Michael J T Leftwich. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
The study of abnormal psychology (also sometimes called psychopathology) often captivates many students, because it is one of the most interesting and provocative topics in psychology. Descriptions of the wide variety of mental disorders and related symptoms can include combinations of bizarre and illogical actions, thoughts, and feelings that may look somewhat like a comic tragedy to the outside observer. However, this may be due in part to the descriptions and perceptions of the cases chosen for presentation to begin with. Various forms of media often portray people with mental disorders in an entertaining yet unrealistic and overly dramatic manner, further reinforcing stereotypes and misconceptions about mental illness. Yet for people suffering with mental illness, without diagnosis and treatment, theirs can be a world of loneliness, fear, alienation, and marginalization.
There are several key questions for students to answer as they work toward mastering the content of abnormal psychology. How do psychologists define and diagnose something as being abnormal? Who are key historical figures, and how have views of mental health and illness changed over the years? How do psychologists use science to better assess and understand mental disorders? What are the primary theoretical perspectives and treatment options? We explore these questions in the following sections.
Definitions of Abnormal
Defining what is abnormal depends on how one first defines what is normal. This may sound simple and obvious, but it is not always so easy to remember that these are dynamic and relative terms. What people consider normal behavior depends on the time, place, and those involved. For example, most people believe that physical aggression against another person is generally unacceptable, but certain forms of aggression under certain circumstances (e.g., a great hit in a football game) may in fact be encouraged and celebrated. Psychologists therefore face a unique challenge when trying to define abnormality, because normality is a complex moving target directly influenced by evolving social values.
Synonyms for the word abnormal include the following: deviant, unusual, distressing, dysfunctional, and maladaptive (among others). These synonyms can help describe key features or dimensions that psychologists and other professionals may use to help identify abnormality. Each dimension represents a unique perspective and offers specific advantages when trying to describe and define normal vs. abnormal. However, each perspective also has specific limitations, and attempting to use any one of them in isolation as the sole determinant of what is abnormal leaves you with an incomplete and oversimplified view of abnormal behavior.
Perhaps the simplest definition of what is abnormal involves deviation from what a group considers correct or acceptable. Each group develops a set of rules and expectations, or norms, for behavior under a variety of circumstances. A norm may be explicit (e.g., written laws) or implicit, but group membership and acceptance is largely determined by adherence to the norm. Deviation from the norm is often discouraged because it threatens group integrity and cohesion, and repeated norm violations may result in negative consequences for the deviant individual. Obviously, groups can vary in size and construction (e.g., your immediate family versus all people in the United States in your age group), and the degree of influence their norms have on your own behavior will depend in part on how much you value being a member of that group and how influential your own behavior is within the group (i.e., it is a feedback loop—your behavior is influenced by the norm while also helping to define the norm). The advantage of this approach is that it necessarily includes norms that are current and relevant to the group in question. The obvious limitation of this viewpoint is that any behavior that is new or different and runs counter to a group’s preexisting norms will be labeled and treated as deviant, a term that carries a strong negative connotation. The negative connotation and resulting stigmatization associated with being labeled deviant may in fact be one of the potential consequences designed to prevent a person from drifting too far away from the values and beliefs of the group. This may sound very stifling and overly rigid to some people. In Western cultures, such as the United States in particular, maintaining balance between group affiliation and individual identity is important because of the value Americans place on individualism and freedom of choice. Another important limitation is the consideration that even the most pervasive norms are not stable or static; what is generally acceptable today (e.g., hairstyles, fashions, tattoos, and body piercing) may be laughably deviant in the future.
If psychologists define what is normal by quantifying what is average or typical of a group, then abnormal is anything unusual, or that which lies outside an accepted range. Psychologists often use a cutoff of two standard deviations above or below the mean to define something as being highly unusual or rare (i.e., statistically significant), as this represents the extreme scores (upper and lower 2.5 percent approximately) of a normal frequency distribution. By comparing an individual’s score to the average score of an entire sample, psychologists can make probabilistic statements about the likelihood of obtaining a specific score randomly or by chance alone, versus obtaining that same score because the individual most likely is truly and statistically different from the sample. This approach has the advantage of being quantified and more objective than other perspectives, and thus applicable in the use of statistical procedures and scientific interpretations of data. However, this approach has the disadvantage of labeling anything that is statistically extreme as abnormal, even if it is a desirable trait (e.g., a very high IQ). Additionally, any cutoff used is an arbitrary one that may be influenced by sample size or the shape of the frequency distribution, and there is lots of gray area between what is easily defined as average and what is obviously atypical in the statistical sense. This issue is made even more apparent when one considers the relative lack of precision and measurement error that psychologists often have to take into account when trying to assess traits and behaviors that may be considered indicators of mental disorder.
