Chapter 15
Abnormality, Therapy, and
Social Issues
Abnormality, Therapy and Social Issues • On the surface it would appear that there is
normal and abnormal behavior, and the
distinction between normal and “weird” is clear to everyone.
• But when we go deeper into the issue of normal versus abnormal, we start to see that behavior must be interpreted in its context. Normal is a matter of place and time as well as mental state and action.
Module 15.1
Psychopathology
• Most of us feel sad, anxious, or angry occasionally.
• Our moods change, we have or develop bad habits, and we have “funny” beliefs.
• Mental health diagnoses are reserved for people with problems that seriously interfere with their lives.
Defining Abnormal Behavior
• There is probably no definition of “abnormal” that can’t be questioned.
– If we use the standard of “subjective feelings of distress” than anyone who thinks they have a problem automatically qualifies.
– If someone behaves in bizarre and dangerous ways, but insists that they are fine, many
people who are in fact suffering from mental illness could not be diagnosed and treated.
Defining Abnormal Behavior
• If we say that behavior that could result in suffering or death is a sign of mental illness, heroic deeds would be a bona fide symptom.
• If we say that behavior that is very different from the usual is a sign of a psychological disorder, very depressed people would be diagnosed, but so would very happy people.
Defining Abnormal Behavior
• Cultural influences on abnormality
– Culture-specific disorders are found everywhere and in every era.
• Demonic possession has been a common diagnosis for thousands of years.
• Brain fag syndrome is a frequent complaint of West African students.
• Running amok consists of episodes of indiscriminant violent behavior in young Southeast Asian men.
Defining Abnormal Behavior
• Cultural influences on abnormality
– An American example: Multiple Personality
Disorder
• The “split personality” syndrome, this is now
referred to as dissociative identity disorder.
• There is alternation between two or more personalities.
• Each has its own disposition, behavior, and name, as if each were a separate person.
Defining Abnormal Behavior • Cultural influences on abnormality
– This was a very rare disorder until the 1950’s, when a few cases received widespread
publicity The movie, “Sybil.”
– By the early 1990s there were many cases of DID reported.
– Some observers began to claim that the disorder did not exist at all.
– It is most likely that it was promoted by suggestion of over eager therapists.
Defining Abnormal Behavior • The biopsychosocial model
– The predominant view in Western culture today uses the biopsychosocial model to understand mental illness.
• Biological roots - include genetic factors, injury, disease processes that result in
abnormal brain development, damage, imbalances of neurotransmitters and hormones, all of which can result in abnormal behavior.
Defining Abnormal Behavior • The biopsychosocial model
– Psychological roots – an individual’s life history and experiences contribute to his or her ability to cope and degree of vulnerability to stress.
– Social and cultural context – people are greatly influenced by how other people act
toward them and the expectations people hold for them.
Classifying Psychological Disorders • The DSM-IV
– The Diagnostic and Statistical Manual of Mental Disorders
• Establishes uniform definitions and standards for diagnosis.
Classifying Psychological Disorders • The DSM-IV
– The Diagnostic and Statistical Manual of Mental Disorders
• Lists acceptable labels for all psychological disorders.
• Lists symptoms and criteria for making diagnoses and contains information on
differential diagnosis – making distinctions between similar diagnoses.
Classifying Psychological Disorders • The DSM-IV
– Diagnosis is made along five axes (lists).
– A person can have one or more diagnoses on a given axis, or none at all.
– Clinical disorders are diagnosed on Axis I. These are disorders that involve deterioration of functioning.
– Most common psychological disorders are listed on Axis I.
Table 15.1
Classifying Psychological Disorders • The DSM-IV
– Axis II is reserved for personality disorders and mental retardation.
– These are disorders that persist throughout life.
– A personality disorder is a maladaptive,
inflexible way of dealing with situations and people.
Table 15.2
Classifying Psychological Disorders • The DSM-IV
– Axis III is for general medical conditions that
influence the person’s mood or behavior.
