the past year or at some point in their lives for several major diagnostic categories. The mood disorders category includes major depressive episode, manic episode, and dysthymia (discussed in Chapter 8). Anxiety disorders include panic disorder, agoraphobia without panic disorder, social phobia, specific phobia, and generalized anxiety disorder (discussed in Chapter 6). Substance use disorders include abuse or dependence disorders involving alcohol or other drugs (discussed in Chapter 9).
Source: Kessler, Chiu, et al., 2005a; Kessler, Kessler, Demler, et al., 2005b.
Although effective treatments exist for some psychological disorders, we still lack the means of effectively treating most types of psychological disorders. ❑ FALSE. The good news is that effective treat- ments exist for most psychological disorders.
✓
T R U T H or F I C T I O N
medical model A biological perspective in which abnormal behavior is viewed as symptomatic of underlying illness.
[ [ E
6 Chapter 1
- Mental health problems are best understood when we take a broader view and consider the social and cultural contexts in which they occur.
- Mental health services need to be designed and delivered in a manner that takes into account the viewpoints and needs of racial and ethnic minorities. The Surgeon General’s report provides a backdrop for our study of abnormal psychology. As we shall see throughout the text, we believe that understandings of abnormal behav- ior are best revealed through a lens that takes into account interactions of biological and environmental factors. We also believe that social and cultural (or sociocultural ) factors need to be considered in the attempt to both understand abnormal behavior and develop effective treatment services. In this chapter we first address the difficulties of defining abnormal behavior. We see that throughout history, abnormal behavior has been viewed from different perspectives. We chronicle the development of concepts of abnormal behavior and its treatment. We see that in the past, treatment usually referred to what was done to, rather than for, people with abnormal behavior. We then describe the ways in which psychologists and other scholars study abnormal behavior today. ■
HOW DO WE DEFINE ABNORMAL BEHAVIOR?
We all become anxious or depressed from time to time, but is this abnormal? Becoming anx- ious in anticipation of an important job interview or a final examination is perfectly normal. It is appropriate to feel depressed when you have lost someone close to you or when you have failed at a test or on the job. So, where is the line between normal and abnormal behavior? One answer is that emotional states such as anxiety and depression may be considered abnormal when they are not appropriate to the situation. It is normal to feel down when you fail a test, but not when your grades are good or excellent. It is normal to feel anxious before a college admissions interview, but not to panic before entering a department store or boarding a crowded elevator. Abnormality may also be suggested by the magnitude of the problem. Although some anxiety is normal enough before a job interview, feeling that your heart might leap from your chest—and consequently canceling the interview—is not. Nor is it normal to feel so anxious in this situation that your clothing becomes soaked with perspiration.
Criteria for Determining Abnormality
Mental health professionals apply various criteria in making judgments about whether behavior is abnormal. The most commonly used criteria include the following:
1. Unusualness. Behavior that is unusual is often considered abnormal. Only a few of us report seeing or hearing things that are not really there; “seeing things” and “hearing things” are almost always considered abnormal in our culture, except, perhaps, in the case of certain types of religious experiences (USDHHS, 1999a). Moreover, “hearing voices” and other forms of halluci- nations under some circumstances are not considered unusual in some preliterate societies. Becoming overcome with feelings of panic when entering a department store or when standing in a crowded elevator is uncommon and considered abnormal in our culture. Uncommon behavior is not in itself abnormal. Only one person can hold the record for swimming the fastest 100 meters. The record-holding athlete differs from the rest of us but, again, is not considered abnormal. Thus, rarity or statistical deviance is not a sufficient basis for label- ing behavior abnormal; nevertheless, it is one yardstick often used to judge abnormality. 2. Social deviance. All societies have norms (standards) that define the kinds of behaviors acceptable in given contexts. Behavior deemed normal in one cul- ture may be viewed as abnormal in another. For example, people in our culture who assume that all male strangers are devious are usually regarded as
Is this man abnormal? Judgments of abnormality take into account the social and cultural standards of society. Do you believe this man’s body adornment is a sign of abnormality or merely a fashion statement? Why or why not?
Unusual behavior is abnormal.
❑ FALSE. Unusual or statistically deviant behavior is not necessariy abnormal. Exceptional behavior also deviates from the norm.
✓
T R U T H or F I C T I O N
8 Chapter 1
abnormal. Physically aggressive behavior is most often maladaptive in modern life. Moreover, physical aggression is ineffective as a way of resolving conflicts—although it is by no means uncommon.
Abnormal behavior thus has multiple definitions. Depending on the case, some crite- ria may be weighted more heavily than others. But in most cases, a combination of these criteria is used to define abnormality.
