hospital emergency room

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P hilip Berman, a 25-year-old single unemployed former copy editor for a large publishing house, . . . had been hospitalized after a suicide attempt in which he deeply gashed his wrist with a razor blade. He described [to the therapist] how he had sat on the bathroom floor and watched the blood drip into the bathtub for some time before he telephoned

his father at work for help. He and his father went to the hospital emergency room to have the gash stitched, but he convinced himself and the hospital physician that he did not need hospitalization. The next day when his father suggested he needed help, he knocked his dinner to the floor and angrily stormed to his room. When he was calm again, he allowed his father to take him back to the hospital.

The immediate precipitant for his suicide attempt was that he had run into one of his former girlfriends with her new boyfriend. The patient stated that they had a drink together, but all the while he was with them he could not help thinking that “they were dying to run off and jump in bed.” He experienced jealous rage, got up from the table, and walked out of the restaurant. He began to think about how he could “pay her back.”

Mr. Berman had felt frequently depressed for brief periods during the previous several years. He was especially critical of himself for his limited social life and his inability to have managed to have sexual intercourse with a woman even once in his life. As he related this to the therapist, he lifted his eyes from the floor and with a sarcastic smirk said, “I’m a 25-year-old virgin. Go ahead, you can laugh now.” He has had several girlfriends to date, whom he described as very attractive, but who he said had lost interest in him. On further questioning, however, it became apparent that Mr. Berman soon became very critical of them and demanded that they always meet his every need, often to their own detriment. The women then found the relationship very unrewarding and would soon find someone else.

During the past two years Mr. Berman had seen three psychiatrists briefly, one of whom had given him a drug, the name of which he could not remember, but that had precipitated some sort of unusual reaction for which he had to stay in a hospital overnight. . . . Concerning his hospitalization, the patient said that “It was a dump,” that the staff refused to listen to what he had to say or to respond to his needs, and that they, in fact, treated all the patients “sadisti- cally.” The referring doctor corroborated that Mr. Berman was a difficult patient who demanded that he be treated as special, and yet was hostile to most staff members throughout his stay. After one angry exchange with an aide, he left the hospital without leave, and subsequently signed out against medical advice.

Mr. Berman is one of two children of a middle-class family. His father is 55 years old and employed in a managerial position for an insurance company. He perceives his father as weak and ineffectual, completely dominated by the patient’s overbearing and cruel mother. He states that he hates his mother with “a passion I can barely control.” He claims that his mother used to call him names like “pervert” and “sissy” when he was growing up, and that in an argument she once “kicked me in the balls.” Together, he sees his parents as rich, powerful, and selfish, and, in turn, thinks that they see him as lazy, irresponsible, and a behavior problem. When his parents called the therapist to discuss their son’s treatment, they stated that his problem began with the birth of his younger brother, Arnold, when Philip was 10 years old. After Arnold’s birth Philip apparently became an “ornery” child who cursed a lot and was difficult to discipline. Philip recalls this period only vaguely. He reports that his mother once was hospitalized for depression, but that now “she doesn’t believe in psychiatry.”

MODELS OF ABNORMALITY C H A P T E R :2

TOPIC OVERVIEW The Biological Model How Do Biological Theorists Explain Abnormal Behavior? Biological Treatments Assessing the Biological Model

The Psychodynamic Model How Did Freud Explain Normal and Abnormal Functioning? How Do Other Psychodynamic Explanations Differ from Freud’s? Psychodynamic Therapies Assessing the Psychodynamic Model

The Behavioral Model How Do Behaviorists Explain Abnormal Functioning? Behavioral Therapies Assessing the Behavioral Model

The Cognitive Model How Do Cognitive Theorists Explain Abnormal Functioning? Cognitive Therapies Assessing the Cognitive Model

The Humanistic-Existential Model Rogers’s Humanistic Theory and Therapy Gestalt Theory and Therapy Spiritual Views and Interventions Existential Theories and Therapy Assessing the Humanistic-Existential Model

The Sociocultural Model: Family- Social and Multicultural Perspectives How Do Family-Social Theorists Explain Abnormal Functioning? Family-Social Treatments How Do Multicultural Theorists Explain Abnormal Functioning? Multicultural Treatments Assessing the Sociocultural Model

Putting It Together: Integration of the Models

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Mr. Berman had graduated from college with average grades. Since graduating he had worked at three different publishing houses, but at none of them for more than one year. He always found some justifica- tion for quitting. He usually sat around his house doing very little for two or three months after quitting a job, until his parents prodded him into getting a new one. He described innumerable interactions in his life with teachers, friends, and employers in which he felt offended or unfairly treated, . . . and frequent arguments that left him feeling bitter . . . and spent most of his time alone, “bored.” He was unable to commit himself to any person, he held no strong convictions, and he felt no allegiance to any group.