– Axis IV is for psychosocial problems that
increase the person’s level of stress.
– Axis V is a 1-100 scale called the global
assessment of functioning. The lower the
number assigned by the assessing clinician, the less adaptive the person’s functioning is judged to be at the time.
Classifying Psychological Disorders • Criticisms of DSM-IV
– The distinction between normal and abnormal can seem arbitrary at times (5 months of a
problem is not a disorder, but 6 months is). – Are criminal behaviors (such as child
molesting) really a sign of mental illness, or some other serious problem?
Classifying Psychological Disorders • Criticisms of DSM-IV
– Is it an adjustment to a life stressor, or is it a mental illness?
– Statistics on prevalence of disorders are uncertain and at times seem inflated.
– To what extent is the situation the problem, rather than the person?
Figure 15.1
Figure 15.1 In this survey just over a quarter of U.S. adults suffer a psychological disorder in any given year, and nearly half do at some time in life. This figure combines results for men and women of all adult ages. (Based on data of Kessler, Berglund, et al. 2005 Kessler, Chiu, Demler & Walters 2005)
Psychological Disorders
• There is a stigma associated with receiving a mental health diagnosis.
• It is possible that as many as 50% of the
population has a diagnosable mental illness at
some time in their lives (according to the standards of the DSM-IV).
• If this is true, people with psychological disorders are not different from the rest of us.
Module 15.2 • Psychotherapy: An Overview
Psychotherapy
• Psychotherapy is a treatment of psychological disorders by methods that include an ongoing relationship between a trained therapist and a client.
• Psychotherapy is utilized for a wide variety of disorders.
Psychotherapy
• Psychotherapy is sought by or prescribed for a diverse range of clients, from those with very serious emotional disturbance, to the “worried well” and those who are basically well but wish to function more effectively.
• There are many techniques of psychotherapy, but all of them seem to depend in large part on the client’s motivation to improve.
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies are based on the theories of Sigmund Freud.
• These methods relate personality to the interplay of conflicting forces in the person. • The individual may be unaware of these
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies are based on the theories of Sigmund Freud.
• Psychoanalysis is the oldest “talk”
therapy. It attempts to bring unconscious thoughts and emotions to awareness, and help people understand their own thoughts and actions.
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies
• Psychoanalysis uses free association and transference to bring unconscious material to consciousness.
• This in turn produces catharsis, the
release of pent-up emotions associated with unconscious thoughts and memories.
Figure 15.2:
• Figure 15.2: The goal of psychoanalysis is to resolve psychological problems by bringing to awareness the unconscious thought processes that created the difficulty.
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies
• In free association, the client thinks about a symptom or problem and then says
everything that comes to mind related to it. • This process is supposed to uncover
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies
• Transference refers to the client’s experience of feelings previously
associated with a parent or other important figure that are “transferred” to the therapist.
Schools of Psychotherapy • Psychoanalysis
– The psychodynamic therapies
• Psychoanalysts and other psychodynamic therapists make active interpretations of the client’s statements.
• If a client disagrees with the therapist’s interpretations, they may label this as resistance, a continued repression that interferes with therapy.
Schools of Psychotherapy
• Behavior therapy
– Behaviorists believe that human behavior is
learned and can be unlearned. Behavioral
therapy is based on this principle.
• Treatment begins with specific behavioral goals, such as “stay in seat for entire class period” or “spend a maximum of X dollars a week.”
• The treatment plan entails how the client will
learn to behave in ways that will help to achieve the goals.
Figure 15.4
Figure 15.4 A child can be trained not to wet the bed by using classical conditioning techniques. At first, the sensation of a full bladder (the CS) produces no response, and the child wets the bed. This causes a
vibration or other alarm (the UCS), and the child wakes up (the UCR). By associating the sensation of a full bladder with a vibration, the child soon begins waking up to the sensation of a full bladder alone.