Applying the Criteria Let’s now return to the three cases we introduced at the begin- ning of the chapter. Consider the criteria we can apply in determining that the behaviors reported in these case vignettes are abnormal. For one thing, the abnormal behavior pat- terns in these three cases are unusual in the statistical sense. Most people do not encounter these kinds of problems, although we should add that these problems are far from rare. The problem behaviors also meet other criteria of abnormality, as we shall see. Phil suffered from claustrophobia, an excessive fear of enclosed spaces. (This is an example of an anxiety disorder and is discussed more fully in Chapter 6.) His behavior was unusual (relatively few people are so fearful of confinement that they avoid flying in airplanes or riding on elevators) and was associated with significant personal distress. His fear also impaired his ability to carry out his occupational and family responsiblities. But he was not hampered by faulty perceptions of reality. He recognized that his fears exceeded a realistic appraisal of danger in these situations. What criteria of abnormality applies in the case of the woman who cowered under the blankets? She was diagnosed with bipolar disorder (formerly called manic-depression), a type of mood disorder in which a person experiences extreme mood swings from the heights of elation and seemingly boundless energy to the depths of depression and despair. (The vignette described the manic phase of the disorder.) Bipolar disorder, which is discussed in Chapter 8, is associated with extreme personal distress and difficulty functioning effectively in normal life. It is also linked to self-defeating and dangerous behavior, such as reckless driv- ing or exorbitant spending during manic phases and attempted suicide during depressive phases. In some cases, like the one presented here, people in manic phases sometimes have faulty perceptions or interpretations of reality, such as hallucinations and delusions. Thomas, whose story was featured in the third vignette, suffered from both schizophre- nia and depression. It is not unusual for people to have more than one disorder at a time. In the parlance of the psychiatric profession, these clients present with comorbid (co-occurring) diagnoses. Comorbidity complicates treatment because clinicians need to design a treatment approach that focuses on treating two or more disorders. Schizophrenia meets a number of criteria of abnormality in addition to statistical infrequency (it affects about 1% of the general population). The clinical features of schizophrenia include socially deviant or bizarre behavior, disturbed perceptions or interpretations of reality (delusions and hallucinations), maladaptive behavior (difficulty meeting responsibilities of daily life), and personal distress. (See Chapter 12 for more detail on schizophrenia.) Thomas, for example, was plagued by auditory hallucinations (terrorizing voices), which were certainly a source of significant distress. His thinking was also delusional, because he believed that “a presence” in his bedroom was “torturing good forces,” surrounding him and causing him to make mistakes during the day. In Thomas’s case, schizophrenia was complicated by depression that involved feelings of personal distress (irritability and feelings of dread). Depression is also associated with dampened or downcast mood, maladaptive behavior (difficulty getting to work or school or even getting out of bed in the morning), and poten- tial dangerousness (possible suicidal behavior). It is one thing to recognize and label behavior as abnormal; it is another to understand and explain it. Philosophers, physicians, natural scientists, and psychologists have used various approaches, or models, in the effort to explain abnormal behavior. Some approaches have been based on superstition; others have invoked religious explanations. Some cur- rent views are predominantly biological; others are psychological. In considering various historical and contemporary approaches to understanding abnormal behavior, let’s first look further at the importance of cultural beliefs in determining which behavior patterns are deemed abnormal.
Introduction and Methods of Research 9
Cultural Bases of Abnormal Behavior
As noted, behavior that is normal in one culture may be deemed abnormal in another. Australian aborigines believe they can communicate with the spirits of their ancestors and that other people, especially close relatives, share their dreams. These beliefs are con- sidered normal within Aboriginal culture. But were such beliefs to be expressed in our culture, they would likely be deemed delusions, which professionals regard as a common feature of schizophrenia. Thus, the standards we use in making judgments of abnormal behavior must take into account cultural norms. Kleinman (1987) offers an example of “hearing voices” among Native Americans to underscore the ways in which judgments about abnormality are embedded within a cultural context:
Ten psychiatrists trained in the same assessment technique and diagnostic criteria who are asked to examine 100 American Indians shortly after the latter have experienced the death of a spouse, a parent or a child may determine with close to 100% consistency that those individuals report hearing, in the first month of grieving, the voice of the dead per- son calling to them as the spirit ascends to the afterworld. [Although such judgments may be consistent across observers] the determination of whether such reports are a sign of an abnormal mental state is an interpretation based on knowledge of this group’s behav- ioural norms and range of normal experiences of bereavement. (p. 453)
To these Native Americans, bereaved people who report hearing the spirits of the deceased calling to them as they ascend to the afterlife are normal. Behavior that is nor- mative within the cultural setting in which it occurs should not be considered abnormal. Concepts of health and illness vary across cultures. Traditional Native American cul- tures distinguish between illnesses that are believed to arise from influences outside the culture, called “White man’s sicknesses,” such as alcoholism and drug addiction, and those that emanate from a lack of harmony with traditional tribal life and thought, which are called “Indian sicknesses” (Trimble, 1991). Traditional healers, shamans, and medicine men and women are called on to treat “Indian sickness.” When the problem is thought to have its cause outside the community, help is sought from “White man’s medicine.” Abnormal behavior patterns take different forms in different cul- tures. Westerners experience anxiety, for example, in the form of wor- rying about paying the mortgage, losing a job, and so on. Yet “in a number of African cultures, anxiety is expressed as fears of failure in procreation, in dreams and complaints about witchcraft” (Kleinman, 1987). Australian aborigines can develop intense fears of sorcery, accompanied by the belief that one is in mortal danger from evil spir- its (Spencer, 1983). Trancelike states in which young aboriginal women are mute, immobile, and unresponsive are also quite common. If these women do not recover from the trance within hours or, at most, a few days, they may be brought to a sacred site for healing. The very words that we use to describe psychological disorders—words such as depression or mental health —have different meanings in other cul- tures, or no equivalent meaning at all. This doesn’t mean that depression doesn’t exist in other cultures. Rather, it suggests we need to learn how people in different cultures experience emotional distress, including states of depression and anxiety, rather than imposing our perspectives on their experiences. Among people in China and other countries in the Far East, emotional distress is more often expressed through the development of physical or somatic symptoms, such as headaches, fatigue, or weakness, rather than by feelings of guilt or sadness, which are more common in the West (Draguns & Tanaka-Matsumi, 2003; Ryder et al., 2008). These differences demonstrate how important it is that we deter- mine whether our concepts of abnormal behavior are valid before we
A traditional Native American healer. Many traditional Native Americans distinguish between illnesses believed to arise from influences external to their own culture (“White man’s sicknesses”) and those that emanate from a lack of harmony with traditional tribal life and thought (“Indian sicknesses”). Traditional healers such as the one shown here may be called on to treat “Indian sickness,” whereas “White man’s medicine” may be sought to help people deal with problems whose causes are seen as lying outside the community, such as alcoholism and drug addiction.
