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Abnormal Psychology, Third Canadian

Edition
by David H. Barlow, V. Mark Durand, and
Sherry H. Stewart
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Abnormal Behaviour
1 in Historical Context
CHAPT ER OUT L IN E
JODY: The Boy Who Fainted at the Sight of Blood
What Is a Psychological Disorder?
Psychological Dysfunction
Personal Distress
Atypical or Not Culturally Expected
The Science of Psychopathology
The Scientist-Practitioner
Clinical Description
Causation, Treatment, and Outcomes
The Past: Historical Conceptions of Abnormal
Behaviour
The Supernatural Tradition
Demons and Witches
Stress and Melancholy
CHARLES VI: The Mad King
Treatments for Possession
The Moon and the Stars
Comments
The Biological Tradition
Hippocrates and Galen
The 19th Century
The Development of Biological Treatments
Consequences of the Biological Tradition
The Psychological Tradition
Moral Therapy
Asylum Reform and the Decline of Moral Therapy
Psychoanalytic Theory
Humanistic Theory
The Behavioural Model
The Present: The Scientific Method and an
Integrative Approach
Bert Hardy/HultonArchive/Getty Images
Abnormal Psychology Video

Roots of Behaviour Therapy
A clear and complete insight into the nature of

madness, a correct and distinct conception of what
constitutes the difference between the sane and the
insane has, as far as I know, not been found.
—Schopenhauer, The World as Will and Idea
2 NEL
S T U DE N T LE A RNI NG OU T COM ES*

Characterize the nature of psychology as a discipline. ❯ Explain why psychology is a science (APA SLO 1.1.a) (see textbook pages 6–9)
Demonstrate knowledge and understanding representing ❯ The history of psychology, including the evolution of methods of psychology, its
appropriate breadth and depth in selected content areas of theoretical conflicts, and its sociocultural contexts (APA SLO 1.2.b) (see textbook
psychology. pages 9–29)
Use the concepts, language, and major theories of the ❯ Use theories to explain and predict behaviour and mental processes (APA SLO
discipline to account for psychological phenomena. 1.3.d) (see textbook pages 15–29)
❯ Integrate theoretical perspectives to produce comprehensive and multifaceted
explanations (APA SLO 1.3.e) (see textbook page 27)
Explain major perspectives of psychology (e.g., behavioural, ❯ Explain major perspectives in psychology (APA SLO 1.4a) (see textbook
biological, cognitive, evolutionary, humanistic, psychodynamic, pages 12–29)
and sociocultural).
* Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2007) in their guidelines for the undergraduate psychology major. Chapter coverage of these
outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO).
Today you may have gotten out of bed, had breakfast, gone to
class, studied, and at the end of the day, enjoyed the company of sodes were problematic for him and disruptive in school;
your friends before falling asleep. It probably did not occur to you each time he fainted, the other students flocked around him,
that many physically healthy people are unable to do some or any trying to help, and class was interrupted. Because no one
of these things. What they have in common is a psychological could find anything wrong with Jody, the principal finally
disorder, a psychological dysfunction within an individual that is concluded that he was being manipulative and suspended
associated with distress or impairment in functioning and a him from school, even though he was an honour student.
response that is not typical or culturally expected. Before examin- Jody had what we now call blood-injury-injection phobia.
ing exactly what this means, let’s look at one individual’s His reaction was quite severe, thereby meeting the criteria for
situation. phobia, a psychological disorder characterized by marked
and persistent fear of an object or situation. But many people
have similar reactions that are not as severe when they
JODY The Boy Who Fainted at the Sight of receive an injection or see someone who is injured, whether
Blood or not blood is visible. For people who react as severely as
Jody, this phobia can be very disabling. They may avoid cer-
Jody, a 16-year-old boy, was referred to our anxiety disor-
tain careers, such as medicine or nursing. If they are so afraid
ders clinic after increasing episodes of fainting. Jody
of needles and injections that they avoid them even when
reported that he had always been somewhat queasy at the
they are necessary, they put their health at risk.
sight of blood. About two years before coming to our clinic,
in his first biology class, the teacher showed a movie of a
frog dissection to illustrate various points about anatomy.
The film was particularly graphic, with vivid images of What Is a Psychological Disorder?
blood, tissue, and muscle. About halfway through, Jody felt
a bit lightheaded and left the room, but the images did not Keeping in mind the real-life problems faced by Jody, let’s look
leave him. He continued to be bothered by them and occa- more closely at the definition of a psychological disorder, or abnor-
sionally felt slightly queasy. He began to avoid situations in mal behaviour: It is a psychological dysfunction within an individ-
which he might see blood or an injury. He stopped looking ual associated with distress or impairment in functioning and a
at magazines that might have gory pictures. He found it response that is not typical or culturally expected (■ Figure 1.1).
difficult to look at raw meat, or even Band-Aids, because On the surface, these three criteria may seem obvious, but they
they brought the feared images to mind. Eventually, any- were not easily arrived at, and it is worth exploring what they
thing his friends or parents said that evoked an image of mean. You will see that no one criterion has yet been developed
blood or injury caused Jody to feel lightheaded. It became that fully defines abnormality.
so bad that if one of his friends exclaimed, “Cut it out!” he
felt faint. Beginning about six months before his visit to the
Psychological Dysfunction
clinic, Jody actually fainted when he unavoidably encoun-
tered something bloody. His family physician could find Psychological dysfunction refers to a breakdown in cognitive,
nothing wrong with him, nor could several other physicians. emotional, or behavioural functioning. For example, if you are out
By the time he was referred to our clinic, he was fainting on a date, it should be fun. If you experience severe fear all evening
five to ten times a week, often in class. Clearly, these epi- and just want to go home, even though you have nothing to be
afraid of, and if the severe fear happens on every date, your
NEL What Is a Psychological Disorder? 3

