Abnormal Psychology Exam 1

1.15. Compare and contrast the different clinical research methods used in studying abnormal behavior. The basic concepts should be review from prior courses, so know the basics of correlational and experimental methods. Perhaps less familiar are the concepts related to epidemiology and the protection of human participants.

A case study is a detailed description of a person's life and psychological problems. It describes the person's history, present circumstances, and symptoms. It may also include speculation about why the problems developed, and it may describe the person's treatment. When investigators are able to rule out all possible causes except one, a study is said to have internal accuracy, or internal validity. Obviously, case studies rate low on that score. When the findings of an investigation can be generalized beyond the immediate study, the investigation is said to have external accuracy, or external validity. Case studies rate low on external validity, too. Correlation is the degree to which events or characteristics vary with each other. The correlational method is a research procedure used to determine this "co-relationship" between variables. Epidemiological studies reveal the incidence and prevalence of a disorder in a particular population. Incidence is the number of new cases that emerge during a given period of time. Prevalence is the total number of cases in the population during a given period; prevalence includes both existing and new cases. In quasi-experiments, or mixed designs, investigators do not randomly assign participants to control and experimental groups but instead make use of groups that already exist in the world at large. In natural experiments, nature itself manipulates the independent variable, and the experimenter observes the effects. Natural experiments must be used for studying the psychological effects of unusual and unpredictable events, such as floods, earthquakes, plane crashes, and fires. Because the participants in these studies are selected by an accident of fate rather than by the investigators' design, natural experiments are actually a kind of quasi-experiment. Experimenters often run analogue experiments. Here they induce laboratory participants to behave in ways that seem to resemble real-life abnormal behavior and then conduct experiments on the participants in the hope of shedding light on the real-life abnormality. Finally, scientists sometimes do not have the luxury of experimenting on many participants. They may, for example, be investigating a disorder so rare that few participants are available. Experimentation is still possible, however, with a single-subject experimental design. Here a single participant is observed both before and after the manipulation of an independent variable

3.2. Discuss the roles of the clinical interview, tests, and observations in diagnosing mental illness.

A clinical interview is just such a face-to-face encounter. Beyond gathering basic background data of this kind, clinical interviewers give special attention to those topics they consider most important. Psychodynamic interviewers try to learn about the person's needs and memories of past events and relationships. Behavioral interviewers try to pinpoint information about the stimuli that trigger responses and their consequences. Cognitive interviewers try to discover assumptions and interpretations that influence the person. Humanistic clinicians ask about the person's self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client's awareness, orientation with regard to time and place, attention span, memory, judgment and insight, thought content and processes, mood, and appearance. A structured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals. Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by behavioral and cognitive clinicians, who need to pinpoint behaviors, attitudes, or thinking processes that may underlie abnormal behavior. Clinical tests are devices for gathering information about a few aspects of a person's psychological functioning, from which broader information about the person can be inferred. More than 500 clinical tests are currently in use throughout the United States. Clinicians use six kinds most often: projective tests, personality inventories, response inventories, psychophysiological tests, neurological and neuropsychological tests, and intelligence tests. Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as "Draw a person." Theoretically, when clues and instructions are so general, people will "project" aspects of their personality into the task. Respondents to a personality inventory answer a wide range of questions about their behavior, beliefs, and feelings. In the typical personality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person's personality and psychological functioning. Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning. Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychological problems. Scientists have developed a number of neurological tests, which are designed to measure brain structure and activity directly. Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks; clinicians interpret abnormal performances as an indicator of underlying brain problems. Intelligence tests consist of a series of tasks requiring people to use various verbal and nonverbal skills. The general score derived from this and later intelligence tests is termed an intelligence quotient (IQ). There are now more than 100 intelligence tests available. In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe clients in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self-monitoring, clients are instructed to observe themselves.