Psychological problems like depression may be experienced differently by people in different cultures. ❑ TRUE. For example, depression is more likely to be associated with the devleopment of physical symptoms among people in East Asian cultures than in Western cultures.
✓
T R U T H or F I C T I O N
Introduction and Methods of Research 11
Hippocrates (ca. 460–377 B.C.E.), the celebrated physician of the Golden Age of Greece, challenged the prevailing beliefs of his time by arguing that illnesses of the body and mind were the result of natural causes, not possession by supernatural spirits. He believed the health of the body and mind depended on the balance of humors, or vital fluids, in the body: phlegm, black bile, blood, and yellow bile. An imbalance of humors, he thought, accounted for abnormal behavior. A lethargic or sluggish person was believed to have an excess of phlegm, from which we derive the word phlegmatic. An overabundance of black bile was believed to cause depression, or melancholia. An excess of blood created a sanguine disposition: cheerful, confident, and optimistic. An excess of yellow bile made people “bilious” and choleric —that is, quick-tempered. Though we no longer subscribe to Hippocrates’s theory of bodily humors, his theory is important because of its break from demonology. It foreshadowed the modern medical model, the view that abnormal behavior results from underlying biological processes. Hippocrates made other contributions to modern thought and, indeed, to modern med- ical practice. He classified abnormal behavior patterns, using three main categories that still have equivalents today: melancholia to characterize excessive depression, mania to refer to exceptional excitement, and phrenitis (from the Greek “inflammation of the brain”) to characterize the bizarre behavior that might today typify schizophrenia. To this day, medical schools honor Hippocrates by having students swear an oath of medical ethics that he originated, the Hippocratic oath. Galen (ca. 130–200 C.E.), a Greek physician who attended Roman emperor–philoso- pher Marcus Aurelius, adopted and expanded on the teachings of Hippocrates. Among Galen’s contributions was the discovery that arteries carry blood, not air, as had been formerly believed.
Medieval Times
The Middle Ages, or medieval times, cover the millennium of European history from about 476 C.E. through 1450 C.E. After the passing of Galen, belief in supernatural causes, especially the doctrine of possession, increased in influence and eventually dominated medieval thought. This doctrine held that abnormal behaviors were a sign of possession by evil spirits or the devil. This belief was part of the teachings of the Roman Catholic Church, the central institution in Western Europe after the decline of the Roman Empire. Although belief in possession preceded the Church and is found in ancient Egyptian and Greek writings, the Church revitalized it. The Church’s treatment of choice for posses- sion was exorcism. Exorcists were employed to persuade evil spirits that the bodies of the “possessed” were no longer habitable. Methods of persuasion included prayer, incantations, waving a cross at the victim, beating and flogging, even starving the victim. If the victim continued to display unseemly behavior, there were yet more persua- sive remedies, such as the rack, a device of torture. No doubt, recipi- ents of these “remedies” desperately wished the devil would vacate the premises immediately. The Renaissance—a great revival of classical learning, art, and literature—began in Italy in the 1400s and spread throughout Europe. Ironically, although the Renaissance is considered the tran- sition from the medieval to the modern world, the fear of witches also reached its height during this period.
Witchcraft
The late 15th through the late 17th centuries were especially bad times to annoy your neighbors. These were times of massive perse- cutions, particularly of women, who were accused of witchcraft. Church officials believed that witches made pacts with the devil, practiced satanic rituals, ate babies, and poisoned crops. In 1484,
Exorcism. This medieval woodcut illustrates the practice of exorcism, which was used to expel the evil spirits that were believed to have possessed people.
humors According to the ancient Hippocratic belief system, the vital bodily fluids (phlegm, black bile, blood, yellow bile).