The patient appeared as a very thin, bearded, and bespectacled young man with pale skin who main- tained little eye contact with the therapist and who had an air of angry bitterness about him. Although he complained of depression, he denied other symptoms of the depressive syndrome. He seemed preoccupied with his rage at his parents, and seemed particularly invested in conveying a despicable image of himself. . . .

(Spitzer et al., 1983, pp. 59–61)

Philip Berman is clearly a troubled person, but how did he come to be that way? How do we explain and correct his many problems? To answer these questions, we must first look at the wide range of complaints we are trying to understand: Philip’s depression and anger, his social failures, his lack of employment, his distrust of those around him, and the problems within his family. Then we must sort through all kinds of potential causes—internal and external, biological and interpersonal, past and present.

Although we may not realize it, we all use theoretical frameworks as we read about Philip. Over the course of our lives, each of us has developed a perspective that helps us make sense of the things other people say and do. In science, the perspectives used to explain events are known as models, or paradigms. Each model spells out the scientist’s basic assumptions, gives order to the field under study, and sets guidelines for its investigation (Kuhn, 1962). It influences what the investigators observe as well as the questions they ask, the information they seek, and how they interpret this information (Sharf, 2008). To understand how a clinician explains or treats a specific set of symptoms, such as Philip’s, we must know his or her preferred model of abnormal functioning.

Until recently, clinical scientists of a given place and time tended to agree on a single model of abnormality—a model greatly influenced by the beliefs of their culture. The demonological model that was used to explain abnormal functioning during the Middle Ages, for example, borrowed heavily from medieval society’s concerns with religion, superstition, and warfare. Medieval practitioners would have seen the devil’s guiding hand in Philip Berman’s efforts to commit suicide and his feelings of depres- sion, rage, jealousy, and hatred. Similarly, their treatments for him—from prayers to whippings—would have sought to drive foreign spirits from his body.

Today several models are used to explain and treat abnormal functioning. This va- riety has resulted from shifts in values and beliefs over the past half-century, as well as improvements in clinical research. At one end of the spectrum is the biological model, which sees physical processes as key to human behavior. In the middle are four mod- els that focus on more psychological and personal aspects of human functioning: The psychodynamic model looks at people’s unconscious internal processes and conflicts, the behavioral model emphasizes behavior and the ways in which it is learned, the cognitive model concentrates on the thinking that underlies behavior, and the humanistic-existential model stresses the role of values and choices. At the far end of the spectrum is the socio- cultural model, which looks to social and cultural forces as the keys to human functioning. This model includes the family-social perspective, which focuses on an individual’s family and social interactions, and the multicultural perspective, which emphasizes an individual’s culture and the shared beliefs, values, and history of that culture.

Given their different assumptions and concepts, the models are sometimes in conflict. Those who follow one perspective often scoff at the “naive” interpretations, investigations, and treatment efforts of the others. Yet none of the models is complete in itself. Each focuses mainly on one aspect of human functioning, and none can explain all aspects of abnormality.

•model•A set of assumptions and concepts that help scientists explain and interpret observations. Also called a paradigm.

•neuron•A nerve cell.

•synapse•The tiny space between the nerve ending of one neuron and the den- drite of another.

•neurotransmitter•A chemical that, released by one neuron, crosses the syn- aptic space to be received at receptors on the dendrites of neighboring neurons.

BETWEEN THE LINES

Famous Psych Lines from the Movies: Take 2 “Do you have any idea how crazy you are?” (No Country for Old Men, 2007) <<

“Are you talkin’ to me?” (Taxi Driver, 1976) <<

“Mother’s not herself today.” (Psycho, 1960) <<

“Insanity runs in my family. . . . It practically gallops.” (Arsenic and Old Lace, 1944) <<

“Ah, but the strawberries! That’s where I had them!” (The Caine Mutiny, 1954) <<

“I won’t be ignored!” (Fatal Attraction, 1987) <<

“I’ve wrestled with reality for thirty-five years, doctor, and I’m happy to state I fi- nally won out over it.” (Harvey, 1950) <<

“I begged you to get therapy.” (Tootsie, 1982) <<

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Models of Abnormality :// 33

jjThe Biological Model Philip Berman is a biological being. His thoughts and feelings are the results of bio- chemical and bioelectrical processes throughout his brain and body. Proponents of the biological model believe that a full understanding of Philip’s thoughts, emotions, and behavior must therefore include an understanding of their biological basis. Not surpris- ingly, then, they believe that the most effective treatments for Philip’s problems will be biological ones.