Psychological
disorder
Psychological dysfunction
Distress or impairment
Atypical response
■ FIGURE 1.1 The criteria defining a psychological disorder
emotions are not functioning properly. However, if all your friends

agree that the person who asked you out is dangerous, then it would
not be “dysfunctional” for you to be fearful and avoid the date.
A dysfunction was present for Jody: he fainted at the sight of
blood. But many people experience a mild version of this reaction
(feeling queasy at the sight of blood) without meeting the criteria
for the disorder; knowing where to draw the line between normal
and abnormal dysfunction is often difficult. For this reason, these
problems are often considered to exist on a continuum or as a
dimension, rather than as categories that are either present or
absent. This is one reason that just having a dysfunction is not
enough to meet the criteria for a psychological disorder.
Personal Distress
That the disorder or behaviour must be associated with distress
CP PHOTO/AP/Charles Rex Arbogast

adds an important component and seems clear: the criterion is
satisfied if the individual is extremely upset. We can certainly say
that Jody was very distressed and even suffered with his phobia.
But remember, by itself this criterion does not define abnormal
behaviour. It is often quite normal to be distressed—for example,
if someone close to you dies. The human condition is such that
suffering and distress are very much part of life—and that is not
▲ Distress and suffering are a natural part of life and do not in
likely to change. Furthermore, for some disorders, by definition, themselves constitute a psychological disorder.
suffering and distress are absent. Consider the person who feels
extremely elated and acts impulsively as part of a manic episode.
Atypical or Not Culturally Expected
As we see in Chapter 7, one major difficulty with this problem is
that people enjoy the manic state so much they are reluctant to Finally, the criterion that the response be atypical or not culturally
begin treatment or stay in treatment very long. Thus, defining expected is important but also insufficient to determine abnormality.
psychological disorder by distress alone doesn’t work, although At times, something is considered abnormal because it occurs infre-
the concept of distress contributes to a good definition. The quently; it deviates from the average. The greater the deviation, the
concept of impairment is useful, though it is not entirely satisfac- more abnormal it is. You might say that someone is abnormally short
tory. For example, many people consider themselves shy or lazy, or abnormally tall, meaning that the person’s height deviates substan-
but this doesn’t mean that they’re abnormal. But if you are so shy tially from average, but this obviously isn’t a definition of disorder.
that you find it impossible to date or even interact with people, Many people are far from the average in their behaviour, but few
and if you make every attempt to avoid interactions even though would be considered disordered. We might call them talented or
you would like to have friends, then your social functioning is eccentric. Many artists, movie stars, and athletes fall into this
impaired. Jody was clearly impaired by his phobia, but many category. For example, it’s not normal to plan to have blood spurt
people with similar, less severe reactions are not impaired. This from your clothes, but when Lady Gaga did this while performing it
difference again illustrates the important point that most psycho- only enhanced her celebrity. The late novelist J. D. Salinger, who
logical disorders are simply extreme expressions of otherwise wrote The Catcher in the Rye, retreated to a small town in New
normal emotions, behaviours, and cognitive processes. Hampshire and refused to see any outsiders for years, but he
4 Chapter 1 Abnormal Behaviour in Historical Context NEL
CP Photo/AP/Denis Gray
▲ Some religious behaviours may seem unusual to us but are
culturally or individually appropriate.
“So Rhoda,” I began laconically, “what do you suppose was wrong

with that woman?”
She looked at me as if I was mad.
“She is crazy.”
“But how can you tell?”
“She’s crazy. Can’t you just see from how she acts?”
“But how do you decide that she is crazy? What did she do?”
“She killed that goat.”
“Oh,” I said with anthropological detachment, “but Masai kill
goats all the time.”
She looked at me as if I were an idiot. “Only the men kill
Christopher Polk/Getty Images
goats,” she said.