12 Chapter 1
Pope Innocent VIII decreed that witches be executed. Two Dominican priests com- piled a notorious manual for witch-hunting, called the Malleus Maleficarum (The Witches’ Hammer), to help inquisitors identify suspected witches. Many thousands were accused of witchcraft and put to death in the next two centuries. Witch-hunting required innovative “diagnostic” tests. In the case of the water- float test, suspects were dunked in a pool to certify they were not possessed by the devil. The test was based on the principle that pure metals settle to the bottom during smelting, whereas impurities bob up to the surface. Suspects who sank and drowned were ruled pure. Suspects who kept their heads above water were judged to be in league with the devil. As the saying went, you were “Damned if you do and damned if you don’t.” Modern scholars once believed these so-called witches were actually people with psychological disorders who were persecuted because of their abnormal behavior. Many suspected witches did confess to bizarre behaviors, such as flying or engag- ing in sexual intercourse with the devil, which suggests the types of disturbed behavior associated with modern conceptions of schizophrenia. Yet these confes- sions must be discounted because they were extracted under torture by inquisitors who were bent on finding evidence to support accusations of witchcraft (Spanos, 1978). We know today that the threat of torture and other forms of intimidation are sufficient to extract false confessions. Although some of those who were perse- cuted as witches probably did show abnormal behavior patterns, most did not (Schoenman, 1984). Rather, accusations of witchcraft appeared to be a convenient means of disposing of social nuisances and political rivals, of seizing property, and of suppressing heresy (Spanos, 1978). In English villages, many of the accused were poor, unmarried elderly women who were forced to beg for food from their neigh- bors. If misfortune befell the people who declined to give help, the beggar might be accused of having cast a curse on the household. If the woman was generally unpopular, the accusation of witchcraft was likely to follow. Demons were believed to play roles in both abnormal behavior and witchcraft. However, although some victims of demonic possession were perceived to be afflicted as retribution for their own wrongdoing, others were considered to be inno- cent victims—possessed by demons through no fault of their own. Witches, on the other hand, were believed to have renounced God and voluntarily entered into a pact with the devil. Witches were generally seen as more deserving of torture and execu- tion (Spanos, 1978). Historical trends do not follow straight lines. Although the demonological model held sway during the Middle Ages and much of the Renaissance, it did not completely supplant belief in naturalistic causes. In medieval England, for example, demonic possession was only rarely invoked in cases in which a person was held to be insane by legal authorities (Neugebauer, 1979). Most explanations for unusual behavior involved natural causes, such as physical illness or trauma to the brain. In England, in fact, some disturbed people were kept in hospitals until they were restored to sanity (Allderidge, 1979). The Renaissance Belgian physician Johann Weyer (1515–1588) also took up the cause of Hippocrates and Galen by arguing that abnormal behavior and thought patterns were caused by physical problems.
Asylums
By the late 15th and early 16th centuries, asylums, or madhouses, began to crop up throughout Europe. Many were former leprosariums, which were no longer needed because of the decline in leprosy after the late Middle Ages. Asylums often gave refuge to beggars as well as the mentally disturbed, and conditions were appalling. Residents were chained to their beds and left to lie in their own waste or to wander about unassisted. Some asylums became public spectacles. In one asylum in London, St. Mary’s of Bethlehem Hospital—from which the word bedlam is derived—the public could buy tick- ets to observe the antics of the inmates, much as we would pay to see a circus sideshow or animals at the zoo.
The water-float test. This so-called test was one way in which medieval authorities sought to detect possession and witchcraft. Managing to float above the waterline was deemed a sign of impurity. In the lower right hand corner, you can see the bound hands and feet of one poor unfortunate who failed to remain afloat, but whose drowning would have cleared away any suspicions of possession.
A night’s entertainment in London a few hundred years ago might have included gaping at the inmates at the local asylum.
❑ TRUE. A night on the town for the gentry of London sometimes included a visit to a local asylum, St. Mary’s of Bethlehem Hospital, to gawk at the patients. We derive the word bedlam from Bethlehem Hospital.
✓
T R U T H or F I C T I O N
14 Chapter 1
A Step Backward
In the latter half of the 19th century, the belief that abnormal behaviors could be suc- cessfully treated or cured by moral therapy fell into disfavor (USDHHS, 1999a). A period of apathy ensued in which patterns of abnormal behavior were deemed incurable (Grob, 1994). Mental institutions in the United States grew in size but provided little more than custodial care. Conditions deteriorated. Mental hospitals became frightening places. It was not uncommon to find residents “wallowing in their own excrements,” in the words of a New York State official of the time (Grob, 1983). Straitjackets, handcuffs, cribs, straps, and other devices were used to restrain excitable or violent patients. Deplorable hospital conditions remained commonplace through the middle of the 20th century. By the mid-1950s, the population in mental hospitals had risen to half a million patients. Although some state hospitals provided decent and humane care, many were described as little more than human snakepits. Residents were crowded into wards that lacked even rudimentary sanitation. Mental patients in back wards were essentially warehoused; that is, they were left to live out their lives with little hope or expectation of recovery or return to the community. Many received little professional care and were abused by poorly trained and supervised staffs. Finally, these appalling conditions led to calls for reforms of the mental health system.