How Do Biological Theorists Explain Abnormal Behavior? Adopting a medical perspective, biological theorists view abnormal behavior as an ill- ness brought about by malfunctioning parts of the organism. Typically, they point to problems in brain anatomy or brain chemistry as the cause of such behavior (Garrett, 2009; Lambert & Kinsley, 2005).

Brain Anatomy and Abnormal Behavior The brain is made up of approxi- mately 100 billion nerve cells, called neurons, and thousands of billions of support cells, called glia (from the Greek meaning “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 cal- losum, basal ganglia, hippocampus, and amygdala (see Figure 2-1).The neurons in each of these brain regions control important functions. The cortex is the outer layer of the brain, the corpus callosum connects the brain’s two ce- rebral hemispheres, the basal ganglia plays a crucial role in planning and producing movement, the hippocampus helps control emotions and memory, and the amygdala plays a key role in emotional memory. Clinical research- ers have discovered connections between certain psy- chological disorders and problems in specific areas of the brain. One such disorder is Huntington’s disease, a disorder marked by violent emotional outbursts, memory loss, suicidal thinking, involuntary body movements, and ab- surd beliefs. This disease has been traced to a loss of cells in the basal ganglia.

Brain Chemistry and Abnormal Behavior Biological researchers have also learned that psychologi- cal disorders can be related to problems in the transmis- sion of messages from neuron to neuron. Information is communicated throughout the brain in the form of electrical impulses that travel from one neuron to one or more others. An impulse is first received by a neuron’s dendrites, antenna-like extensions located at one end of the neuron. From there it travels down the neuron’s axon, a long fiber extending from the neuron’s body. Finally, it is transmit- ted through the nerve ending at the end of the axon to the dendrites of other neurons (see Figure 2-2 on the next page).

But how do messages get from the nerve ending of one neuron to the dendrites of another? After all, the neurons do not actually touch each other. 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. After binding to the receiving neuron’s receptors, some neurotransmitters tell the receiving neurons to “fire,” that is, to trigger their own electrical impulse. Other neurotransmitters carry an inhibitory message; they tell receiving neurons to stop all firing. Obviously, neurotrans- mitters play a key role in moving information through the brain.

Amygdala

Hippocampus

Cerebral cortex

Basal ganglia

Corpus callosum

Figure 2-1 The cerebrum Some psychological disorders can be traced to abnormal functioning of neurons in the cerebrum, which includes brain structures such as the basal ganglia, hippocampus, amygdala, corpus callosum, and cerebral cortex.

BETWEEN THE LINES

In Their Words “My brain? That’s my second favorite organ.” <<

Woody Allen

“I am a brain, Watson. The rest of me is a mere appendix.” <<

Sherlock Holmes, in Arthur Conan Doyle’s “The Adventure of the Mazarin Stone”

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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 (Sarter et al., 2007). Depression, for example, has been linked to low activity of the neurotransmitters serotonin and norepinephrine. Perhaps low se- rotonin activity is partly responsible for Philip Berman’s pattern of depression and rage.

In addition to focusing on neurons and neurotransmitters, researchers have learned that mental disorders are sometimes related to abnormal chemical activity in the body’s endocrine system. Endocrine glands, located throughout the body, work along with neurons to control such vital activities as growth, reproduction, sexual activity, heart rate, body temperature, energy, and responses to stress. The glands release chemicals called hormones into the bloodstream, and these chemicals then propel body organs into action. During times of stress, for example, the adrenal glands, located on top of the kidneys, secrete the hor- mone cortisol. Abnormal secretions of this chemical have been tied to anxiety and mood disorders.

Sources of Biological Abnormalities Why do some people have brain structures or biochemical activities that differ from the norm? Three factors have received particular attention in recent years—genetics, evolution, and viral infections.

GENETICS AND ABNORMAL BEHAVIOR Abnormalities in brain anatomy or chemistry are sometimes the result of genetic inheritance. Each cell in the human brain and body contains 23 pairs of chromosomes, with each chromosome in a pair inherited from one of the person’s parents. Every chromosome contains numer- ous genes—segments that control the characteristics and traits a person inherits. Altogether, each cell contains between 30,000 and 40,000 genes (Andreasen, 2005, 2001). Scientists have known for years that genes help determine such physical characteristics as hair color, height, and eyesight. Genes can make people more prone to heart disease, cancer, or diabetes, and perhaps to possess-

ing artistic or musical skill. Studies suggest that inheritance also plays a part in mood disorders, schizophrenia, and other mental disorders.