“Well, how else do you know that she is crazy?”
“She hears voices.”
Again, I made a pain of myself. “Oh, but the Masai hear voices
sometimes.” (At ceremonies before long cattle drives, the Masai
trace-dance and claim to hear voices.) And in one sentence, Rhoda
▲ We accept extreme behaviours by entertainers, such as Lady summed up half of what anyone needs to know about cross-cultural
Gaga, that would not be tolerated in other members of our society. psychiatry. “But she hears voices at the wrong time.” (2002, p. 138)
continued to write. Some male rock singers wear heavy makeup on However, a social standard of normal has been misused. Consider,
stage. These people are well paid and seem to enjoy their careers. In for example, the practice of committing political dissidents to mental
most cases, the more productive you are in the eyes of society, the institutions, which was common in the former Soviet Union before
more eccentricities society will tolerate. Therefore, “deviating from the fall of Communism. Although such dissident behaviour clearly
the average” doesn’t work very well as a definition. violates social norms, it should not alone be cause for commitment.
Another view is that your behaviour is abnormal if you are violat-
ing social norms, even if some people are sympathetic to your point
of view. This definition is very useful in considering important Concept Check 1.1
cultural differences in psychological disorders. For example, to enter
a trance state and believe you are possessed would point to a psycho- Check your understanding of the definitions of abnormal
logical disorder in most Western cultures, but in many other societies behaviour. Write the letter for any, all, or none of the following
the behaviour is accepted and expected (see Chapter 6). (A cultural definitions in the blanks: (a) societal norm violation,
perspective is an important point of reference throughout this book.) (b) impairment in functioning, (c) dysfunction, and (d) distress.
An informative example of this view is provided by the prom- 1. Jan’s neighbour collects aluminum cans and attaches
inent neuroscientist Sapolsky (2002), who worked closely with them to the inside walls of her house for decoration. She
the Masai tribe in East Africa. One day Sapolsky’s Masai friend has two rooms completely wallpapered with cans and
Rhoda asked him to bring his jeep as quickly as possible to the has started on a third. Jan knows of no one else who
Masai village, where a woman had been acting very aggressively engages in similar behaviour and, therefore, believes her
and had been hearing voices. The woman had actually killed a neighbour to be abnormal. Jan could be using one of two
goat with her own hands. Sapolsky and several Masai were able definitions of abnormality. Which, if any, are they?
to subdue her and transport her to a local health centre. Realizing ______________
that this was an opportunity to learn more of the Masai’s view of (continued)
psychological disorders, Sapolsky had the following discussion:
NEL What Is a Psychological Disorder? 5

Some controversial figures such as Thomas Szasz and George

2. Miguel recently began feeling sad and lonely. Although Albee are highly critical of medical diagnoses being used in the
still able to function at work and fulfill his other respon- case of psychological disorders. In 1960, Szasz advanced his
sibilities, he finds himself feeling down much of the time, position that mental illness is a myth and that the practice of
and he worries about what is happening to him. Which of labelling mental illnesses should be abolished. For example,
the definitions of abnormality apply to Miguel’s situation? Szasz (1960) argued that a fundamental difference exists between
______________ the use of diagnoses for physical diseases and their use in mental
illnesses. The former uses objective criteria (e.g., results of blood
3. Three weeks ago, Tony, a 35-year-old business executive,
tests), but for mental illness, subjective judgments are required.
stopped showering, refused to leave his apartment, and
Albee (1998, 2000) has argued that the biggest mistake made by
started watching television talk shows. Threats of being
the clinical psychology profession was uncritically accepting the
fired have failed to bring Tony back to reality, and he
concept of “mental disease” and using the medical model and
continues to spend his days staring blankly at the tele-
associated diagnoses (e.g., the DSM system) in conceptualizing
vision screen. Which of the definitions seem to describe
abnormal behaviour. Even among the many proponents of the
Tony’s situation? ______________
DSM system, disagreement continues about how to define the
4. Jane is afraid to leave her home. She used to force herself concept of “disorder.”
to go out to maintain contact with friends and relatives; As noted earlier, creation of the DSM-5 is in progress (Brown &
however, recently she refuses to go anywhere. Which def- Barlow, 2005; Krueger, Watson, & Barlow, 2005; Regier, Narrow,
initions apply to this situation? ______________ Kuhl, & Kupfer 2009), with publication due in May 2013. But the
basic definition of psychological disorder will be largely
unchanged.
In a very thoughtful analysis of the matter, Wakefield (1992, As a challenge, take the problem of defining abnormal behav-
1999) uses the shorthand definition “harmful dysfunction.” A related iour a step further and consider this: What if Jody passed out
concept that is also useful is to determine whether the behaviour is repeatedly but regained consciousness so quickly that neither his
beyond the individual’s control (something he or she doesn’t want to classmates nor his teachers even noticed? Furthermore, what if
do; Widiger & Sankis, 2000). Variants of these approaches are most Jody continued to get good grades? Would fainting all the time at
often used in current diagnostic practice, as outlined in the fourth the mere thought of blood be a disorder? Would it be impairing?
edition, text revision, of the Diagnostic and Statistical Manual Dysfunctional? Distressing? What do you think?
(DSM-IV-TR, American Psychiatric Association, 2000a), which
contains the current listing of criteria for psychological disorders.
These approaches, which are largely unchanged in the fifth edition The Science of Psychopathology
(DSM-5) based on recent drafts, guide our thinking in this book.
In conclusion, it is difficult to define “normal” and “abnormal” Psychopathology is the scientific study of psychological disor-
(Lilienfeld & Marino, 1995, 1999)—and the debate continues ders. Within this field are specially trained professionals, includ-
(Clark, 1999; Klein, 1999; Spitzer, 1999). The most widely accepted ing clinical and counselling psychologists, psychiatrists,
definition used in the DSM-IV-TR (and drafts of the DSM-5) psychiatric social workers, psychiatric nurses, marriage and family
describes behavioural, psychological, or biological dysfunctions therapists, and mental health counsellors. Clinical psychologists
that are unexpected in their cultural context and associated with typically receive a Ph.D. (Doctor of Philosophy) following a
present distress and impairment in functioning, or increased risk of course of graduate-level study that lasts approximately five years.
suffering, death, pain, or impairment. This definition can be useful This education prepares them to conduct research into the causes
across cultures and subcultures if we pay careful attention to what and treatment of psychological disorders and to diagnose, assess,
is functional or dysfunctional (or out of control) in a given society. and treat these disorders. Instead of a Ph.D., clinical psychologists
But it is never easy to decide what represents dysfunction, and sometimes receive a Psy.D. (Doctor of Psychology) degree for
some scholars have argued persuasively that the health professions which the training is similar to the Ph.D. but with more emphasis
will never be able to satisfactorily define disease or disorder (see, on clinical practice and less on research training. No Psy.D.
for example, Lilienfeld & Marino, 1995, 1999). Perhaps the best programs currently exist in Canada; however, programs are
we can do is consider how the apparent disease or disorder matches currently in development in Québec (Dobson, 2003; Hunsley &
a “typical” profile of a disorder—for example, major depression or Johnston, 2000). In Canada, regulation of the psychology profes-
schizophrenia—when most or all symptoms that experts agree are sion is under the jurisdiction of the provinces and territories.
part of the disorder are present. We call this typical profile a proto- Depending on the jurisdiction, a psychologist may have either a
type, and, as described in Chapter 3, the diagnostic criteria from doctoral or a master’s degree (Hunsley & Johnston, 2000). For
DSM-IV-TR as well as the emerging criteria for DSM-5 found example, within the province of Ontario, professional psycholo-
throughout this book are all prototypes. This means that the patient gists are regulated by the College of Psychologists of Ontario, as
may have only some features or symptoms of the disorder (a outlined in the Regulated Health Professions Act (1991). Largely
minimum number) and still meet criteria for the disorder because to protect the public, but also in the interest of the profession
his or her set of symptoms is close to the prototype. This concept is (Goodman, 2000), only those who are licensed or registered with
described more fully in Chapter 3, where the diagnosis of psycho- their provincial board or college are permitted to call themselves
logical disorder is discussed. “psychologists” (e.g., in advertising). Note that the labels
“psychotherapist” and “therapist” are not regulated by the provin-