Schools of Psychotherapy
• Therapies that focus on thoughts and beliefs
– Some therapies focus on what current mental processes, not past thoughts and feelings.
• Cognitive therapy improves functioning by
changing people’s thoughts and beliefs about situations.
• Rational-emotive therapy assumes that
thoughts precede emotions, and that
unpleasant feelings result from irrational thoughts.
Schools of Psychotherapy
• Therapies that focus on thoughts and beliefs
– Cognitive-behavior therapy sets clear goals for changing behavior (like a behavioral
therapist).
– The therapist puts more emphasis on also changing the person’s interpretation of
thoughts and events (like a cognitive therapist).
Schools of Psychotherapy • Humanistic therapy
– Humanistic therapists believe that people
naturally strive to achieve their full potentials. • The source of psychological distress is
perceived incongruence between an
individual’s self-concept and ideal image of self.
• The most common humanistic therapy is
person-centered
Schools of Psychotherapy • Humanistic therapy
– Person-centered therapy
• The therapist listens to the client
non-judgmentally and provides unconditional
positive regard, an ideal state like the
regard that a loving parent has for a child.
• The therapist tries to be genuine, empathetic and caring, and tries not to interpret the
Table 15.4
Concept Check:
In which type of therapy would the therapist be
most likely to interpret a thought, feeling or dream?
Concept Check:
In which therapies are treatment goals stated in clear and specific terms?
Concept Check:
In which therapy is the client viewed as
essentially good and wishing to achieve full potential in life?
Schools of Psychotherapy • Family systems therapy
– Family systems therapy treats the person in the context of the family.
• The underlying assumption is that an individual’s problems arise in a family setting.
• The best way to deal with these is to improve family relationships and
Schools of Psychotherapy • Other trends in psychotherapy
– Eclectic therapists do not use a single method exclusively, but a combination of approaches.
– Brief therapy models in which the therapist and client agree to a certain length, number of meetings, expectations and goals for the
Schools of Psychotherapy • Other trends in psychotherapy
– Group therapy involves the treatment of many clients by one or two therapists on an ongoing basis.
– It’s less expensive and allows the clients to help each other with advice and feedback. – Self-help groups work in a similar way but
Psychotherapy • How effective is psychotherapy?
– According to some research studies, many people start to feel better anyway without psychotherapy (spontaneous remission). – Meta-analysis of many studies of
psychotherapy suggests that a majority of people do show improvements after therapy. – Keep in mind the “file-drawer” effect when
Psychotherapy • How effective is psychotherapy?
– A recent study by Consumer Reports of
mental health treatment and psychotherapy supported the conclusion that most mental health treatment is helpful in improving the psychological and emotional well being of clients.
Psychotherapy • How effective is psychotherapy?
– Evaluating effectiveness of psychotherapeutic treatment is complicated, but there are distinct advantages to seeking professional mental
health care.
– A trained clinician keeps confidentiality, uses methods with some demonstrated level of
effectiveness, makes referrals to other
professionals if other problems are suspected (for example, additional medical problems).
Psychotherapy • How effective is psychotherapy?
– Similarities among psychotherapeutic methods
• The creation of a therapeutic alliance that offers social support for the client.
• The opportunity for the client to engage in self-examination (this is not an advantage cross-culturally, though).
Psychotherapy • How effective is psychotherapy?
– Similarities among psychotherapeutic methods
• The opportunity to receive encouragement from the therapist on a regular basis.
• There is an affirmation of the client’s desire to change and improve.
Psychotherapy
• How effective is psychotherapy? – Advice for potential clients
• Ask the local Mental Health Association for some recommendations.
• You may feel most comfortable with a
therapist from a cultural background that is similar to yours.
• If spirituality or religion is important to you, you may want to find a therapist who
Psychotherapy
• How effective is psychotherapy?