The precise contributions of various genes to mental disorders have become clearer in recent years, thanks in part to the completion of the Human Genome Project in 2000. In this major undertaking, scientists used the tools of molecular biology to map, or sequence, all of the genes in the human body in great detail. With this information in hand, researchers hope eventually to be able to prevent or change genes that help cause medical or psychological disorders (Holman et al., 2007).

Dendrites

Cell body

Electrical impulse

Axon

Nerve ending

Neurotransmitters

Release of neurotransmitters

Receptor sites on receiving neuron Receptor sites on receiving neuron

Synapse

More than coincidence? Studies of twins suggest that some aspects of behavior and personality are influenced by genetic factors. Many identical twins, like these musicians, are found to have similar tastes, behave in similar ways, and make similar life choices. Some even develop similar abnormal behaviors.

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Figure 2-2 A neuron communicating information A message in the form of an electrical impulse travels down the sending neuron’s axon to its nerve ending, where neuro- transmitters are released and carry the message across the synaptic space to the dendrites of a receiving neuron.

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Models of Abnormality :// 35

EVOLUTION AND ABNORMAL BEHAVIOR Genes that contribute to mental disorders are typi- cally viewed as unfortunate occurrences—almost mistakes of inheritance. The respon- sible gene may be a mutation, an abnormal form of the appropriate gene that emerges by accident. Or the problematic gene may be inherited by an individual after it has initially entered the family line as a mutation. According to some theorists, however, many of the genes that contribute to abnormal functioning are actually the result of normal evolutionary principles (Fábrega, 2007, 2006, 2002).

In general, evolutionary theorists argue that human reactions and the genes respon- sible for them have survived over the course of time because they have helped individu- als to thrive and adapt. Ancestors who had the ability to run fast, for example, or the craftiness to hide were most able to escape their enemies and to reproduce. Thus, the genes responsible for effective walking, running, or problem solving were particularly likely to be passed on from generation to generation to the present day.

Similarly, say evolutionary theorists, the capacity to experience fear was, and in many instances still is, adaptive. Fear alerted our ancestors to dangers, threats, and losses, so that persons could avoid or escape potential problems. People who were particularly sensitive to danger—those with greater fear responses—were more likely to survive catastrophes, battles, and the like and to reproduce, and so to pass on their fear genes. Of course, in today’s world pressures are more numerous, subtle, and complex than they were in the past, condemning many individuals with such genes to a near-endless stream of fear and arousal. That is, the very genes that helped their ancestors to survive and reproduce might now leave these individuals particularly prone to fear reactions, anxiety disorders, or related psychological disorders.

The evolutionary perspective is controversial in the clinical field and has been re- jected by many theorists. Imprecise and at times impossible to research, this explanation requires leaps of faith that many scientists find unacceptable.

VIRAL INFECTIONS AND ABNORMAL BEHAVIOR Another possible source of abnor- mal brain structure or biochemical dysfunctioning is viral infections. As you will see in Chapter 12, for example, research suggests that schizophrenia, a disorder marked by delusions, hallucinations, or other departures from real- ity, may be related to exposure to certain viruses during childhood or before birth (Meyer et al., 2008; Shirts et al., 2007). Studies have found that the mothers of many individuals with this disorder contracted influenza or re- lated viruses during their pregnancy. This and related pieces of circumstantial evidence suggest that a damaging virus may enter the fetus’s brain and remain dormant there until the individual reaches adolescence or young adulthood. At that time, the virus may produce the symptoms of schizophrenia. During the past decade, researchers have sometimes linked viruses to anxiety and mood disorders, as well as to psychotic disorders (Dale et al., 2004).

Biological Treatments Biological practitioners look for certain kinds of clues when they try to understand abnormal behavior. Does the person’s family have a history of that behavior, and hence a possible genetic predisposition to it? (Philip Berman’s case history mentions that his mother was once hospitalized for depression.) Is the behavior produced by events that could have had a physiological effect? (Philip was having a drink when he flew into a jealous rage at the restaurant.)

Once the clinicians have pinpointed physical sources of dysfunctioning, they are in a better position to choose a biological course of treatment. The three leading kinds of biological treatments used today are drug therapy, electroconvulsive therapy, and psychosurgery. Drug therapy is by far the most common of these approaches.