The Community Mental Health Movement:
The Exodus from State Hospitals
In response to the growing call for reform, Congress in 1963 established a nationwide system of community mental health centers (CMHCs) that was intended to offer an alter- native to long-term custodial care in bleak institutions. CMHCs were charged with pro- viding continuing support and care to former hospital residents who were released from state mental hospitals under a policy of deinstitutionalization. Another factor that laid the groundwork for the mass exodus from mental hospitals was the development of a new class of drugs—the phenothiazines. This group of antipsychotic drugs, which helped quell the most flagrant behavior patterns associated with schizophrenia, was introduced in the 1950s. Phenothiazines reduced the need for indefinite hospital stays and permitted many people with schizophrenia to be discharged to halfway houses, group homes, and inde- pendent living. The mental hospital population across the United States plummeted from 559,000 in 1955 to fewer than 100,000 by the 1990s (Grob, 2001). Some mental hospitals were closed entirely. The community mental health movement and the policy of deinstitutionalization were developed with the hope that mental patients could return to their communities and assume more independent and fulfilling lives. However, the exodus from state hospitals left tens of thousands of marginally functioning people in communities that lacked ade- quate housing and other forms of support. Even today, many of the homeless we see wan- dering city streets and sleeping in bus terminals and train stations are discharged mental patients. (In Chapter 4, we take a closer look at the policy of deinstitutionalization and the problems faced by the psychiatric homeless population.)
Contemporary Perspectives on Abnormal Behavior
Beliefs in possession or demonology persisted until the 18th century, when society began to turn toward reason and science to explain natural phenomena and human behavior. The nascent sciences of biology, chemistry, physics, and astronomy promised knowledge derived from scientific methods of observation and experimentation. Scientific observation in turn uncovered the microbial causes of some kinds of diseases and gave rise to preventive measures. Scientific models of abnormal behavior also began to emerge, including models representing biological, psychological, sociocultu- ral, and biopsychosocial perspectives. We briefly discuss each of these models here, par- ticularly in terms of their historical background, which will lead to a fuller discussion in Chapter 2.
Introduction and Methods of Research 15
The Biological Perspective Against the backdrop of advances in medical science, the German physician Wilhelm Griesinger (1817–1868) argued that abnormal behavior was rooted in diseases of the brain. Griesinger’s views influenced another German physician, Emil Kraepelin (1856–1926), who wrote an influential textbook on psychiatry in 1883 in which he likened mental disorders to physical diseases. Griesinger and Kraepelin paved the way for the modern medical model, which attempts to explain abnormal behavior on the basis of underlying biological defects or abnormalities, not evil spirits. According to the medical model, people behaving abnormally suffer from mental illnesses or disorders that can be classified, like physical illnesses, according to their distinctive causes and symp- toms. Adopters of the medical model don’t necessarily believe that every mental disorder is a product of defective biology, but they maintain that it is useful to classify patterns of abnormal behavior as disorders that can be identified on the basis of their distinctive features or symptoms. Kraepelin specified two main groups of mental disorders or diseases: dementia praecox (from roots meaning “precocious [premature] insanity”), which we now call schizophrenia, and manic–depressive psychosis, which is now labeled bipolar disorder. Kraepelin believed that dementia praecox was caused by a biochemical imbalance and manic–depressive psychosis by an abnormality in body metabolism. His major contribu- tion was the development of a classification system that forms the cornerstone of current diagnostic systems. The medical model gained support in the late 19th century with the discovery that an advanced stage of syphilis —in which the bacterium that causes the disease directly invades the brain itself—led to a form of disturbed behavior called general paresis (from the Greek parienai, meaning “to relax”). General paresis is associated with physical symp- toms and psychological impairment, including personality and mood changes, and with progressive deterioration of memory functioning and judgment. With the advent of antibiotics for treating syphilis, general paresis has become extremely uncommon. General paresis is of interest to us mostly for historical reasons. With the discovery of the connection between general paresis and syphilis, scientists became optimistic that other biological causes would soon be discovered for many other types of disturbed behavior. The later discovery of Alzheimer’s disease (discussed in Chapter 15), a brain dis- ease that is the major cause of dementia, lent further support to the medical model. Yet we realize today that the great majority of psychological disorders involve a complex web of factors we are still struggling to understand. Much of the terminology used in abnormal psychology has been “medicalized.” Because of the medical model, we commonly speak of people whose behavior is abnormal as being mentally ill. Because of the medical model, we commonly refer to the symptoms of abnormal behavior, rather than the features or characteristics of abnormal behav- ior. Other terminological offspring of the medical model include mental health, syndrome, diagnosis, patient, mental patient, mental hospital, prog- nosis, treatment, therapy, cure, relapse, and remission. The medical model is a major advance over demonology. It inspired the idea that abnormal behavior should be treated by learned profes- sionals, not punished. Compassion supplanted hatred, fear, and perse- cution. But the medical model has also led to controversy over the extent to which certain behavior patterns should be considered forms of mental illness. We address this issue in Controversies in Abnormal Psychology on page 17.
The Psychological Perspective Even as the medical model was gain- ing influence in the 19th century, some scientists argued that organic factors alone could not explain the many forms of abnormal behavior. In Paris, a respected neurologist, Jean-Martin Charcot (1825–1893), experimented with the use of hypnosis in treating hysteria, a condition characterized by paralysis or numbness that cannot be explained by any underlying physical cause. [Interestingly, cases of hysteria were
dementia praecox The term given by Kraepelin to the disorder now called schizophrenia.
general paresis A degenerative brain disease occurring when the bacterium that causes syphilis directly invades brain tissue.