If psychologists use measures of daily functioning (occupational success, academic performance, social/interpersonal interaction, aspects of self-care, etc.) to define what is normal, then they would define as abnormal or dysfunctional anything that prevents maximal or ideal functioning. This approach has the advantage of using behaviors that are typically observable and measurable (e.g., salary, GPA, number of close friends, cholesterol levels, etc.), and is flexible enough to account for different developmental stages and individual differences. This flexibility, however, is also the primary disadvantage of this perspective because maximal functioning is a concept that depends on numerous other factors: age, cultural expectations, personal values, and so on. Getting an average grade on an important exam may be perfectly acceptable to a struggling student simply trying to pass a course, yet thoroughly unacceptable to another student on academic scholarship who wants to pursue a graduate degree. The issue then becomes one of deciding which expert determines what ideal functioning looks like for any given person. This is not impossible to do, but it does require sound clinical judgment combined with a high level of skill and experience to gather and assess relevant data.
Because normality differs from person to person, it might be necessary to use a perspective that pays very close attention to individual levels of distress. Assessing personal distress or unhappiness as a means of defining what is abnormal includes measuring the frequency, intensity, and duration of symptoms that are cognitive, emotional, physical, or some combination of the three. Whereas using dysfunction includes elements of interpersonal functioning as already mentioned, using distress could be thought of as a way of determining intrapersonal functioning. Individual levels of pain, anxiety, anguish, and so forth are important indicators of abnormality regardless of social norms, statistical rarity, or daily functioning. Self-reports of the severity, origin, and meaning of symptoms are an important source of information, and can be a powerful component of a therapeutic relationship. In fact, the goal of therapy may often include work on defining what being happy means and helping a person find ways to move closer to that ideal state. Relying on personal distress as the defining feature of abnormality obviously assumes that personal distress exists in the first place, an assumption that may very well be fallacious, particularly in cases of acute psychosis or severe personality disorders. Additionally, people are often motivated toward productive goals by their anxieties and insecurities, thus one could question if an equal but opposite state of perfect happiness exists, and whether it is even possible or beneficial to eliminate all sources of personal distress. This may be an important philosophical or existential issue, but in reality it represents an artificial and oversimplified dichotomy. When levels of distress paralyze, debilitate, and otherwise prevent individuals from feeling like themselves on a daily basis, even modest relief can be a welcome change of pace and a more achievable goal, thus rendering the issue of achieving total happiness and eliminating all sources of stress a moot point.
Finally, if the synonym “maladaptive” is used as the primary reference point, then anything that causes harm or increases the risk of harm to self or others serves as an indicator of abnormality. Physical injuries, suicide attempts, substance abuse, indiscriminant sexual behavior, and extreme sensation seeking could all be easily seen as maladaptive behaviors, because they all represent a high level of severity and risk. The problem is that even though this elevated level of harm and risk is easy to spot when it occurs, it does not occur in every case of what professionals consider abnormal, and in fact may be the least prevalent of all indicators of abnormality (Comer, 2001). This obviously limits the utility of this criterion to define what is and is not normal.
It should be apparent by now that, as stated previously, no single element can be used in isolation to achieve a definition of abnormality that is sufficient. By combining several of these factors into a working definition of abnormality, psychologists can take advantage of the strengths of each perspective while avoiding or minimizing the inherent individual disadvantages. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000), specifically incorporates several of these dimensions into each set of diagnostic criteria for various disorders and syndromes. However, even this approach is relative and dynamic, and will always depend on the culture and timing surrounding what is defined as normal.
Just as there are multiple dimensions used to define what is abnormal, there are multiple theoretical models in use today to help describe and predict abnormal behavior as well as dictate treatment methods and techniques. In order to fully understand these models and put them in proper perspective, a brief review of the history of abnormal psychology is in order.
Brief History of Abnormality
Historians of psychology trace the roots of abnormal psychology all the way back to prehistoric practices such as trephining, which is the puncturing of the skull with a sharp object presumably to release something—whether it be blood, pressure, swelling, or possibly even evil spirits believed to possess the mentally ill (Bootzin & Acocella, 1996). Imagine what it must have been like to be the first person ever to observe someone else actively hallucinating, or experiencing symptoms of depression or anxiety so severe that the person is literally immobilized, or in the throes of a violent epileptic seizure, or suffering from delirium, and so on. You would probably have had a very difficult time making sense of his or her behavior, and even more difficulty trying to relay what was happening to someone else. In order to better understand, describe, and if necessary treat or alter these conditions, you would need a system to classify and explain human behaviors and experiences, particularly when they reached extremes.