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, ei- ther alone or with other forms of therapy. However, the psychotropic drug revolution

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The brain bank At Cornell University’s “brain bank,” researcher Barbara Finlay holds the brain of a person who had schizophrenia. There are currently more than 100 brain banks, each preserving dozens of brains for study by researchers around the world ( Kennedy, 2004).

•hormones•The chemicals released by endocrine glands into the bloodstream.

•gene•Chromosome segments that control the characteristics and traits we inherit.

•psychotropic medications•Drugs that primarily affect the brain and reduce many symptoms of mental dysfunctioning.

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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 (see Figure 2-3).

Four major psychotropic drug groups are used in therapy: antianxiety, antidepressant, antibipolar, and antipsychotic drugs. Antianxiety drugs, also called minor tranquilizers or anxiolytics, help reduce tension and anxiety. Antidepressant drugs help improve the mood of people who are depressed. Antibipolar drugs, also called mood stabilizers, help steady the moods of those with a bipolar disorder, a condition marked by mood swings from mania to depression. And antipsychotic drugs help reduce the confusion, hallucinations, and delusions of psychotic disorders, disorders (such as schizophrenia) marked by a loss of contact with reality.

A second form of biological treatment, used primarily on depressed patients, is elec- troconvulsive 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 (Eschweiler et al., 2007; Pagnin et al., 2004).

A third form of biological treatment is psychosurgery, or neurosurgery, brain surgery for mental disorders. It is thought to have roots as far back as trephining, the prehistoric practice of chipping a hole in the skull of a person who behaved strangely. Modern procedures are derived from a technique first developed in the late 1930s by a Portuguese neuropsychiatrist, Antonio de Egas Moniz. In that procedure, known as a lobotomy, a surgeon would cut the connections between the brain’s frontal lobes and the lower regions of the brain. Today’s psychosurgery procedures are much more precise than the lobotomies of the past. Even so, they are considered experimental and are used only after certain severe disorders have continued for years without responding to any other form of treatment (Sachdev & Chen, 2009).

Assessing the Biological Model Today the biological model enjoys considerable respect. Biological research constantly produces valuable new information. And biological treatments often bring great relief when other approaches have failed. At the same time, this model has its shortcomings.

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“Don’t judge me until you’ve walked a mile on my medication.”

•electroconvulsive therapy (ECT)• A form of biological treatment, used primarily on depressed patients, in which a brain seizure is triggered as an elec- tric current passes through electrodes attached to the patient’s forehead.

•psychosurgery•Brain surgery for men- tal disorders. Also called neurosurgery.

BETWEEN THE LINES

Whose Brain Has the Most Neurons? Human 100,000,000,000 neurons <<

Octopus 300,000,000 neurons <<

Rat 21,000,000 neurons <<

Frog 16,000,000 neurons <<

Cockroach 1,000,000 neurons <<

Honey bee 850,000 neurons <<

Fruit fly 100,000 neurons <<

Ant 10,000 neurons <<

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Models of Abnormality :// 37

Some of its proponents seem to expect that all human behavior can be explained in biological terms and treated with biological methods. This view can limit rather than enhance our understanding of abnormal functioning. Our mental life is an interplay of biological and nonbiological factors, and it is important to understand that interplay rather than to focus on biological variables alone.

Another shortcoming is that several of today’s biological treatments are capable of producing significant undesirable effects. Certain antipsychotic drugs, for example, may produce movement problems such as severe shaking, bizarre-looking contractions of the face and body, and extreme restlessness. Clearly such costs must be addressed and weighed against the drug’s benefits.

Clinical Phase II: Preliminary Testing (2 years) Investigators conduct studies with human

subjects to determine how drug can best be evaluated and to obtain preliminary estimates of correct dosage and treatment procedures.

• Number of subjects: 50–500 • Typical cost: $20 million

Clinical Phase III: Final Testing (3–5 years) Investigators conduct controlled studies

to fully determine drug’s efficacy and important side effects.

• Number of subjects: 300–30,000 • Typical cost: $45 million

Review by FDA (1–5 years) Research is reviewed by FDA, and drug

is approved or disapproved.

Postmarketing Surveillance (10 years) Long after the drug is on the market-

place, testing continues and doctors’ reports are gathered. Manufacturer must report any unexpected long-term effects and side effects.

Preclinical Phase (5 years) New drug is developed and identified. Drug is tested on animals, usually rats,

to help determine its safety and efficacy.