Charcot’s teaching clinic. Parisian neurologist Jean-Martin Charcot presents a female patient who exhibits the highly dramatic behavior associated with hysteria, such as falling faint at a moment’s notice. Charcot was an important influence on the young Sigmund Freud.
Introduction and Methods of Research 17
The question of where to draw the line between “normal” and “abnormal” behavior continues to be a subject of debate within the mental health field and the broader society. Unlike medical illness, a psychological or mental disorder cannot be identified by a spot on an X-ray or from a blood sample. Classifying these disorders involves clinical judgments, not findings of fact; and as we have noted, these judgments can change over time and can vary from culture to culture. For example, medical professionals once considered masturbation a form of mental illness. Although some people today may object to masturbation on moral grounds, professionals no longer regard it as a mental disturbance. Consider other behaviors that may blur the boundaries between normal and abnormal: Is body-piercing abnormal, or is it simply a fashion statement? (How much piercing do you consider “normal”?) Might excessive shopping behavior or overuse of the Internet be forms of mental illness? Is bullying a symptom of an underlying disorder, or is it just “bad behavior”? Mental health professionals base their judgments on the kinds of criteria we outline in this text. But even in professional circles, debate continues about whether some behaviors should be classified as forms of abnormal behavior or mental disorders. One of the longest of these debates concerns homosexuality. Until 1973, the American Psychiatric Association classified homosexuality as a mental disorder. In that year, however, the organization voted to drop homosexuality from its listing of classified mental disorders in its diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, or DSM (discussed in Chapter 3). The DSM retained, however, a diagnostic classification that could be applied to individuals who are distressed or confused about their sexual orientation. The decision to declassify homosexuality as a mental disorder was not unanimous among the nation’s psychiatrists. Many argued that the decision was motivated more by political reasons than by good science. Some objected to basing such a decision on a vote. After all, would it be reasonable to drop cancer as a recognized medical illness based on a vote? Shouldn’t scientific criteria determine these kinds of judgments, rather than a popular vote? What do you think? Is homosexuality a variation in the normal spectrum of sexual orientation, or is it a form of abnormal behavior? What is the basis of your judgment? What criteria did you apply in forming a judgment? What evidence do you have to support your beliefs?
Within the DSM system, mental disorders are recognized on the basis of behavior patterns associated with either emotional distress and/or significant impairment in psychological functioning. Researchers have found that people with a gay male or lesbian sexual orientation tend to have a greater frequency of suicide and of states of emotional distress, especially anxiety and depression, than people with a heterosexual orientation (Bagley & D’Augelli, 2000; Cochran, Sullivan, & Mays, 2003; Skegg et al., 2003). Even if gay males and lesbians are more prone to develop psychological problems, it doesn’t necessarily follow that these problems are the result of their sexual orientation. Gay adolescents in our society come to terms with their sexuality against a backdrop of deep-seated prejudices and resentment toward gays. The process of achieving a sense of self-acceptance against this backdrop of societal intolerance can be so difficult that many gay adoles- cents seriously consider or attempt suicide (Bagley & D’Augelli, 2000; Simonsen et al., 2000). As adults, gay men and lesbians often continue to bear the brunt of prejudice and negative attitudes toward them, including negative reactions from family members that often follow the disclosure of their sexual orientation. The social stress associated with stigma, prejudice, and discrimination that gay people encounter may directly cause mental health problems (Meyer, 2003). Understood in this context, it is little wonder that many gay males and lesbians develop psychological problems. As a leading authority in the field, psychologist J. Michael Bailey (1999) wrote, “Surely, it must be difficult for young people to come to grips with their homosexuality in a world where homosexual people are often scorned, mocked, mourned, and feared.” Should we then accept the claim that societal intolerance is the root cause of psychological problems in people with a homosexual orientation? As critical thinkers, we should recognize that other factors may be involved. We need more evidence before we can arrive at any judgments concerning why gay males and lesbians are more prone to psychological problems, especially suicide. One of these other factors may be lifestyle choice. A classic study of gay couples showed that those living in committed, close relationships were as well adjusted as married heterosexual couples (Bell & Weinberg, 1978). Differences in psychological adjustment or mental health may be more of a reflection of lifestyle factors than sexual orientation. Imagine a society in which homosexuality was the norm and heterosexual people were shunned, scorned, or ridiculed. Would we find that heterosexual people are more likely to have psychological problems? Would this evidence lead us to assume that heterosexuality is a mental disorder? What do you think?
Critical Thinking
- How do you decide when any behavior, such as social drinking or even shopping or Internet use, crosses the line from “normal” to “abnormal”?
- Is there a set of criteria you use in all cases? How does your criteria differ from the criteria specified in the text?
- Do you believe that homosexuality is abnormal? Why or why not? [[E CH
CONTROVERSIES IN ABNORMAL PSYCHOLOGY
What Is Abnormal Behavior?
Is homosexuality a mental disorder? Until 1973, homosexuality was classified as a mental disorder by the American Psychiatric Association. What criteria should be used to form judgments about determining whether particular patterns of behavior comprise a mental or psychological disorder?