cial and territorial psychology boards or colleges. Thus, in Canada,
the label of “psychologist” conveys information about the training
and qualifications of the professional, whereas the label of Scientist-
“psychotherapist” does not. In addition, the terms “therapist” and practioner
“psychotherapist” are not specific to a particular profession. For
Consumer of science
example, a social worker, a psychologist, and a psychiatrist can all • Enhancing the practice
refer to themselves as “psychotherapists” if they provide therapy
services to members of the public around psychological issues. Evaluator of science
• Determining the
Psychologists with other specialty training, such as experi- effectiveness of the
mental and social psychologists, concentrate on investigating the practice
basic determinants of behaviour but do not assess or treat
Creator of science
psychological disorders. Although a great deal of overlap exists, • Conducting research
counselling psychologists (who can receive a Ph.D., Psy.D., or that leads to new
Ed.D.—Doctor of Education) tend to study and treat adjustment procedures useful
in practice
and vocational issues encountered by relatively healthy individ-
uals, whereas clinical psychologists usually concentrate on more ■ FIGURE 1.2 Functioning as a scientist-practitioner
severe psychological disorders.
Psychiatrists first earn an M.D. in medical school and then
specialize in psychiatry during a three-year to four-year residency their treatment. Many mental health professionals take a scientific
training program. Psychiatrists also investigate the nature and approach to their clinical work and are therefore referred to as
causes of psychological disorders, often from a biological point scientist-practitioners (Barlow, Hayes, & Nelson, 1984; Hayes,
of view, make diagnoses, and offer treatments. Many psychiatrists Barlow, & Nelson-Gray, 1999). Mental health practitioners may
emphasize drugs or other biological treatments, although most function as scientist-practitioners at least one of three ways (see
use psychosocial treatments as well. ■ Figure 1.2). First, they may keep up with the latest scientific
Psychiatric social workers typically earn a master’s degree in developments in their field and therefore use the most current
social work as they develop expertise in collecting information diagnostic and treatment procedures. In this sense, they are
relevant to the social and family situation of the individual with a consumers of the science of psychopathology to the advantage of
psychological disorder. Social workers also treat disorders, often their patients. Second, scientist-practitioners evaluate their own
concentrating on family problems associated with them. Psychi- assessments or treatment procedures to see whether they work.
atric nurses have advanced degrees, such as a master’s or a Ph.D., They are accountable not only to their patients but also to the
and specialize in the care and treatment of patients with psycho- government agencies and insurance companies that pay for the
logical disorders, usually in hospitals as part of a treatment team. treatments, so they must demonstrate clearly that their treatments
Finally, marriage and family therapists and mental health coun- work. Third, scientist-practitioners might conduct research, often
sellors typically spend one to two years earning a master’s degree in clinics or hospitals, that produces new information about disor-
and provide clinical services in hospitals or clinics, usually under ders or their treatment, thus becoming immune to the fads that
the supervision of a doctoral-level clinician. Table 1.1 shows the plague our field often at the expense of patients and their families.
number of each major category of mental health professionals For example, new “miracle cures” for psychological disorders
currently practising in Canada. that are reported several times a year in the popular media would
not be used by a scientist-practitioner who did not have sound
scientific data showing that they work. Such data flow from
The Scientist-Practitioner
research that attempts three basic things: to describe psycho-
The most important recent development in the history of psychological disorders, to determine their causes, and to treat them (see
pathology is the adoption of scientific methods to learn more ■ Figure 1.3). These three categories compose an organizational
about the nature of psychological disorders, their causes, and structure that recurs throughout this book and is formally evident
in the discussions of specific disorders beginning in Chapter 5.
TABLE 1.1 Mental Health Professionals Currently Practising
in Canada
Focus
Profession Number Currently Practising
Clinical description
Psychiatrists 3 600 Studying
psychological Causation (etiology)
Psychologists, master’s level, and 13 000 disorders
psychological associates Treatment and outcome
Psychiatric nurses 11 000
Psychiatric social workers thousands ■ FIGURE 1.3 Three major categories compose the study and
discussion of psychological disorders
Source: Adapted from Goering, Wasylenki, & Durbin, 2000.
NEL The Science of Psychopathology 7