Clinical Phase I: Safety Screening (1.5 years) Investigators test drug on human

subjects to determine its safety. • Number of subjects: 10–100 • Typical cost: $10 million

SUMMING UP The Biological Model

Biological theorists look at the biological processes of human functioning to explain abnormal behavior, pointing to anatomical or biochemical problems in the brain and body. Such abnormalities are sometimes the result of genetic inheritance, evo- lution, or viral infections. Biological therapists use physical and chemical methods to help people overcome their psychological problems. The leading ones are drug therapy, electroconvulsive therapy, and, on rare occasions, psychosurgery.

jjThe Psychodynamic Model 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 (Luborsky et al., 2008).

Psychodynamic theorists would view Philip Berman as a person in conflict. They would want to explore his past experiences because, in their view, psychological con- flicts are tied to early relationships and to traumatic experiences that occurred during childhood. Psychodynamic theories rest on the deterministic assumption that no symp- tom or behavior is “accidental”: All behavior is determined by past experiences. Thus Philip’s hatred for his mother, his memories of her as cruel and overbearing, the weak- ness of his father, and the birth of a younger brother when Philip was 10 may all be important to the understanding of his current problems.

The psychodynamic model was first formulated by Viennese neurologist Sigmund Freud (1856–1939) at the turn of the twentieth century. After studying hypnosis, Freud developed the theory of psychoanalysis to explain both normal and abnormal psycho- logical functioning and a corresponding method of treatment, a conversational approach also called psychoanalysis. During the early 1900s, Freud and several of his colleagues in the Vienna Psychoanalytic Society—including Carl Gustav Jung (1875–1961) and Alfred Adler (1870–1937)—became the most influential clinical theorists in the Western world.

How Did Freud Explain Normal and Abnormal Functioning? Freud believed that three central forces shape the personality—instinctual needs, rational thinking, and moral standards. All of these forces, he believed, operate at the unconscious level, unavailable to immediate awareness; he further believed these forces to be dynamic, or interactive. Freud called the forces the id, the ego, and the superego.

Figure 2-3 How does a new drug reach the market- place? It takes an average of 14 years and tens of millions of dollars for a pharma- ceutical company in the United States to bring a newly discovered drug to market. The company must carefully follow steps that are specified by law. (Adapted from Lemonick & Goldstein, 2002; Zivin, 2000.)

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The Id 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 en- gaging in other activities that he considered to have sexual ties. He further suggested that a person’s libido, or sexual energy, fuels the id.

The Ego During our early years we come to recognize that our environment will not meet every instinctual need. Our mother, for example, is not always available to do our bidding. A part of the id separates off and becomes the ego. Like the id, the ego un- consciously 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 can- not express those impulses.

The ego develops basic strategies, called ego defense mechanisms, to control unacceptable id impulses and avoid or reduce the anxiety they arouse. The most basic defense mechanism, repression, prevents unacceptable impulses from ever reaching con- sciousness. There are many other ego defense mechanisms, and each of us tends to favor some over others (see Table 2-1).

The Superego The superego grows from the ego, just as the ego grows out of the id. As we learn from our parents that many of our id impulses are unacceptable, we un- consciously adopt our parents’ values. Judging ourselves by their standards, we feel good when we uphold their values; conversely, when we go against them, we feel guilty. In short, we develop a conscience.

According to Freud, these three parts of the personality—the id, the ego, and the superego—are often in some degree of conflict. A healthy personality is one in which

table: 2-1

The Defense Never Rests: Defense Mechanisms to the Rescue

Defense Operation Example Repression Person avoids anxiety by simply not

allowing painful or dangerous thoughts to become conscious.

An executive’s desire to run amok and attack his boss and colleagues at a board meeting is denied access to his awareness.

Denial Person simply refuses to acknowledge the existence of an external source of anxiety.

You are not prepared for tomorrow’s final exam, but you tell yourself that it’s not actually an important exam and that there’s no good reason not to go to a movie tonight.

Projection Person attributes own unacceptable impulses, motives, or desires to other individuals.

The executive who repressed his destructive desires may project his anger onto his boss and claim that it is actually the boss who is hostile.

Rationalization Person creates a socially acceptable reason for an action that actually reflects unacceptable motives.

A student explains away poor grades by citing the importance of the “total experience” of going to college and claiming that too much emphasis on grades would actually interfere with a well- rounded education.

Displacement Person displaces hostility away from a dangerous object and onto a safer substitute.

After your parking spot is taken, you release your pent-up anger by starting an argument with your roommate.

Intellectualization Person represses emotional reactions in favor of overly logical response to a problem.

A woman who has been beaten and raped gives a detached, methodical description of the effects that such attacks may have on victims.

Regression Person retreats from an upsetting conflict to an early developmental stage at which no one is expected to behave maturely or responsibly.