The ancient Greek physician Hippocrates, whom you may recognize as the principal author of the Hippocratic Oath (the pledge made by medical doctors to do no harm to their patients, among other things), was among the first to develop and record such a classification system. Hippocrates believed that our bodily fluids or humors (blood, yellow bile, black bile, and phlegm) were directly related to the four seasons (spring, summer, autumn, and winter, respectively) as well as the four universal elements (air, fire, earth, and water, respectively), and were also linked to our thoughts and behaviors. He also believed that, when people exhibited strange behaviors and symptoms of sickness, an imbalance in their humors had occurred. For example, he believed an excess of black bile (from the Greek melas + kholé) caused people to feel sad or dysphoric, a state that people still sometimes describe as “melancholy” (Comer, 2001; Monte & Sollod, 2003). Treatments were developed based on the notion that in order to correct the imbalance, one must make use of things that possessed the opposite characteristics of the humor causing the illness. An excess of black bile, associated with the element earth and the season autumn, both viewed as primarily cold and dry, causing melancholia, would presumably be reversed via something with hot and wet properties—perhaps a warm bath, a nice bowl of hot soup, or maybe vigorous exercise. Treatments usually revolved around changing a person’s diet or having him or her engage in physical activity, and resorted to more invasive and potentially deadly methods (e.g., using poison to cause vomiting and/or diarrhea) only when more standard methods failed. Some of what Hippocrates believed and wrote may seem silly, based on what is known today, but at the very least he should be given due credit for being very curious and observant, and for keeping the patient’s health and well-being at the forefront of medical practice. In addition, there are some interesting parallels between his original characterization of human temperament based on humors and more modern models of the structure of personality (e.g., the Big 5 factor analytic model of personality; Monte & Sollod, 2003). To be sure, his model of personality and abnormal behavior was inadequate and grossly oversimplified, but he was a keen observer who paid special attention to patterns and similarities occurring among his patients. He could easily describe what he saw, but had difficulty explaining things without relying on concepts like seasons, elements, the Gods, and so on. He lacked the methods and values of science that people simply take for granted today.
Relying on explanations and methods that were not scientific was a problem that carried forward through the Middle Ages. Although some theories put forth economic or political explanations, there is some speculation that the witch hunts in Europe (roughly 1400-1500)—and later (the 1600s) in the United States in places like Salem, Massachusetts—were essentially cases of mass hysteria caused by an inability to understand or explain things that were new or different. As a result, there was a tendency to rely solely on preexisting belief systems (e.g., religion) to make sense of strange behaviors and decide how best to handle them. Some people accused of being witches were believed to be “possessed” by evil spirits, and were subjected to everything from harassment to execution as a result. It is plausible that at least some of these “witches” may simply have been people who were showing signs and symptoms of what psychologists would now call mental illness or disorder, but popular beliefs during those times made little room for such a notion, let alone providing a way of supporting and treating these people in a humane manner.
Not until the Renaissance were more regular records and descriptions of the hospitalization of the mentally ill seen. A perfect example is the St. Mary of Bethlehem hospital in London, which was converted from medical to psychiatric facilities to house the mentally ill. Although the conditions were less than ideal (the term “bedlam,” meaning chaos or mayhem, is derived from the name of this hospital; Bootzin & Acocella, 1996), it was still an improvement over cracking a person’s skull open or burning him or her at the stake. The good news was that society finally had places (other than prisons or the gallows) where people exhibiting abnormal behavior could go to receive some measure of protection from harm, either to themselves or others, and possibly some kind of treatment. The bad news was that these were also places where people were warehoused like animals, ostracized from their families and communities, and treated with unproven methods. At best, the methods were comical (e.g., spinning them around in a mechanical chair at dizzying speeds). At their worst, the techniques were degrading, inhumane, or even deadly (e.g., keeping people chained up indefinitely or confined to very small cells or boxes).
Reforms in the 18th century by influential figures such as Jean-Baptiste Pussin and Philippe Pinel (in Paris) and William Tuke (in England) helped solidify the notion that those who exhibited strange behaviors and experienced disturbing symptoms should be treated in a humane fashion and given the respect and support that individuals would want for themselves or their loved ones. They pioneered a new approach that was known as “moral therapy,” which essentially provided patients with peaceful and supportive environments designed to improve their morale. This was dramatically different from previous approaches and was highly effective, as some records indicate that up to 70 percent of patients showed improvement or recovery (Bootzin & Acocella, 1996).