Despite changing attitudes in society toward homosexuality, the psychiatric profession continues to classify homosexuality as a mental disorder. ❑ FALSE. The psychiatric profession dropped homosexuality from its listing of mental disorders in 1973.
✓
T R U T H or F I C T I O N
18 Chapter 1
followed based on behavioral, humanistic, and cognitive models. Each of these perspectives, as well as the contemporary medical model, spawned particular forms of therapy to treat psychological disorders.
The Sociocultural Perspective Mustn’t we also consider the broader social context in which behavior occurs to understand the roots of abnormal behavior? Sociocultural theorists believe the causes of abnormal behavior may be found in the failures of society rather than in the person. Accordingly, psychological problems may be rooted in the ills of society, such as unemployment, poverty, family breakdown, injustice, ignorance, and the lack of opportunity. Sociocultural factors also focus on relationships between mental health and social factors such as gender, social class, ethnicity, and lifestyle. Sociocultural theorists also observe that once a person is called “mentally ill,” the label is hard to remove. It also distorts other people’s responses to the “patient.” Mental patients are stigmatized and marginalized. Job opportunities may disappear, friendships may dis- solve, and the “patient” may feel increasingly alienated from society. Sociocultural theo- rists focus our attention on the social consequences of becoming labeled as a “mental patient.” They argue that we need to provide access to meaningful societal roles, as work- ers, students, and colleagues, to people with long-term mental health problems, rather than shunt them aside.
The Biopsychosocial Perspective Aren’t patterns of abnormal behavior too complex to be understood from any one model or perspective? Many mental health professionals endorse the view that abnormal behavior is best understood by taking into account mul- tiple causes representing the biological, psychological, and sociocultural domains (Levine & Schmelkin, 2006). The biopsychosocial model, or interactionist model, informs this text’s approach toward understanding the origins of abnormal behavior. We believe it’s essential to consider the interplay of biological, psychological, and sociocultural factors in the development of psychological disorders. Although our understanding of these factors may be incomplete, we must consider all possible pathways and account for multiple factors, influences, and interactions. Perspectives on psychological disorders provide a framework not only for explanation but also for treatment (see Chapter 4). The perspectives we use also lead to the predic- tions, or hypotheses, that guide our research or inquiries into the causes and treatments of abnormal behavior. The medical model, for example, fosters inquiry into genetic and biochemical treatment methods. In the next section, we consider the ways in which psychologists and other mental health professionals study abnormal behavior.
RESEARCH METHODS IN ABNORMAL PSYCHOLOGY
Abnormal psychology is a branch of the scientific discipline of psychology. Research in the field is based on the application of the scientific method. Before we explore the basic steps in the scientific method, let us consider the four overarching objectives of science: description, explanation, prediction, and control.
Description, Explanation, Prediction, and Control:
The Objectives of Science
To understand abnormal behavior, we must first learn to describe it. Description allows us to recognize abnormal behavior and provides the basis for explaining it. Descriptions should be clear, unbiased, and based on careful observation. Let us pose a vignette that challenges you to put yourself in the position of graduate student in psychology who is asked to describe the behavior of a laboratory rat the professor places on the desk in front of you: Imagine you are a brand-new graduate student in psychology and are sitting in your research methods class on the first day of the term. The professor, a distinguished woman of about 50, enters the class. She is carrying a small wire-mesh cage containing a white rat. The professor removes the rat from the cage and places it on the desk. She asks the class to observe
biopsychosocial model An integrative model for explaining abnormal behavior in terms of the interactions of biological, psychological, and sociocultural factors.
scientific method A systematic method of conducting scientific research in which theories or assumptions are examined in light of evidence.
20 Chapter 1
disturbed, the goal is to assist them in overcoming their agitation and regaining the ability to exercise meaningful choices in their lives. Ethical standards prohibit the use of injurious techniques in research or practice. Psychologists and other scientists use the scientific method to advance the description, explanation, prediction, and control of abnormal behavior.
The Scientific Method
The scientific method tests assumptions and theories about the world through gathering objective evidence. Gathering evidence that is objective requires thoughtful observational and experimental methods. Here let us focus on the basic steps involved in using the scientific method in experimentation.
1. Formulating a research question. Scientists derive research questions from previous observations and current theories. For instance, based on their clinical observations and theoretical understanding of the underlying mechanisms in depression, psychol- ogists may formulate questions about whether certain experimental drugs or partic- ular types of psychotherapy help people overcome depression. 2. Framing the research question in the form of a hypothesis. A hypothesis is a prediction tested in an experiment. For example, scientists might hypothesize that people who are clinically depressed will show greater improvement on measures of depression if they are given an experimental drug than if they receive an inert placebo (a “sugar pill”). 3. Testing the hypothesis. Scientists test hypotheses through experiments in which vari- ables are controlled and the differences are observed. For instance, they can test the hypothesis about the experimental drug by giving the drug to one group of people with depression and giving another group the placebo. They can then test to see if the people who received the active drug showed greater improvement over a period of time than those who received the placebo. 4. Drawing conclusions about the hypothesis. In the final step, scientists draw conclu- sions from their findings about the accuracy of their hypotheses. Psychologists use statistical methods to determine the likelihood that differences between groups are significant, as opposed to chance fluctuations. Psychologists can be reasonably confi- dent that group differences are significant—that is, not due to chance—when there is a probability of less than 5% that chance alone can explain the differences. When well-designed research findings fail to bear out hypotheses, scientists rethink the theories from which the hypotheses are derived. Research findings often lead to modifications in theory, new hypotheses, and in turn, subsequent research. Let us consider the major research methods used by psychologists and others in study- ing abnormal behavior. Before we do so, let us consider some of the principles that guide ethical conduct in research.