A general overview of the categories now will give you a clearer

perspective on our efforts to understand abnormality.
Clinical Description
In hospitals and clinics we often say that a patient “presents”
with a specific problem or set of problems, or we discuss the
presenting problem. Presents is a traditional shorthand way of
indicating why the person came to the clinic. Describing Jody’s
presenting problem is the first step in determining his clinical
description, which represents the unique combination of behav-
iours, thoughts, and feelings that make up a specific disorder.
The word clinical refers both to the types of problems or disor-
ders you would find in a clinic or hospital and to the activities
connected with assessment and treatment. Throughout this text
are excerpts from many individual cases, most of them from our
personal files.
Clearly, one important function of the clinical description is
to specify what makes the disorder different from normal
behaviour or from other disorders. Statistical data may also be
© Lawrence Manning/Corbis
relevant. For example, how many people in the population as a
whole have the disorder? This figure is called the prevalence of
the disorder. Statistics on how many new cases occur during a
given period, such as a year, represent the incidence of the
disorder. Other statistics include the sex ratio—that is, what
percentage of males and females have the disorder—and the ▲ Children experience panic and anxiety differently from adults, so
typical age of onset, which often differs from one disorder to their reactions may be mistaken for symptoms of physical illness.
another.
In addition to having different symptoms, a different age of
onset, and possibly a different sex ratio and prevalence, most The patient’s age may be a very important part of the clinical
disorders follow a somewhat individual pattern, or course. For description. A specific psychological disorder occurring in child-
example, some disorders, such as schizophrenia (see Chapter 13), hood may present very differently from the same disorder in
follow a chronic course, meaning that they tend to last a long adulthood or old age. Children experiencing severe anxiety and
time, sometimes a whole lifetime. Other disorders, like mood panic often assume that they are physically ill because they have
disorders (see Chapter 7), follow an episodic course in which the difficulty understanding there is nothing physically wrong.
individual is likely to recover within a few months, only to have Because their thoughts and feelings are different from those
a recurrence of the disorder later. This pattern may repeat experienced by adults with anxiety and panic, children are often
throughout a person’s life. Still other disorders may have a time- misdiagnosed and treated for a medical disorder.
limited course, meaning the disorder will improve without treat-
ment in a relatively short period.
Causation, Treatment, and Outcomes
Closely related to differences in the course of disorders are
differences in onset. Some disorders have an acute onset, mean- Etiology, or the study of origins, has to do with why a disorder
ing that they begin suddenly; others develop gradually over an begins (what causes it) and includes biological, psychological,
extended time, which is sometimes called an insidious onset. It is and social dimensions. Because the etiology of psychological
important to know the typical course of a disorder so that we disorders is so important to this field, we devote an entire chapter
know what to expect and how best to deal with the problem. The to it (Chapter 2). Treatment is often important to the study of
anticipated course is an important part of the clinical description. psychological disorders. If a new drug or psychosocial treatment
For example, if someone has a mild disorder with acute onset that is successful in treating a disorder, it may give us some hints
we know is time limited, we might advise the individual to forgo about the nature of the disorder and its causes. For example, if a
expensive treatment, because the problem will resolve soon drug with a specific known effect within the nervous system
enough, like a common cold. However, if the disorder is likely to alleviates a certain psychological disorder, we know that some-
last a long time (become chronic), the individual might want to thing in that part of the nervous system might be either causing
seek treatment and take other appropriate steps. The anticipated the disorder or helping maintain it. Similarly, if a psychosocial
course of a disorder is called the prognosis. So we might say, “the treatment designed to help clients regain a sense of control over
prognosis is good,” meaning the individual will probably recover, their lives is effective with a certain disorder, a diminished sense
or “the prognosis is guarded,” meaning the probable outcome of control may be an important psychological component of the
doesn’t look good. disorder itself.
treatment that allow us to function as scientist-practitioners. In