2.6. Summarize the sociocultural models. Describe the various sociocultural-based therapies.

According to the sociocultural model, abnormal behavior is best understood in light of the broad forces that influence an individual. What are the norms of the individual's society and culture? What roles does the person play in the social environment? What kind of family structure or cultural background is the person a part of? And how do other people view and react to him or her? In fact, the sociocultural model is composed of two major perspectives—the family-social perspective and the multicultural perspective. Proponents of the family-social perspective argue that clinical theorists should concentrate on those broad forces that operate directly on an individual as he or she moves through life—that is, family relationships, social interactions, and community events. They believe that such forces help account for both normal and abnormal behavior, and they pay particular attention to three kinds of factors: social labels and roles, social networks, and family structure and communication. The family-social perspective has helped spur the growth of several treatment approaches, including group, family, and couple therapy and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models. However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.

1.6. Describe the somatogenic and psychogenic perspectives of the early 1900s. This lays the foundation for the rest of the course when we study the biological, psychological, and social causes of mental illness.

As the moral movement was declining in the late 1800s, two opposing perspectives emerged and began to compete for the attention of clinicians: the somatogenic perspective, the view that abnormal psychological functioning has physical causes, and the psychogenic perspective, the view that the chief causes of abnormal functioning are psychological. These perspectives came into full bloom during the twentieth century. New biological discoveries also triggered the rise of the somatogenic perspective. One of the most important discoveries was that an organic disease, syphilis, led to general paresis, an irreversible disorder with both physical and mental symptoms, including paralysis and delusions of grandeur. Despite the general optimism, biological approaches yielded mostly disappointing results throughout the first half of the twentieth century. Although many medical treatments were developed for patients in mental hospitals during that time, most of the techniques failed to work. Not until the 1950s, when a number of effective medications were finally discovered, did the somatogenic perspective truly begin to pay off for patients. The psychogenic perspective also had a long history, but it did not gain much of a following until studies of hypnotism demonstrated its potential. Hypnotism is a procedure in which a person is placed in a trancelike mental state during which he or she becomes extremely suggestible. It was used to help treat psychological disorders as far back as 1778, when an Austrian physician named Friedrich Anton Mesmer (1734-1815) established a clinic in Paris. His patients suffered from hysterical disorders, mysterious bodily ailments that had no apparent physical basis. Mesmer had his patients sit in a darkened room filled with music; then he appeared, dressed in a colorful costume, and touched the troubled area of each patient's body with a special rod. A surprising number of patients seemed to be helped by this treatment, called mesmerism. Their pain, numbness, or paralysis disappeared. Several scientists believed that Mesmer was inducing a trancelike state in his patients and that this state was causing their symptoms to disappear. The treatment was so controversial, however, that eventually Mesmer was banished from Paris. Physicians could make normal people experience deafness, paralysis, blindness, or numbness by means of hypnotic suggestion—and they could remove these artificial symptoms by the same means. Thus they established that a mental process—hypnotic suggestion—could both cause and cure even a physical dysfunction. Leading scientists concluded that hysterical disorders were largely psychological in origin, and the psychogenic perspective rose in popularity.

1.13. Compare and contrast the professions that study and treat abnormal behavior.

Before the 1950s, psychotherapy was offered only by psychiatrists, physicians who complete three to four additional years of training after medical school. After World War II, however, the demand for mental health services expanded so rapidly that other professional groups had to step in to fill the need. Among those other groups are clinical psychologists—professionals who earn a doctorate in clinical psychology by completing four to five years of graduate training in abnormal functioning and its treatment and also complete a one-year internship in a mental health setting. Psychotherapy and related services are also provided by counseling psychologists, educational and school psychologists, psychiatric nurses, marriage therapists, family therapists, and—the largest group—clinical social workers. Each of these specialties has its own graduate training program. Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the various specialties often use similar techniques. Clinical researchers have tried to determine which concepts best explain and predict abnormal behavior, which treatments are most effective, and what kinds of changes may be required. Well-trained clinical researchers conduct studies in universities, medical schools, laboratories, mental hospitals, mental health centers, and other clinical settings throughout the world. Their work has produced important discoveries and has changed many of our ideas about abnormal psychological functioning.