– As with any other “remedy” be skeptical of
overconfidence and claims of amazing results. – Expect at least some small improvement within
a couple of months of starting, and don’t be afraid to ask for your therapist’s input if this doesn’t happen.
– Be an active participant in your own treatment – nobody “fixes” you, rather, you receive help in changing your own life.
Finding the Best Therapy
• Research suggests that the various methods of therapy and professionals who provide services are about equally effective. There is no “best” type of therapist or best method.
• But no one way of doing psychotherapy is right for every client. You need to use your knowledge to “shop” for the therapist who will work best with you.
Module 15.3
Deinstitutionalization
• Deinstitutionalization refers to the trend over the second part of the twentieth century of removing patients from mental hospitals.
• There are alternatives to long-term inpatient care. Unfortunately, many patients were
discharged without the benefit of adequate planning for their future care.
Deinstitutionalization
• As a result of this lack of foresight, many former mental hospital patients are now:
– Homeless
– Placed in nursing homes – Imprisoned
Involuntary Commitment and Treatment
• In the case of people with severe mental health problems, the right to live freely among others can come into conflict with the rights of others. • If a person’s mental state represents a serious
danger to self, others or causes the individual to be completely unable to care for him or herself, serious ethical issues are raised.
Involuntary Commitment and Treatment • There are many potential problems in the
process of involuntary commitment:
– Not all seriously mentally ill patients realize that they are ill.
– People have been committed to mental hospitals just to be put “out of the way.” – It is extremely difficult to determine which
Involuntary Commitment and Treatment • Usually the opinion of one or more trained
professionals plus court action must be obtained in order to commit a person with a mental
illness.
• Even after commitment, the patient is always given the right to refuse specific treatments.
The Duty to Protect • The Tarasoff case
– The Tarasoff case established that a therapist who knows that a client has harmful intent
towards an identified person or persons has a duty to break confidentiality with the client to protect the endangered person.
– Judging dangerousness is not a clear-cut matter and the therapist must often weigh
carefully the factors. Breach of confidentiality is a serious violation of the patient’s rights.
The Duty to Protect • The insanity defense
– Insanity is a legal term, not a psychological or medical one.
• Its definition is more judicial than scientific. • Bizarre crimes in and of themselves do not
demonstrate insanity.
• The most famous definition of insanity is based on the M’Naghten rule, from 19th Century British law.
The Duty to Protect • The insanity defense
– The M’Naghten rule
• The gist of the law states that in order to be judged insane at the time of a crime, a
person must be so disordered that they cannot understand what they are doing.
• Some legal authorities felt that this rule was too narrow and rigid.
The Duty to Protect • The insanity defense
– Under 1% of accused felons plead insanity. – The insanity defense is extremely rare.
– These cases receive a great deal of media attention.
– If the person is found not guilty by reason of insanity, they will likely be institutionalized for a very long time.
Preventing Mental Illness
• Some psychologists, especially community
psychologists have started to create movement towards preventing mental illness.
– Community psychologists focus on the needs of groups rather than individuals.
– They look at various routes to circumventing mental illness or lessening its damaging
Preventing Mental Illness
• Prevention methods are aimed at stopping mental illness before it begins.
• Intervention involves identifying a disorder in its early stages and relieving it.
• Maintenance is taking steps to prevent an illness from becoming more serious.
“An ounce of prevention is worth a pound of cure.” -- Old aphorism
Preventing Mental Illness
• Some steps that would help in prevention efforts: – Ban use of environmental toxins
– Promote good prenatal care and education
– Control smoking in public places and educate the public about the risks of smoking
– Promote full employment
– Provide high quality and affordable child care – Improve educational opportunities
Concept Check:
• Can you think of some other steps that would promote good mental health and improve
Mental Illness: Science and Society
• The issues we have examined in this module are complex and involve scientific, social and ethical dimensions.
• Even if you do not grow up to be a psychologist, as a citizen of our country it is in your best
interest to be informed about the social and legal aspects of mental illness and the benefits to