Concept Check 1.2 Chapters 5 through 15, we examine specific disorders; our discus-
sion is organized in each case in the now familiar triad of descrip-
A clinical description includes the unique combination of tion, cause, and treatment. Finally, in Chapter 16 we examine legal,
behaviours, thoughts, and feelings that compose a given professional, and ethical issues that are relevant to psychological
psychological disorder. Match the following words that are disorders and their treatment in Canada today. With that interview
used in clinical descriptions with their corresponding in mind, let us turn to the past.
examples: (a) presenting problem, (b) prevalence, (c) inci-
dence, (d) prognosis, (e) course, or (f) etiology.
1. Maria should recover quickly with no intervention neces-
sary. Without treatment, David will deteriorate rapidly. The Past: Historical Conceptions of
______________ Abnormal Behaviour
2. Three new cases of bulimia have been reported in this
For thousands of years, humans have tried to explain and control
county during the past month and only one in the next
problematic behaviour. But our efforts always derive from the
county. ______________
theories or models of behaviour that are popular at the time. The
3. Elizabeth visited the campus mental health centre purpose of these models is to explain why someone is “acting like
because of her increasing feelings of guilt and anxiety. that.” Three major models that have guided us date back to the
______________ beginnings of civilization.
4. Biological, psychological, and social influences all con- Humans have always supposed that certain agents outside our
tribute to a variety of disorders. ______________ bodies and environment influence our behaviour, thinking, and
5. The pattern a disorder follows can be chronic, time lim- emotions. These agents, which might be divinities, demons, spirits,
ited, or episodic. ______________ or other phenomena such as magnetic fields or the moon or the
stars, are the driving forces behind the supernatural model. In addi-
6. How many people in the population as a whole have
tion, since ancient Greece, the mind has often been called the soul
obsessive-compulsive disorder? ______________
or the psyche and considered separate from the body. Although
many have thought that the mind can influence the body and, in
As we see in the next chapter, psychology is never that simple. turn, the body can influence the mind, most philosophers looked
This is because the effect does not necessarily imply the cause. To for causes of abnormal behaviour in one or the other. This split
use a common example, you might take an aspirin to relieve a gave rise to two traditions of thought about abnormal behaviour,
tension headache that you developed during a gruelling day of summarized as the biological model and the psychological model.
taking exams. If you then feel better, it does not mean the headache These three models—the supernatural, the biological, and the
was caused by a lack of aspirin in the first place. Nevertheless, psychological—are very old but still in use today.
many people seek treatment for psychological disorders, and treat-
ment can provide interesting hints about the nature of the disorder.
In the past, textbooks emphasized treatment approaches in a The Supernatural Tradition
very general sense, with little attention to the disorder being
treated. For example, a mental health professional might be For much of our recorded history, deviant behaviour has been
thoroughly trained in a single theoretical approach, such as considered a reflection of the battle between good and evil. When
psychoanalysis or behaviour therapy (both described later in the confronted with unexplainable, irrational behaviour and by
chapter), and then use that approach on every disorder. More suffering and upheaval, people perceived evil. A noted historian
recently, as our science has advanced, we have developed specific chronicled the second half of the 14th century, a particularly diffi-
effective treatments that do not always adhere neatly to one theor- cult time for humanity, in A Distant Mirror (Tuchman, 1978). She
etical approach but that have grown out of a deeper understanding very ably captures the conflicting tides of opinion on the origins
of the disorder in question. For this reason, this book does not and treatment of insanity during that bleak and tumultuous period.
have separate chapters on such types of treatment approaches as
psychodynamic, cognitive behavioural, or humanistic. Rather, the
Demons and Witches
latest and most effective drug and psychosocial treatments are
described in the context of specific disorders, in keeping with our One strong current of opinion put the causes and treatment of
integrative multidimensional perspective. psychological disorders squarely in the realm of the supernatural.
We now survey many early attempts to describe and treat abnor- During the last quarter of the 14th century, religious and lay author-
mal behaviour, and more still to comprehend its causes, which will ities supported these popular superstitions, and society as a whole
give you a better perspective on current approaches. In Chapter 2, began to believe in the reality and power of demons and witches.
we examine contemporary views of causation and treatment. In The Catholic Church had split, and a second centre, complete with
Chapter 3, we discuss efforts to describe, or classify, abnormal a pope, emerged in the south of France to compete with Rome. In
behaviour. In Chapter 4, we review research methods—our system- reaction to this schism, the Roman church fought back against the
atic efforts to discover the truths underlying description, cause, and evil in the world that must have been behind this heresy.
NEL The Supernatural Tradition 9