1.12. List the current dominant theories in abnormal psychology.

Before the 1950s, the psychoanalytic perspective, with its emphasis on unconscious psychological problems as the cause of abnormal behavior, was dominant. Since then, additional influential perspectives have emerged, particularly the biological, behavioral, cognitive, humanistic-existential, and sociocultural schools of thought. At present, no single viewpoint dominates the clinical field as the psychoanalytic perspective once did. In fact, the perspectives often conflict and compete with one another.

3.1. Define clinical assessment, and describe the concepts of reliability and validity as they pertain to assessment tools, and to classification systems.

Clinical assessment is used to determine whether, how, and why a person is behaving abnormally and how that person may be helped. It also enables clinicians to evaluate people's progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity. Reliability refers to the consistency of assessment measures. A good assessment tool will always yield similar results in the same situation. An assessment tool must have validity: it must accurately measure what it is supposed to measure

2.4. Summarize the cognitive model. Give examples of typical maladaptive assumptions, specific upsetting thoughts, and illogical thinking processes. Describe cognitive therapy. These concepts are key for understanding and treating anxiety and depressive disorders.

Cognitive processes are at the center of behaviors, thoughts, and emotions; we can best understand abnormal functioning by looking to cognition—a perspective known as the cognitive model. Some people may make assumptions and adopt attitudes that are disturbing and inaccurate. Illogical thinking processes are another source of abnormal functioning, according to cognitive theorists. Some people consistently think in illogical ways and keep arriving at self-defeating conclusions, such as through overgeneralization, the drawing of broad negative conclusions on the basis of a single insignificant event. In Beck's approach, called simply cognitive therapy, therapists help clients recognize the negative thoughts, biased interpretations, and errors in logic that dominate their thinking and, according to Beck, cause them to feel depressed. Therapists also guide clients to challenge their dysfunctional thoughts, try out new interpretations, and ultimately apply the new ways of thinking in their daily lives.

3.4. Explain some of the key changes in DSM-5.

DSM-5 is the first edition of the DSM to consistently seek both categorical and dimensional information as equally important parts of the diagnosis, rather than categorical information alone. The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would have greater reliability than the previous DSMs.

3.3. Describe the process of diagnosis using DSM-5, which requires both categorical and dimensional information.

DSM-5 lists more than 500 mental disorders. Each entry describes the criteria for diagnosing the disorder and the key clinical features of the disorder. The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by background information such as research findings; age, culture, or gender trends; and each disorder's prevalence, risk, course, complications, predisposing factors, and family patterns. DSM-5 requires clinicians to provide both categorical and dimensional information as part of a proper diagnosis. Categorical information refers to the name of the particular category (disorder) indicated by the client's symptoms. Dimensional information is a rating of how severe a client's symptoms are and how dysfunctional the client is across various dimensions of personality.

1.3. Discuss what is meant by the "elusive nature of abnormality."

Efforts to define psychological abnormality typically raise as many questions as they answer. Ultimately, a society selects general criteria for defining abnormality and then uses those criteria to judge particular cases. Even if we assume that psychological abnormality is a valid concept and that it can indeed be defined, we may be unable to apply our definition consistently. If a behavior—excessive use of alcohol among college students, say—is familiar enough, the society may fail to recognize that it is deviant, distressful, dysfunctional, and dangerous. In short, while we may agree to define psychological abnormalities as patterns of functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that these criteria are often vague and subjective. In turn, few of the current categories of abnormality that you will meet in this book are as clearcut as they may seem, and most continue to be debated by clinicians.

2.5. Summarize Rogers' theory and therapy, including definitions of unconditional positive regard, unconditional self-regard, and conditions of worth. Describe existential theories and therapies.