Ethics in Research
Ethical principles are designed to promote the dignity of the individual, protect human welfare, and preserve scientific integrity (APA, 2002). Psychologists are prohibited by the ethical standards of their profession from using methods that cause psychological or physical harm to subjects or clients. Psychologists also must follow ethical guidelines that protect animal subjects in research. Institutions such as universities and hospitals have review committees, called institutional review boards (IRBs), that review proposed research studies in light of ethical guidelines. Investigators must receive IRB approval before they are permitted to begin their studies. Two of the major principles on which ethical guidelines are based are (a) informed consent and (b) confidentiality. The principle of informed consent requires that people be free to choose whether they want to participate in research studies. They must be given sufficient information in advance about the study’s purposes and methods, and its risks and benefits, in order to make an informed decision about their participation. Research participants must also befree to withdraw from a study at any time without penalty. In some cases, researchers
hypothesis A prediction that is tested through experimentation.
informed consent The principle that research participants should receive enough information about an experiment beforehand to decide freely whether to participate.
Introduction and Methods of Research 21
may withhold certain information until all the data are collected. For instance, participants in placebo control studies of experimental drugs are told that they may receive an inert placebo rather than the active drug. In studies in which information was withheld or deception was used, participants must be debriefed afterward. That is, they must receive an explanation of the true methods and purposes of the study and why it was necessary to keep them in the dark. After the study is concluded, participants who received the placebo would be given the option of receiving the active treatment, if warranted. Research participants also have a right to expect that their identities will not be revealed. Investigators are required to protect their confidentiality by keeping the records of their participation secure and by not disclosing their identities to others. We now turn to discussion of the research methods used to investi- gate abnormal behavior.
Naturalistic Observation
In naturalistic observation, the investigator observes behavior in the field, where it happens. Anthropologists have observed behavior pat- terns in preliterate societies to study human diversity. Sociologists have followed the activities of adolescent gangs in inner cities. Psychologists have spent weeks observing the behavior of homeless people in train stations and bus terminals. They have even observed the eating habits of slender and overweight people in fast-food restaurants, searching for clues to obesity. Scientists try to ensure that their naturalistic observations are unobtrusive, so as to min- imize interference with the behavior they observe. Nevertheless, the presence of the observer may distort the behavior that is observed, and this must be taken into consideration. Naturalistic observation provides information on how people behave, but it does not reveal why they do so. It may reveal, for example, that men who frequent bars and drink often get into fights. But such observations do not show that alcohol causes aggression. As we shall see, questions of cause and effect are best approached by means of controlled experiments.
The Correlational Method
One of the primary methods used to study abnormal behavior is the correlational method, which involves the use of statistical methods to examine relationships between two or more factors that can vary, which are called variables. For example, in Chapter 8 we will see that there is a statistical relationship, or correlation, between the variables of negative thinking and depressive symptoms. The statistical measure used to express the association or correlation between two variables is called the correlation coefficient, which can vary along a continuum ranging from 1.00 to 1.00. When higher values in one variable (negative thinking) are associated with higher values in the other variable (depressive symptoms), there is a positive correlation between the variables. If higher levels of one variable are associated with lower values of another variable, there is a negative cor- relation between the variables. Positive correlations carry positive signs; negative correla- tions carry negative signs. The higher the correlation coefficient—meaning the closer it is to either 1.00 or 1.00—the stronger the relationship is between the variables. The correlational method does not involve manipulation of the variables of interest. In the previous example, the experimenter does not manipulate people’s depressive symp- toms or negative thoughts. Rather, the investigator uses statistical techniques to determine whether these variables tend to be associated with each other. Because the experimenter does not directly manipulate the variables, a correlation between two variables does not prove that they are causally related to each other. It may be the case that two variables are correlated but have no causal connection. For example, children’s foot size is correlated with their vocabulary, but growth in foot size does not cause the growth of vocabulary. Depressive symptoms and negative thoughts are correlated, as we shall see in Chapter 8. Though negative thinking may be a causative factor in depression, it is also possible that
Naturalistic Observation. In naturalistic observation, psychologists take their research into the streets, homes, restaurants, schools, and other settings where behavior can be directly observed. For example, psychologists have unobtrusively positioned themselves in school playgrounds to observe how aggressive or socially anxious children interact with peers.
confidentiality Protection of research participants by keeping records secure and not disclosing their identities.
naturalistic observation A form of research in which behavior is observed and measured in its natural environment.
correlational method A scientific method of study that examines the relationships between factors or variables expressed in statistical terms.
correlation coefficient A statistical measure of the strength of the relationship between two variables expressed along a continuum that ranges between 1.00 and 1.00.