A boy who cannot cope with the anger he feels toward his rejecting mother regresses to infantile behavior, soiling his clothes and no longer taking care of his basic needs.

•id•According to Freud, the psychologi- cal force that produces instinctual needs, drives, and impulses.

•ego•According to Freud, the psycho- logical force that employs reason and operates in accordance with the reality principle.

•ego defense mechanisms•According to psychoanalytic theory, strategies devel- oped by the ego to control unacceptable id impulses and to avoid or reduce the anxiety they arouse.

•superego•According to Freud, the psychological force that represents a per- son’s values and ideals.

•fixation•According to Freud, a condi- tion in which the id, ego, and superego do not mature properly and are frozen at an early stage of development.

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Models of Abnormality :// 39

an effective working relationship, an acceptable compromise, has formed among the three forces. If the id, ego, and superego are in excessive conflict, the person’s behavior may show signs of dysfunction.

Freudians would therefore view Philip Berman as someone whose personality forces have a poor working relationship. His ego and superego are unable to control his id im- pulses, which lead him repeatedly to act in impulsive and often dangerous ways—suicide gestures, jealous rages, job resignations, outbursts of temper, frequent arguments.

Developmental Stages Freud proposed that at each stage of development, from infancy to maturity, new events challenge individuals and require adjustments in their id, ego, and superego. If the adjustments are successful, they lead to personal growth. If not, the person may become fixated, or stuck, at an early stage of development. Then all subsequent development suffers, and the individual may well be headed for abnormal functioning in the future. Because parents are the key figures during the early years of life, they are often seen as the cause of improper development.

Freud named each stage of development after the body area that he considered most important to the child at that time. For example, he referred to the first 18 months of life as the oral stage. During this stage, children fear that the mother who feeds and com- forts them will disappear. Children whose mothers consistently fail to gratify their oral needs may become fixated at the oral stage and display an “oral character” throughout their lives, one marked by extreme dependence or extreme mistrust. Such persons are particularly prone to develop depression. As you will see in later chapters, Freud linked fixations at the other stages of development—anal (18 months to 3 years of age), phallic (3 to 5 years), latency (5 to 12 years), and genital (12 years to adulthood)—to yet other kinds of psychological dysfunction.

How Do Other Psychodynamic Explanations Differ from Freud’s? Personal and professional differences between Freud and his colleagues led to a split in the Vienna Psychoanalytic Society early in the twentieth century. Carl Jung, Alfred Adler, and others developed new theories. Although the new theories departed from Freud’s ideas in important ways, each held on to Freud’s belief that human functioning is shaped by dynamic (interacting) psychological forces. Thus all such theories, including Freud’s, are referred to as psychodynamic.

Three of today’s most influential psychodynamic theories are ego theory, self theory, and object relations theory. Ego theorists emphasize the role of the ego and consider it a more independent and powerful force than Freud did (Sharf, 2008). Self theorists, in contrast, give the greatest attention to the role of the self—the unified personality. They

“Luke, I am your father.” This light-saber fight between Luke Skywalker and Darth Vader highlights the most famous, and contentious, father-son relationship in movie history. According to Freud, however, all fathers and sons experience significant tensions and conflicts that they must work through, even in the absence of the special pressures faced by Luke and his father in the Star Wars series.

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Critical training Freud believed that toilet training is a critical developmental experience. Children whose training is too harsh may become “fixated” at the anal stage and develop an “anal character”—stubborn, contrary, stingy, or controlling.

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40 ://CHAPTER 2

believe that the basic human motive is to strengthen the whole- ness of the self (Luborsky et al., 2008; Kohut, 2001, 1977). Object relations theorists propose that people are motivated mainly by a need to have relationships with others and that severe problems in the relationships between children and their caregivers may lead to abnormal development (Luborsky et al., 2008; Kernberg, 2005, 2001, 1997).

Psychodynamic Therapies Psychodynamic therapies range from Freudian psychoanalysis to modern therapies based on self theory or object relations theory. All seek to uncover past traumas and the inner conflicts that have resulted from them. All try to help clients resolve, or settle, those conflicts and to resume personal development.

According to most psychodynamic therapists, therapists must subtly guide therapy discussions so that the patients discover their underlying problems for themselves. To aid in the process,

the therapists rely on such techniques as free association, therapist interpretation, catharsis, and working through.