Humanistic and existential theorists are often grouped together—in an approach known as the humanistic-existential model— because of their common focus on these broader dimensions of human existence. At the same time, there are important differences between them. Humanists, the more optimistic of the two groups, believe that human beings are born with a natural tendency to be friendly, cooperative, and constructive. People, these theorists propose, are driven to self-actualize—that is, to fulfill this potential for goodness and growth. They can do so, however, only if they honestly recognize and accept their weaknesses as well as their strengths and establish satisfying personal values to live by. Humanists further suggest that self-actualization leads naturally to a concern for the welfare of others and to behavior that is loving, courageous, spontaneous, and independent. Existentialists agree that human beings must have an accurate awareness of themselves and live meaningful—they say "authentic"—lives in order to be psychologically well adjusted. These theorists do not believe, however, that people are naturally inclined to live positively. They believe that from birth we have total freedom, either to face up to our existence and give meaning to our lives or to shrink from that responsibility. Those who choose to "hide" from responsibility and choice will view themselves as helpless and may live empty, inauthentic, and dysfunctional lives as a result. Carl Rogers (1902-1987), often considered the pioneer of the humanistic perspective, developed client-centered therapy, a warm and supportive approach that contrasted sharply with the psychodynamic techniques of the day. He also proposed a theory of personality that paid little attention to irrational instincts and conflicts. We all have a basic need to receive positive regard from the important people in our lives (primarily our parents). Those who receive unconditional (nonjudgmental) positive regard early in life are likely to develop unconditional self-regard. That is, they come to recognize their worth as persons, even while recognizing that they are not perfect. Such people are in a good position to actualize their positive potential. Unfortunately, some children repeatedly are made to feel that they are not worthy of positive regard. As a result, they acquire conditions of worth, standards that tell them they are lovable and acceptable only when they conform to certain guidelines. To maintain positive self-regard, these people have to look at themselves very selectively, denying or distorting thoughts and actions that do not measure up to their conditions of worth. They thus acquire a distorted view of themselves and their experiences. They do not know what they are truly feeling, what they genuinely need, or what values and goals would be meaningful for them. Problems in functioning are then inevitable. Clinicians who practice Rogers' client-centered therapy try to create a supportive climate in which clients feel able to look at themselves honestly and acceptingly. The therapist must display three important qualities throughout the therapy—unconditional positive regard (full and warm acceptance for the client), accurate empathy (skillful listening and restating), and genuineness (sincere communication).

1.8. Discuss the impact of deinstitutionalization on the care and treatment of the severely mentally ill. Where do people with severe mental illness often end up if not in a mental health institution?

Hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets. In fact, only 40 to 60 percent of persons with severe psychological disturbances currently receive treatment of any kind. At least 100,000 people with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons. Their abandonment is truly a national disgrace.

1.7. Describe the current treatment of severely disturbed individuals. Contrast this to the current treatment of less severely disturbed individuals.

Hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets. In fact, only 40 to 60 percent of persons with severe psychological disturbances currently receive treatment of any kind. At least 100,000 people with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons. Their abandonment is truly a national disgrace. The treatment picture for people with moderate psychological disturbances has been more positive than that for people with severe disorders. Since the 1950s, outpatient care has continued to be the preferred mode of treatment for them, and the number and types of facilities that offer such care have expanded to meet the need. Outpatient therapy is now offered in a number of less expensive settings, such as community mental health centers, crisis intervention centers, family service centers, and other social service agencies. The new settings have spurred a dramatic increase in the number of people seeking outpatient care for psychological problems. Surveys suggest that nearly one of every six adults in the United States receives treatment for psychological disorders in the course of a year. Yet another change in outpatient care since the 1950s has been the development of programs devoted exclusively to one kind of psychological problem. Clinicians in these programs have the kind of expertise that can be acquired only by concentration in a single area.

1.4. Describe the ways that ancient peoples, Greeks, Romans, and persons in the age of the Renaissance viewed and treated abnormal behavior.