Benjamin Rush and Dorothea Dix carried on the tradition of moral therapy in 19th-century America, which continued important reforms and led to the rapid construction and expansion of psychiatric hospital facilities directly supported at the state level. Unfortunately, the growth of the facilities outpaced the training of new professionals in the methods of moral therapy, and there were not enough qualified people to staff these new hospitals (Comer, 2003). At about the same time, with the rise in power of the medical profession, the focus in Europe and America began to shift toward biological research and interventions. Thus, moral therapy fell out of favor, and the therapeutic gains and impressive rates of improvement and recovery were also lost.
However, there were some positives to come out of this period of rapid growth in the number of hospitals and the emphasis on studying and classifying abnormal behavior. For example, Wilhelm Wundt, considered by many as the father of experimental psychology, established the first experimental psychology lab in 1879 in Leipzig, Germany. Emil Kraepelin, one of Wundt’s students, devoted his career to applying Wundt’s methods and techniques to the study of abnormal behavior (Bootzin & Acocella, 1996). If Wundt is the father of experimental psychology, then his student Kraepelin can be considered the father of experimental abnormal psychology. Kraeplin published his Textbook of Psychiatry in 1883 and gave professionals one of the first comprehensive classification systems of psychopathology. In the early 1900s, several hospitals developed their own research labs, capitalizing on the powerful combination of science and medicine, which would lead to exciting discoveries and advances, particularly in the rapid development and trials of new medications. The 1950s in particular saw dramatic advances with the discovery of new medications, most notably antipsychotics (also known as neuroleptics or major tranquilizers) such as Thorazine.
Assessment and Research
Psychologists use many tools and methods to help answer questions pertaining to abnormal psychology. Regardless of the setting or their primary role (clinician, researcher, or some combination of both), psychologists strive to be systematic and scientific in their approach to studying and treating abnormal behavior so that their findings might help further the knowledge base of the field and improve the lives of other people who may be struggling with a similar set of distressing symptoms.
In order to collect data, psychologists must perform some kind of assessment. Assessment comes in many forms to suit many purposes, but all assessments have in common the properties of reliability and validity. Reliability is similar to the concept of consistency or the ability to get the same result each time you measure something. Measuring a person’s height repeatedly with a steel tape measure will give you a highly reliable value (assuming there is no human error in using the tape measure). The scale used (inches and feet) is extremely precise, and the material used to construct the tape measure is highly durable. Imagine instead that you were trying to measure someone’s height with a device employing scale that simply divided everyone into two categories (short or tall) and was constructed of elastic. You would not be able to reliably measure height (especially for those whose height put them around the cutoff between “tall” and “short”) because the scale is extremely broad and the elasticity of the instrument might cause that cutoff to shift around each time you stretched the elastic from head to toe.
If reliability is similar to consistency, then validity is comparable to the concept of fidelity or the idea that you are truly measuring what you think you are measuring. If you wanted to measure a person’s weight, then you would have them step on a good (i.e., reliable) scale of some kind that would give you information about total pounds, kilograms, and so on. However, borrowing from the previous example, imagine again that you are using a steel tape measure (using a scale of inches and feet) but you are interested in measuring a person’s weight. You extend the tape measure from head to toe, record that value, and then draw a conclusion about how much the person weighs based on the numbers generated by your measurement using the steel tape measure. Although height and weight are correlated (the taller a person is, the more he or she weighs, generally speaking), height and weight are separate concepts with different units of measurement (i.e., distance vs. mass). In this example, even though the tape measure is still very precise (i.e., reliable), you have not measured what you originally intended to measure. Therefore, using a measure of distance to assess mass is not a valid assessment. This example also illustrates a very important relation between reliability and validity, because although it is possible to have reliability without validity, you can never have validity without reliability.
Psychologists use statistical procedures (usually a correlation or some variation of it) to help establish and communicate the reliability and validity of an assessment, and both reliability and validity come in various forms. Once multiple types of reliability and validity are established, other psychologists can begin to use an assessment to collect data.
The type of assessments psychologists use depends on the nature of the data and the questions they are trying to answer. Assessments come in several formats, such as self-report instruments, behavioral observations, psychological tests, and physiological measures. Examples of self-report assessments include the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996), the State-Trait Anxiety Inventory (STAI Form Y; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), and the Minnesota Multiphasic Personality Inventory (MMPI-2; REF). The BDI and STAI have a series of statements that are rated on a Likert-type scale based on how much the reader believes the statement applies to his/her symptoms and behavior. The MMPI is a well-known and widely used assessment that consists of over 500 true/false statements. All of these instruments have been standardized and normed on various groups so that psychologists can take the scores obtained in clinical and research settings and meaningfully interpret and compare them relative to the norms.