Free Association In psychodynamic therapies, the patient is responsible for starting and leading each discussion. The therapist tells the patient to describe any thought, feel- ing, or image that comes to mind, even if it seems unimportant. This practice is known as free association. The therapist expects that the patient’s associations will eventually un- cover unconscious events. Notice how free association helps this New Yorker to discover threatening impulses and conflicts within herself:

Patient: So I started walking, and walking, and decided to go behind the museum and walk through Central Park. So I walked and went through a back field and felt very excited and wonderful. I saw a park bench next to a clump of bushes and sat down. There was a rustle behind me and I got frightened. I thought of men concealing themselves in the bushes. I thought of the sex perverts I read about in Central Park. I wondered if there was someone behind me exposing himself. The idea is repulsive, but exciting too. I think of father now and feel excited. I think of an erect penis. This is connected with my father. There is something about this pushing in my mind. I don’t know what it is, like on the border of my memory. (Pause)

Therapist: Mm-hmm. (Pause) On the border of your memory? Patient: (The patient breathes rapidly and seems to be under great tension.) As a little

girl, I slept with my father. I get a funny feeling. I get a funny feeling over my skin, tingly-like. It’s a strange feeling, like a blindness, like not seeing something. My mind blurs and spreads over anything I look at. I’ve had this feeling off and on since I walked in the park. My mind seems to blank off like I can’t think or ab- sorb anything.

(Wolberg, 1967, p. 662)

Therapist Interpretation Psychodynamic therapists listen carefully as patients talk, looking for clues, drawing tentative conclusions, and sharing interpretations when they think the patient is ready to hear them. Interpretations of three phenomena are particu- larly important—resistance, transference, and dreams.

Patients are showing resistance, an unconscious refusal to participate fully in ther- apy, when they suddenly cannot free associate or when they change a subject to avoid

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Freud takes a closer look at Freud Sigmund Freud, founder of psychoanalytic theory and therapy, examines a sculptured bust of himself in 1931 at his village home near Vienna. As Freud and the bust go eyeball to eyeball, one can only imagine what conclusions each is drawing about the other.

•free association•A psychodynamic technique in which the patient describes any thought, feeling, or image that comes to mind, even if it seems unimportant.

•resistance•An unconscious refusal to participate fully in therapy.

•transference•According to psychody- namic theorists, the redirection toward the psychotherapist of feelings associated with important figures in a patient’s life, now or in the past.

•dream•A series of ideas and images that form during sleep.

•catharsis•The reliving of past repressed feelings in order to settle inter- nal conflicts and overcome problems.

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Models of Abnormality :// 41

a painful discussion. They demonstrate transference when they act and feel toward the therapist as they did or do toward important persons in their lives, especially their parents, siblings, and spouses. Consider again the woman who walked in Central Park. As she continues talking, the therapist helps her to explore her transference:

Patient: I get so excited by what is happening here. I feel I’m being held back by needing to be nice. I’d like to blast loose sometimes, but I don’t dare.

Therapist: Because you fear my reaction? Patient: The worst thing would be that you wouldn’t like me. You wouldn’t speak to me

friendly; you wouldn’t smile; you’d feel you can’t treat me and discharge me from treatment. But I know this isn’t so, I know it.

Therapist: Where do you think these attitudes come from? Patient: When I was nine years old, I read a lot about great men in history. I’d quote

them and be dramatic. I’d want a sword at my side; I’d dress like an Indian. Mother would scold me. Don’t frown, don’t talk so much. Sit on your hands, over and over again. I did all kinds of things. I was a naughty child. She told me I’d be hurt. Then at fourteen I fell off a horse and broke my back. I had to be in bed. Mother told me on the day I went riding not to, that I’d get hurt because the ground was frozen. I was a stubborn, self-willed child. Then I went against her will and suffered an accident that changed my life, a fractured back. Her attitude was, “I told you so.” I was put in a cast and kept in bed for months.

(Wolberg, 1967, p. 662)

Finally, many psychodynamic therapists try to help patients interpret their dreams (see Figure 2-4). Freud (1924) called dreams the “royal road to the unconscious.” He believed that repression and other defense mechanisms operate less completely during sleep and that dreams, if correctly interpreted, can reveal unconscious instincts, needs, and wishes. Freud identified two kinds of dream content—manifest and latent. Manifest content is the consciously remembered dream; latent content is its symbolic meaning. To interpret a dream, therapists must translate its manifest content into its latent content.

Catharsis Insight must be an emotional as well as an intellectual process. Psychody- namic therapists believe that patients must experience catharsis, a reliving of past re- pressed feelings, if they are to settle internal conflicts and overcome their problems.

Working Through A single episode of interpretation and catharsis will not change the way a person functions. The patient and therapist must examine the same issues over and over in the course of many sessions, each time with greater clarity. This process, called working through, usually takes a long time, often years.

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