In the years from roughly 500 B.C. to 500 A.D., when the Greek and Roman civilizations thrived, philosophers and physicians often offered different explanations and treatments for abnormal behaviors. Hippocrates (460-377 B.C.), often called the father of modern medicine, taught that illnesses had natural causes. He saw abnormal behavior as a disease arising from internal physical problems. Specifically, he believed that some form of brain pathology was the culprit and that it resulted—like all other forms of disease, in his view—from an imbalance of four fluids, or humors, that flowed through the body: yellow bile, black bile, blood, and phlegm. An excess of yellow bile, for example, caused mania, a state of frenzied activity; an excess of black bile was the source of melancholia, a condition marked by unshakable sadness. To treat psychological dysfunctioning, Hippocrates sought to correct the underlying physical pathology. He believed, for instance, that the excess of black bile underlying melancholia could be reduced by a quiet life; a diet of vegetables; temperance; exercise; celibacy; and even bleeding. Hippocrates' focus on internal causes for abnormal behavior was shared by the great Greek philosophers Plato (427-347 B.C.) and Aristotle (384-322 B.C.) and by influential Greek and Roman physicians. From 500 to 1350 a.d., the period known as the Middle Ages, the power of the clergy increased greatly throughout Europe. In those days the church rejected scientific forms of investigation, and it controlled all education. Religious beliefs, which were highly superstitious and demonological, came to dominate all aspects of life. Deviant behavior, particularly psychological dysfunctioning, was seen as evidence of Satan's influence. The Middle Ages were a time of great stress and anxiety—of war, urban uprisings, and plagues. People blamed the devil for these troubles and feared being possessed by him. Abnormal behavior apparently increased greatly during this period. In addition, there were outbreaks of mass madness, in which large numbers of people apparently shared absurd false beliefs and imagined sights or sounds. German physician Johann Weyer (1515-1588), the first physician to specialize in mental illness, believed that the mind was as susceptible to sickness as the body was. He is now considered the founder of the modern study of psychopathology. The care of people with mental disorders continued to improve in this atmosphere. In England, such individuals might be kept at home while their families were aided financially by the local parish. Across Europe, religious shrines were devoted to the humane and loving treatment of people with mental disorders. Unfortunately, these improvements in care began to fade by the midsixteenth century. Government officials discovered that private homes and community residences could house only a small percentage of those with severe mental disorders and that medical hospitals were too few and too small. More and more, they converted hospitals and monasteries into asylums, institutions whose primary purpose was to care for people with mental illness. These institutions were begun with the intention that they would provide good care. Once the asylums started to overflow, however, they became virtual prisons where patients were held in filthy conditions and treated with unspeakable cruelty. As 1800 approached, the treatment of people with mental disorders began to improve once again.

1.5. Describe moral treatment.

Moral treatment emphasized moral guidance and humane and respectful techniques. Patients with psychological problems were increasingly perceived as potentially productive human beings whose mental functioning had broken down under stress. They were considered deserving of individual care, including discussions of their problems, useful activities, work, companionship, and quiet. By the early years of the twentieth century, the moral treatment movement had ground to a halt in both the United States and Europe. Public mental hospitals were providing only custodial care and ineffective medical treatments and were becoming more overcrowded every year. Long-term hospitalization became the rule once again.

1.10. Define multicultural psychology. How does it enhance the clinical practice?

Multicultural psychologists seek to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders may differ psychologically.