Behavioral observation is a popular assessment strategy that psychologists have used for many years. It offers objectivity and translates easily into quantifiable values, and can be a simple but elegant way to determine if changes in behavior are occurring. Psychologists design and use various devices (called apparatus) to collect different types of data, depending on what the researcher needs to quantify. Counting the number of times a behavior occurs would require some measure of frequency. The length of time a behavior lasts would be a measure of duration. The amount of time that passes before a behavior occurs is latency. The amount of effort required to engage in an activity or accomplish a task would be a measure of intensity. Variations and combinations of these measures allow psychologists to quantify a number of important dimensions of behaviors. A good example of this combined approach is behavioral coding, which is a form of behavioral observation where expertly trained and supervised researchers watch (either live in an unobtrusive manner or via video recording) for target behaviors and then rate or code them along various dimensions using predetermined definitions and coding sheets.
A good example of a psychological test is the Wechsler Adult Intelligence Scale (WAIS-III; Wechsler, 1997), which has various tasks and several subscales, including domains assessing motor performance and verbal abilities. A trained professional gives standardized instructions for each task, records the responses, and then scores the responses and generates subscale scores as well as an overall intelligence score (sometimes called the intelligence quotient, or IQ). A psychological test like the WAIS is essentially a combination of self-report (since the subject is required to report his or her own level of knowledge about certain things) and behavioral observation or behavioral coding (since the clinician must observe, record, and score responses based on standardized instructions and scoring criteria).
As technology continues to evolve, what psychologists can measure (and the precision they can measure it with) continues to expand as well. Recent advances in medical technology have allowed psychologists to go inside the active mind and body and measure responses that previously they could only speculate about or measure indirectly. A good example of a relatively recent advance is functional magnetic resonance imaging (fMRI), a technique that maps the structure and function of the brain (and other parts of the body) in real time. Previously, psychologists were more limited to techniques that singularly measured electrical activity, muscle activity, and rates of metabolism, for example. Assessments of these characteristics are still useful and being performed in many labs, and have also improved with technological advances such as faster and more powerful computers. All of these technological assessment strategies are highly precise, and the equipment used to measure and record data, while often very expensive, is highly valuable to a psychologist who is helping to study, diagnose, and treat conditions that would otherwise remain a mystery.
No matter the question and the measures used to help provide answers, psychologists recognize that using a single measure of a single type and in a single way is very limiting. Therefore, a good rule of thumb is to take multiple measurements in multiple formats and under various conditions, often referred to as a multimodal, multimethod assessment strategy. This approach gives psychologists a much broader, clearer picture of the individual and his or her behavior and helps put everything into context and perspective.
The research questions and assessment strategies will also directly influence the research methods used. Many studies in abnormal psychology are not true experiments, per se, because it is not possible or ethical to experimentally control or manipulate a certain condition. For example, it is important to know if there are significant sex differences in the prevalence of certain disorders, because this may provide clues as to the etiology of symptoms. However, it is not possible to randomly assign research participants to their sex; they bring this characteristic and all things related to it with them into the study. Psychologists can statistically analyze these variables, also known as subject variables, and treat them as independent variables. However, this does not change the fact that they have not experimentally manipulated anything, and therefore cannot draw cause-and-effect conclusions based on their results. Much of the epidemiological data gathered on the prevalence of mental disorders and their associated features is correlational because of the design limitations mentioned above. However, this research strategy is still useful and important, because it not only provides good descriptive data but also often points researchers toward important questions needing additional experimental exploration.
Research designs that are experimental in the more traditional sense include longitudinal studies and twin studies. Longitudinal studies involve tracking the same people over time, or gathering repeated measures of a behavior, trait, physiological response, and so on. This design is very helpful in terms of documenting changes within people over time. However, its primary limitation lies in the inability to attribute any changes that occur to a specific cause. In other words, if a young man’s symptoms of social phobia improve over time, is it because he received good treatment, is it a matter of development and maturation, or is it simply a matter of severe symptoms moving closer to an average level because statistically there is nowhere else to go? In order to overcome this limitation, scientists must use a control group of some kind.