during the 14th and 15th centuries, people

with mental illnesses, along with people who
had physical deformities or disabilities, were
often moved from house to house in medieval
villages, as neighbours took turns caring for
them. We now know that this medieval prac-
tice of keeping people who have psycho-
logical disturbances in their own community
is beneficial (see Chapter 13). (We return to
this subject when we discuss biological and
psychological models later in this chapter.)
One of the chief advisers to the king of
France, a bishop and philosopher named
Nicholas Oresme, also suggested that the
disease of melancholy (depression), rather
than demons, was the source of some
bizarre behaviour. Oresme pointed out that
much of the evidence for the existence of
Mary Evans Picture Library

sorcery and witchcraft, particularly among
people with psychological disorders, was
obtained from people who were tortured
and who, quite understandably, confessed
to anything.
▲ During the Middle Ages, individuals with psychological disorders were sometimes These conflicting crosscurrents of natural
thought to be possessed by evil spirits that had to be exorcised through rituals.
and supernatural explanations for mental
disorders are represented more or less
People turned increasingly to magic and sorcery to solve strongly in various historical works, depending on the sources
their problems. During these turbulent times, the bizarre behav- consulted by historians. Some assume that demonic influences
iour of people afflicted with psychological disorders was seen as were the predominant explanations of abnormal behaviour
the work of the devil and witches. It followed that individuals during the Middle Ages (e.g., Zilboorg & Henry, 1941); others
possessed by evil spirits were probably responsible for any believe the supernatural had little or no influence. As we see in
misfortune experienced by the townspeople, which inspired the handling of the severe psychological disorder experienced by
drastic action against the possessed. Treatments included exor- King Charles VI of France in the late 14th century, both influ-
cism, in which various religious rituals were performed to rid ences were strong, sometimes alternating in the treatment of the
the victim of evil spirits. Other approaches included shaving the same case.
pattern of a cross in the victims’ hair and securing them to a wall
near the front of a church so that they might benefit from hear-
ing mass.
CHARLES VI The Mad King
The conviction that sorcery and witches were causes of
madness and other evils continued into the 15th century. Evil In the summer of 1392, King Charles VI of France was under a
continued to be blamed for unexplainable behaviour, even after great deal of stress, in part because of the division of the Cath-
the European founding of the New World, as evidenced by the olic Church. As he rode with his army to the province of Brit-
1692 Salem witch trials. This event involved an outbreak of tany, a nearby aide dropped his lance with a loud clatter and
accusations of witchcraft alleged toward women in a Massachu- the king, thinking he was under attack, turned on his own army,
setts village community (Boyer & Nissenbaum, 1974). killing several prominent knights before being subdued from
behind. The army immediately marched back to Paris. The
king’s lieutenants and advisers concluded that he was mad.
Stress and Melancholy
During the following years, at his worst the king hid in
An equally strong opinion, even during this period, reflected the a corner of his castle, believing he was made of glass, or
enlightened view that insanity was a natural phenomenon, roamed the corridors howling like a wolf. At other times he
caused by mental or emotional stress, and that it was curable couldn’t remember who or what he was. He became fearful
(Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental and enraged whenever he saw his own royal coat of arms
depression and anxiety were recognized as illnesses (Kemp, and would try to destroy it if it were brought near him.
1990; Schoeneman, 1977), although symptoms such as despair The people of Paris were devastated by their leader’s
and lethargy were often identified by the church with the sin of apparent madness. Some thought it reflected God’s anger,
acedia, or sloth (Tuchman, 1978). Common treatments were because the king had failed to take up arms to end the
rest, sleep, and a healthy and happy environment. Other treat- schism in the Catholic Church; others thought it was God’s
ments included baths, ointments, and various potions. Indeed,
(AIDS) epidemic reflects a very similar belief among some

warning against taking up people. Because the human immunodeficiency virus (HIV) is, in
arms; still others thought it Western societies, most prevalent among practising homosexuals,
was divine punishment for some people believe it is a divine punishment for what they
heavy taxes (a conclusion consider abhorrent behaviour. This view is slowly dissipating as
some people might make the AIDS virus spreads to other “less sinful” segments of the
today). But most thought population, but it still persists. Possession, however, is not always
the king’s madness was connected with sin and may be seen as involuntary and the
caused by sorcery, a belief possessed individual as blameless. Furthermore, exorcisms at