1.14. Discuss positive and negative influences of technology on mental health and its treatment.

Our digital world provides new triggers and vehicles for the expression of abnormal behavior. The Internet, texting, and social media have become convenient tools for those who wish to stalk or bully others, express sexual exhibitionism, pursue pedophilic desires, or gamble. Likewise, some clinicians believe that violent video games may contribute to the development of antisocial behavior, and perhaps even to the onset of conduct disorders among children and teenagers. And, in the opinion of many clinicians, constant texting, tweeting, and Internet browsing may contribute to shorter attention spans and establish a foundation for attention problems. A number of clinicians also worry that social networking can contribute to psychological dysfunctioning in certain cases. On the positive side, research indicates that, on average, social media users maintain more close relationships than other people do, receive more social support, are more trusting and open to differing points of view, and are more likely to participate in groups and lead active lives. On the negative side, however, there is research suggesting that social networking sites may provide a new venue for peer pressure that increases social anxiety in some adolescents. The sites may, for example, cause some people to develop fears that others in their network will exclude them socially. Similarly, there is clinical concern that sites such as Facebook may facilitate shy or socially anxious people's withdrawal from valuable face-to-face relationships. In addition, the face of clinical treatment is constantly changing in our fastmoving digital world. The use of cybertherapy, for example, is growing by leaps and bounds as a treatment option. Cybertherapy takes such forms as long-distance therapy between clients and therapists using Skype, therapy offered by computer programs, treatment enhanced by the use of video game-like avatars and other virtual reality experiences, and Internet-based support groups. Similarly, countless Web sites offer a wealth of mental health information, enabling people to better inform themselves, their friends, and their family members about psychological dysfunctioning and treatment options. And literally thousands of apps are devoted to relaxing people, cheering them up, or otherwise improving their psychological states. Along with the wealth of mental health information now available online comes an enormous amount of misinformation about psychological problems and their treatments, offered by persons and sites that at best, are far from knowledgeable. Similarly, the issue of quality control is a major problem for Internet-based therapy, support groups, and the like. Moreover, there are now numerous antitreatment Web sites that try to guide people away from seeking help for their psychological problems. Clearly, the impact of technological change on the mental health field today is wide-ranging and both positive and negative. Its impact presents formidable challenges for clinicians and researchers alike.

1.2. Describe the different ways of defining abnormality from the perspectives of deviance, distress, dysfunction, and danger.

Patterns of psychological abnormality are typically deviant (different, extreme, unusual, perhaps even bizarre), distressing (unpleasant and upsetting to the person), dysfunctional (interfering with the person's ability to conduct daily activities in a constructive way), and possibly dangerous. This definition offers a useful starting point from which to explore the phenomena of psychological abnormality. Behavior, thoughts, and emotions that break norms of psychological functioning are called abnormal. Even functioning that is considered unusual does not necessarily qualify as abnormal. According to many clinical theorists, behavior, ideas, or emotions usually have to cause distress before they can be labeled abnormal. Abnormal behavior tends to be dysfunctional; that is, it interferes with daily functioning. It so upsets, distracts, or confuses people that they cannot care for themselves properly, participate in ordinary social interactions, or work productively. Dysfunction alone, though, does not necessarily indicate psychological abnormality. Perhaps the ultimate in psychological dysfunctioning is behavior that becomes dangerous to oneself or others. Individuals whose behavior is consistently careless, hostile, or confused may be placing themselves or those around them at risk.

2.7. Compare and contrast the various models of abnormal functioning.

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1.9. Discuss the development and foci of (a) prevention programs and (b) positive psychology. How are they related to the community mental health approach?

Rather than wait for psychological disorders to occur, many of today's community programs try to correct the social conditions that underlie psychological problems and to help individuals who are at risk for developing emotional problems. Prevention programs have been further energized in the past few years by the field of psychology's ever-growing interest in positive psychology. Positive psychology is the study and enhancement of positive feelings such as optimism and happiness, positive traits like hard work and wisdom, positive abilities such as social skills and other talents, and group-directed virtues, including altruism and tolerance.

1.11. Describe the influence of managed care programs on the treatment of psychological abnormality. What is parity?

So many people now seek therapy that private insurance companies have changed their coverage for mental health patients. Today the dominant form of coverage is the managed care program—a program in which the insurance company determines such key issues as which therapists its clients may choose, the cost of sessions, and the number of sessions for which a client may be reimbursed. At least 75 percent of all privately insured persons in the United States are currently enrolled in managed care programs. The coverage for mental health treatment under such programs follows the same basic principles as coverage for medical treatment, including a limited pool of practitioners from which patients can choose, preapproval of treatment by the insurance company, strict standards for judging whether problems and treatments qualify for reimbursement, and ongoing reviews and assessments. In the mental health realm, both therapists and clients typically dislike managed care programs. They fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments whose results are not always lasting (for example, drug therapy), pose a special hardship for those with severe mental disorders, and result in treatments determined by insurance companies rather than by therapists. In 2008, the U.S. Congress passed a federal parity law that directed insurance companies to provide equal coverage for mental and medical problems. However, a number of insurance companies found ways around that law and continued to deny or limit payments for mental health treatments. The Affordable Care Act designates mental health care as 1 of 10 types of "essential health benefits" that must be provided by all insurers. It also requires all health plans to provide preventive mental health services at no additional cost and to allow new and continued membership to individuals who have preexisting mental conditions. Although such changes have heartened mental health advocates, it is not yet clear whether such provisions will in fact result in significantly better treatment for people with psychological problems.