Studies of twins, particularly identical or monozygotic twins, can provide the control group that longitudinal studies may lack. Because identical twins are exactly the same genetically, studying them provides important clues about the respective influences of nature and nurture in the development of abnormal behaviors and mental disorders. Identical twins reared separately provide a unique opportunity to study two genetically identical people raised in different environments. Tracking identical twins reared together and apart over time can be a very powerful, albeit very resource-intensive, research strategy because it combines the advantages of both longitudinal and cross-sectional methods.
Because of the relative rarity of many disorders, and because of practical and ethical limitations on what researchers are allowed to do, psychologists have developed research strategies and observational methods based on very small sample sizes or even single cases. Descriptive case studies were informal precursors to single case designs used today, because they provided a wealth of information about the background and baseline of a client’s functioning and his or her progression through treatment. The simplest single case design is the treatment withdrawal design, or the ABAB design. This design strategy involves measuring target behaviors during a baseline phase, “A,” followed by the intervention phase, “B,” and then a withdrawal of the treatment, the second “A,” and finally a second implementation of the intervention, the second “B.” This design helps psychologists be confident that any changes that occur within the person are not simply due to the passage of time or spontaneous remission of symptoms. As you can imagine, withdrawing a successful treatment is not always ethical or practical, and in the absence of large, grant-funded treatment outcome studies, many practicing clinicians must be satisfied with AB designs and the hope that it is, in fact, the treatment that contributes to positive changes and symptom reductions.
Diagnosis and Treatment
Many psychologists are interested in classifying and treating disorders that cause distress and impairment. Clinical psychologists, in particular, have specialized training that teaches them to recognize characteristic symptom clusters (sometimes called syndromes) and apply empirically supported theories and techniques to treat the disorders.
The first step in any successful treatment is the correct identification of the problem(s) at hand. This may sound simple, but because multiple problems often cluster together and symptoms of different disorders can overlap with one another, the process of differential diagnosis can be quite complex and requires a psychologist to be very patient, observant, objective, and thorough in his or her exploration. Most psychologists also use a common diagnostic system that many different professionals are familiar with (the DSM-IV-TR, mentioned previously) and that makes accurate diagnosis somewhat easier. The DSM system provides psychologists not only with an approved set of diagnostic labels that facilitate communication and record keeping but also empirically validated diagnostic criteria for each disorder, descriptions of associated features and prevalence data, suggestions of other disorders to double-check and rule out as part of a differential diagnosis, and a standardized method of recording information on five different dimensions or axes (American Psychiatric Association, 2000).
Even with a classification system like the DSM in place, treating mental disorders (also referred to as psychotherapy or simply therapy) can be difficult and complex work. People are complicated, and so are their problems and their motivations for change. Each new client represents a single-case design experiment, of sorts, in that once a psychologist has identified the problems and potential solutions (i.e., the hypotheses), he or she uses theory to develop and implement interventions (i.e., the independent variables) and then evaluates the outcomes (i.e., the dependent variables) of therapy.
The theories used depend in part on the training background of the psychologist, what the scientific literature says about certain treatment methods for certain disorders, and the preferences of the client. Each theoretical perspective on therapy has its own concepts, definitions, and explanations for the causes and treatments of mental disorders. Although some sources indicate that there are over 400 unique theories of psychotherapy (Kottler, 2002), most psychologists agree that there are only a handful of primary perspectives; the different combinations and points of emphasis of these perspectives can account for the wide variety of therapeutic approaches.
The biological or medical perspective needs to be mentioned here, because even though most psychologists do not typically receive medical training, it is still important for them to know what the current medication options are, how they work, and what some of the potential side effects might be so they can liaise with prescribing physicians as part of a treatment team. Additionally, although hotly debated and controversial within the disciplines of both psychology and medicine, there are situations in which a psychologist could receive training and certification for limited prescription privileges. Essentially, the biological perspective looks for changes in the structure or functioning of the physical body to explain abnormal behavior and emotional states. If medical researchers can identify biological causes, then finding a way to reverse or minimize those physical changes becomes an obvious target for medical treatments. For example, changes in levels of certain chemicals or neurotransmitters in the brain, particularly decreases in serotonin, can cause increases in depressive symptoms. Therefore, finding a medication that has the net result of increasing serotonin levels should theoretically help minimize or eliminate those symptoms. This is, in fact, the very strategy employed when a professional prescribes a selective serotonin reuptake inhibitor (SSRI) for depressive symptoms that are severe enough to impair a person’s day-to-day functioning. By blocking the natural processes of reuptake and breakdown of serotonin, more of it remains in the synaptic gaps and is therefore readily available to receptors on other neurons in the brain. Unfortunately, there may be side effects that result from interfering with these processes, and that is why close monitoring and considerable medical knowledge and experience with dosage and side-effects profiles are critical. The medications used today have a much milder side-effects profile than those used just a few decades ago, and pharmaceutical companies spend record amounts on research and development of new medications each year. Other biomedical treatments besides psychotropic medications exist—for example, electroconvulsive shock therapy (ECT) and various forms of psychosurgery (e.g., severing the corpus callosum in cases of severe epilepsy).