3.5. Discuss the dangers of diagnosing and labeling in classifying mental disorders.

Studies show that they may be overly influenced by information gathered early in the assessment process. In addition, they may pay too much attention to certain sources of information, such as a parent's report about a child, and too little to others, such as the child's point of view. Finally, their judgments can be distorted by any number of personal biases—gender, age, race, and socioeconomic status. Given the limitations of assessment tools, assessors, and classification systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals. Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. When people are diagnosed as mentally disturbed, they may be perceived and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality. People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time.

2.3. Summarize the behavioral model of abnormal functioning, including the main features of classical conditioning and operant conditioning and how they are used to explain abnormal behavior. These concepts are key for understanding and treating many anxiety disorders.

The behavioral model concentrates on behaviors, the responses an organism makes to its environment. Behaviors can be external (going to work, say) or internal (having a feeling or thought). In turn, behavioral theorists base their explanations and treatments on principles of learning, the processes by which these behaviors change in response to the environment. In operant conditioning, humans and animals learn to behave in certain ways as a result of receiving rewards—consequences of one kind or another- whenever they do so. In modeling, individuals learn responses simply by observing other individuals and repeating their behaviors. In a third form of conditioning, classical conditioning, learning occurs when two events repeatedly occur close together in time. The events become fused in a person's mind, and before long the person responds in the same way to both events.

2.1. Define and describe the basic biological terminology, function of neurons, parts the brain, and types of neurotransmitters. Discuss the various therapies used by the biological model, including a discussion of drugs, electroconvulsive therapy, and psychosurgery.

The brain is made up of approximately 100 billion nerve cells, called neurons, and thousands of billions of support cells, called glia (from the Greek word for "glue"). Within the brain large groups of neurons form distinct areas, or brain regions. Toward the top of the brain, for example, is a cluster of regions, collectively referred to as the cerebrum, which includes the cortex, corpus callosum, basal ganglia, hippocampus, and amygdala. The cortex is the outer layer of the brain, the corpus callosum connects the brain's two cerebral hemispheres, the basal ganglia plays a crucial role in planning and producing movement, the hippocampus helps regulate emotions and memory, and the amygdala plays a key role in emotional memory. A tiny space, called the synapse, separates one neuron from the next, and the message must somehow move across that space. When an electrical impulse reaches a neuron's ending, the nerve ending is stimulated to release a chemical, called a neurotransmitter, that travels across the synaptic space to receptors on the dendrites of the neighboring neurons. Researchers have identified dozens of neurotransmitters in the brain, and they have learned that each neuron uses only certain kinds. Studies indicate that abnormal activity by certain neurotransmitters can lead to specific mental disorders. Depression, for example, has been linked to low activity of the neurotransmitters serotonin and norepinephrine. In the 1950s, researchers discovered several effective psychotropic medications, drugs that mainly affect emotions and thought processes. These drugs have greatly changed the outlook for a number of mental disorders and today are used widely, either alone or with other forms of therapy. However, the psychotropic drug revolution has also produced some major problems. Many people believe, for example, that the drugs are overused. Moreover, while drugs are effective in many cases, they do not help everyone. Thus many people seek out a biological alternative to drug therapy—the enormously popular herbal supplements. Four major psychotropic drug groups are used in therapy: antianxiety, antidepressant, antibipolar, and antipsychotic drugs. A second form of biological treatment, used primarily on depressed patients, is electroconvulsive therapy (ECT). Two electrodes are attached to a patient's forehead, and an electrical current of 65 to 140 volts is passed briefly through the brain. The current causes a brain seizure that lasts up to a few minutes. After seven to nine ECT sessions, spaced two or three days apart, many patients feel considerably less depressed. The treatment is used on tens of thousands of depressed persons annually, particularly those whose depression fails to respond to other treatments. A third form of biological treatment is psychosurgery, or neurosurgery, brain surgery for mental disorders. They are considered experimental and are used only after certain severe disorders have continued for years without responding to any other form of treatment.