Sigmund Freud (one of the most influential and controversial figures in psychology) developed and promoted the psychodynamic model in the early 1900s in Europe. Although not very scientific, his theory of personality development and functioning was certainly very descriptive and continues to impact our thinking today. If you’ve ever heard someone described as being anal-retentive because he or she is excessively neat and a little too high-strung, then you are familiar with some of Freud’s concepts. Freud believed that people were driven by unconscious forces and wishes rooted in their past, and that only by uncovering and understanding the unconscious could a person develop into a healthy, mature adult. Although his training as a neurologist caused him to approach many issues from a medical perspective, Freud’s model also had the advantage of incorporating some of the effective elements of moral therapy mentioned previously, most notably listening to patients talk and providing a safe environment in which to express and process emotions. Freud and his colleagues and students expanded and modified the psychodynamic model, and the image from traditional psychoanalysis of a patient lying on a couch and talking about anything and everything while the clinician listens in an intent but detached and objective manner is what many people think of when asked to describe psychotherapy. The notion of the unconscious, or at least differing states of consciousness, descriptions of coping strategies or defense mechanisms, and the concept of resistance as a natural and predictable part of the therapeutic relationship are all important and relevant in discussions of psychotherapy today (Kottler, 2002).
Carl Rogers and Abraham Maslow, the pioneers of the Humanistic perspective, also made significant contributions to our understanding of psychotherapy and the therapeutic alliance. Humanism, at its core, holds the beliefs that all people have intrinsic worth and that unrealistic and unhealthy demands, or conditions of worth, placed on them by significant others as well as themselves interfere with natural development and achievement. Rogers and Maslow taught people that if they could experience therapeutic acceptance from someone else, then they could accept themselves, keep things in proper perspective, and live their day-to-day lives in a more fulfilling manner. Although overly optimistic in some ways, this perspective teaches psychologists the importance of listening to and connecting with their clients in therapy, experiencing the moment, and avoiding being overly judgmental or critical of people (Kottler, 2002).
In the early 1900s, psychology was gaining momentum as a distinct profession and a relatively new branch of science, particularly in America. Psychologists such as James Watson, one of the forefathers of the psychological perspective of behaviorism, proposed that psychologists use the methods of science to better understand and predict observable behavior. Watson believed that if you couldn’t measure it, it couldn’t be studied scientifically, and therefore was not worthy of a true scientist’s attention. His focus on controlling and measuring observable behavior under strict experimental conditions contributed greatly to our understanding of how people learn and develop new behavioral responses. Students of Watson, including Rosalie Rayner and Mary Cover Jones, developed methods that showed how people could learn anxiety and fear, and just as importantly, how these responses could be unlearned and replaced with new behaviors. Other behaviorists, notably B. F. Skinner, have also had considerable influence on the field of psychology because of work with operant conditioning models of learning. Many of the strategies used to control dysfunctional behaviors have at their roots behavioral concepts and interventions. If you have ever witnessed children spending time in “time out” or being asked to eat their vegetables before getting dessert, then you know something about behavior and the context it occurs in, and how behavior can be modified by cues and contingencies.
Psychologists can apply the same principles in therapy. Systematic attention to positive behavior change and selective ignoring of inappropriate or maladaptive behaviors are one example. Differential reinforcement of prosocial behaviors (e.g., eye contact and smiling) in people recovering from an active phase of schizophrenia is another example. Token economies rewarding achievement and engagement in adaptive behaviors in children with pervasive developmental disorders such as mental retardation are yet another example. The applications are practically limitless once you understand the theory and principles of learning. Furthermore, because behaviorism has its roots in empirical psychology, it is relatively easy to evaluate effectiveness of an intervention because assessment is a built-in and continuous element of therapy (Kazdin, 2001). Albert Bandura, the father of social learning theory, took the work of people like Pavlov, Watson, Thorndike, and Skinner and created a comprehensive and integrated model of learning that included cognitive and social components. Although Watson and Skinner might disagree, most psychologists today believe that a person’s thoughts and internal emotional states are valid targets for psychological intervention. The difficulty has always lain in the scientific measurement of these aspects, but there are ways of collecting good, meaningful data if you understand the strengths and limitations of things like self-report measures. Behavioral and cognitive applications of psychology have evolved and merged into one general discipline, often called cognitive behavioral therapy (CBT), and is heavily emphasized in many psychology training programs because of its documented effectiveness and scientific underpinnings.