2.2. Summarize the origins of Freud's theory. Describe Freud's explanation of abnormal functioning, including descriptions of the id, ego, superego, and ego defense mechanisms. Consider how relevant or not these concepts are today.

The psychodynamic model is the oldest and most famous of the modern psychological models. Psychodynamic theorists believe that a person's behavior, whether normal or abnormal, is determined largely by underlying psychological forces of which he or she is not consciously aware. These internal forces are described as dynamic—that is, they interact with one another—and their interaction gives rise to behavior, thoughts, and emotions. Abnormal symptoms are viewed as the result of conflicts between these forces. Freud used the term id to denote instinctual needs, drives, and impulses. The id operates in accordance with the pleasure principle; that is, it always seeks gratification. Freud also believed that all id instincts tend to be sexual, noting that from the very earliest stages of life a child's pleasure is obtained from nursing, defecating, masturbating, or engaging in other activities that he considered to have sexual ties. He further suggested that a person's libido, or sexual energy, fuels the id. A part of the id separates off and becomes the ego. Like the id, the ego unconsciously seeks gratification, but it does so in accordance with the reality principle, the knowledge we acquire through experience that it can be unacceptable to express our id impulses outright. The ego, employing reason, guides us to know when we can and cannot express those impulses. The superego grows from the ego, just as the ego grows out of the id. This personality force operates by the morality principle, a sense of what is right and what is wrong. As we learn from our parents that many of our id impulses are unacceptable, we unconsciously adopt our parents' values. Judging ourselves by their standards, we feel good when we uphold their values; conversely, when we go against them, we feel guilty. In short, we develop a conscience.

3.6. Discuss types and effectiveness of treatments for mental disorders.

Therapists' treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy. Most clinicians say that they value research as a guide to practice. However, not all of them actually read research articles, so they cannot be directly influenced by them. To help clinicians become more familiar with and apply research findings, there is an ever-growing movement in North America, the United Kingdom, and elsewhere toward empirically supported, or evidence-based, treatment. Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such information to clinicians. Critics of the movement worry that such efforts have thus far been simplistic, biased, and at times misleading. However, the empirically supported treatment movement has been gaining considerable momentum over the past decade. Altogether, more than 400 forms of therapy are currently practiced in the clinical field. Studies suggest that therapy often is more helpful than no treatment or than placebos. A number of studies suggest that 5 to 10 percent of patients actually seem to get worse because of therapy. Their symptoms may become more intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy. Some critics suggest that these studies are operating under a uniformity myth—a false belief that all therapies are equivalent despite differences in the therapists' training, experience, theoretical orientations, and personalities. Thus, an alternative approach examines the effectiveness of particular therapies. Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their clients are interacting, and try to promote self-mastery in their clients.

1.1. Discuss some of the difficulties of defining a person's behavior as abnormal.

What is considered normal and abnormal is largely determined by the society one is living in. While many definitions of abnormality have been proposed over the years, none has won total acceptance. Abnormal behavior, thoughts, and emotions are those that differ markedly from a society's ideas about proper functioning. Judgments about what constitutes abnormality vary from society to society. A society that emphasizes cooperation and gentleness may consider aggressive behavior unacceptable and even abnormal. A society's values may also change over time, causing its views of what is psychologically abnormal to change as well. Judgments about what constitutes abnormality depend on specific circumstances as well as on cultural norms. In short, while we may agree to define psychological abnormalities as patterns of functioning that are deviant, distressful, dysfunctional, and sometimes dangerous, we should be clear that these criteria are often vague and subjective. In turn, few of the current categories of abnormality that you will meet in this book are as clearcut as they may seem, and most continue to be debated by clinicians.