Last but not least there is the sociocultural or systemic perspective on therapy. Proponents of this model argue that treating symptoms within an individual essentially ignores the fact that people do not live and function in isolation, but rather move in circles as a part of various systems (family, couples, community, culture, etc.). They also contend that linear models of abnormal behavior are too simplistic, and that circular models involving feedback loops are more descriptive and accurate. The idea is that a member of a system can both cause change in and be changed by other members and dynamics within the system (Gladding, 2006). The emphasis on understanding ethnic and cultural influences also helps psychologists be sensitive to differences between themselves and their clients, and not to assume that values about, beliefs of, and goals for therapy are always going to be the same. There are entire specialties within psychology, such as multicultural psychology and marriage and family therapy, that have many of these key concepts and values at their core. They provide psychologists with a broader perspective and an ability to treat problems in context where possible and necessary, and give clients more options in terms of the type of psychological treatments available.
The research literature on the effectiveness of therapy is clear: seeking professional help is clearly more effective than waiting or doing nothing, and up to the point of diminishing returns more time in therapy is usually better than less (Miller & Rollnick, 2002). However, psychologists have been less successful identifying the exact components of therapy that are necessary for changes to occur. Some argue it is the systematic measurement and control of behavioral contingencies that allows for new learning to occur. Others insist it is the supportive relationship between a psychologist and a client that facilitates a natural developmental process. Still others maintain it is the cathartic release of emotion and constructive identification and resolution of conflict within the individual that creates new insights and choices. Finally, there are those who contend that truly changing a problem or symptom cannot occur until the system (e.g., the family, the community, or the culture) that elicits and maintains such behaviors is also changed.
Even the time required for therapy to be effective varies depending on the client, his or her problems, the treatment setting, and the primary orientation of the clinician. Although more therapy is generally better, there are circumstances in which a single session can be helpful in facilitating meaningful change and relief from symptoms (Kottler, 2002). This is in stark contrast to the classic model of psychoanalytic psychotherapy, which required patients to attend multiple sessions per week for several years. A typical course of therapy today at an outpatient facility would probably require meeting for 45 to 90 minutes once a week (or every other week) for several weeks to months. The psychologist and the client would spend the initial portion of therapy getting to know each other, gathering important information about the presenting problem(s), identifying goals and expectations for treatment, and creating a treatment plan. Implementing interventions consistent with the treatment plan and client goals would occur in the next phase, followed by evaluation of outcomes, termination (if goals had been accomplished and there were not any other issues to address), and follow-up (including checkups or booster sessions, as they are sometimes called) as necessary. Note that assessment in some form should occur at each and every stage of therapy, and is often required in order to fully document and evaluate the effectiveness of therapy.
With a few exceptions, there is no one simple answer and no one perfect treatment. Psychologists view the complexities and ambiguities of treatment as an important challenge, and as reasons to be even more disciplined and systematic in their work. An important part of the discipline of psychology, in particular conducting therapy, is the code of ethics that anyone identifying himself or herself as a psychologist must follow. This code of ethics was developed by the American Psychological Association and contains five general principles and several more specific standards to guide the practice of psychology (American Psychological Association, 2002). The code of ethics serves to protect the public from unscrupulous or incompetent psychologists, and also preserves the integrity of the profession by defining and enforcing standards of behavior that go above and beyond what is simply legal or illegal.
Abnormal psychology is a fascinating and dynamic area of study. Determining what is normal and what is abnormal is a complex and sometimes subjective task for psychologists, and they use multiple dimensions to help make this determination. The roots of abnormal psychology can be traced all the way back to prehistoric practices, but key figures in the Renaissance through the early 1900s helped launch abnormal psychology as a scientific discipline. Psychologists use scientific methods to assess and study abnormal behavior, and must be knowledgeable and creative in the applications of these methods. The emphasis on science also influences the diagnosis and treatment of abnormal behavior and mental disorders. Most psychologists use a common diagnostic and classification system (i.e., the DSM-IV-TR), and are trained in multiple theoretical models (e.g., psychodynamic, humanistic, cognitive-behavioral, and systemic perspectives) of the causes and treatments of abnormal conditions that cause distress and functional impairment. In addition, psychologists follow a detailed code of ethics that guides their behavior when studying and treating psychopathology, which protects the public and preserves the integrity of the profession of psychology.