strengthened by a great least have the virtue of being relatively painless. Interestingly,
drought that dried up the they sometimes work, as do other forms of faith healing, for
ponds and rivers, causing reasons we explore in subsequent chapters. But what if they did
cattle to die of thirst. not? In the Middle Ages, if exorcism failed, some authorities
Merchants claimed their thought that steps were necessary to make the body uninhabitable
worst losses in 20 years. by evil spirits, and many people were subjected to confinement,
Naturally, the king was given the best care available. The beatings, and other forms of torture (Kemp, 1990).
most famous healer in the land was a 92-year-old physician Somewhere along the way, a creative “therapist” decided that
whose treatment program included moving the king to one hanging people over a pit full of poisonous snakes might scare the
of his residences in the country where the air was thought evil spirits right out of their bodies (to say nothing of terrifying
to be the cleanest in the land. The physician prescribed rest, the people themselves). Strangely, this approach sometimes
relaxation, and recreation. After some time, the king seemed worked; that is, the most disturbed, oddly behaving individuals
to recover. The physician recommended that the king not be would suddenly come to their senses and experience relief from
burdened with the responsibilities of running the kingdom, their symptoms, if only temporarily. Naturally, this was reinfor-
claiming that if he had few worries or irritations, his mind cing to the therapist, and, so, snake pits were built in many institu-
would gradually strengthen and further improve. tions. Many other treatments based on the hypothesized
Unfortunately, the physician died and the insanity of King therapeutic element of shock were developed, including dunkings
Charles VI returned more seriously than before. This time, in ice-cold water.
however, he came under the influence of the conflicting
crosscurrent of supernatural causation. “An unkempt evil-
The Moon and the Stars
eyed charlatan and pseudo-mystic named Arnaut Guilhem
was allowed to treat Charles on his claim of possessing a Paracelsus, a Swiss physician who lived from 1493 to 1541,
book given by God to Adam by means of which man could rejected notions of possession by the devil, suggesting instead
overcome all affliction resulting from original sin” (Tuchman, that the movements of the moon and stars had profound effects on
1978, p. 514). Guilhem insisted that the king’s malady was people’s psychological functioning. This influential theory
caused by sorcery, but his treatments failed to effect a cure. inspired the word lunatic, which is derived from the Latin word
A variety of remedies and rituals of all kinds were tried for moon, luna. You might hear some of your friends explain
but none worked. High-ranking officials and doctors of the something crazy they did last night by saying, “It must have been
university called for the “sorcerers” to be discovered and the full moon.” The belief that heavenly bodies affect human
punished. “On one occasion, two Augustinian friars, after behaviour still exists, although no scientific evidence supports it.
getting no results from magic incantations and a liquid made Despite much ridicule, millions of people around the world are
from powdered pearls, proposed to cut incisions in the king’s convinced that their behaviour is influenced by the stages of the
head. When this was not allowed by the king’s council, the moon or the position of the stars. This belief is most noticeable
friars accused those who opposed their recommendation of today in followers of astrology, who hold that their behaviour and
sorcery” (Tuchman, 1978, p. 514). Even the king himself, the major events in their lives can be predicted by their day-to-day
during his lucid moments, came to believe the source of relationship to the position of the planets. However, no serious
madness was evil and sorcery. “In the name of Jesus Christ,” evidence has ever confirmed such a connection.
he cried weeping in his agony, “if there is any one of you
who is an accomplice in this evil I suffer, I beg him to torture
Comments
me no longer but let me die!” (Tuchman, 1978, p. 515).
The supernatural tradition in psychopathology is alive and well,
although it is relegated, for the most part, to some cultures outside
North America and to small religious sects within North America.
Treatments for Possession
Members of organized religions in most parts of the world look to
With a perceived connection between evil deeds and sin on the psychology and medical science for help with major psychological
one hand, and psychological disorders on the other, it is logical to disorders; in fact, the Roman Catholic Church requires that all
conclude that the person is largely responsible for his or her own health care resources be exhausted before spiritual solutions such
disorder, which might well be a punishment for evil deeds. Does as exorcism can be considered. Nonetheless, miraculous cures are
this sound familiar? The acquired immune deficiency syndrome sometimes achieved by exorcism, magic potions, rituals, and other
NEL The Supernatural Tradition 11

within the biological tradition that extended

well into the 19th century. One of the more
interesting and influential legacies of the
Hippocratic-Galenic approach is the humoral
theory of disorders. Hippocrates assumed
that normal brain functioning was related to
four bodily fluids, or humors: blood, black
bile, yellow bile, and phlegm. Blood came
from the heart, black bile from the spleen,
phlegm from the brain, and choler or yellow
bile from the liver. Physicians believed that
disease resulted from too much or too little
of one of the humors; for example, too much
black bile was thought to cause melancholia
(depression). In fact, the term melancholer,
which means black bile, is still used today in
Culver Pictures
its derivative form melancholy to refer to
aspects of depression. The humoral theory
was, perhaps, the first example of associat-
▲ In hydrotherapy, patients were shocked back to their senses by being submerged in ing psychological disorders with chemical
ice-cold water. imbalance, an approach that is widespread
today.
methods that seem to have little connection with modern science. The four humors were related to the Greeks’ conception of the
It is fascinating to explore them when they do occur, and we return four basic qualities: heat, dryness, moisture, and cold. Each
to this topic in subsequent chapters. But such cases are relatively humor was associated with one of these qualities. Terms derived
rare, and almost no one would advocate supernatural treatment for from the four humors are still sometimes applied to personality
severe psychological disorders except, perhaps, as a last resort. traits. For example, sanguine (red, like blood) describes someone
who is ruddy in complexion—presumably from copious blood
flowing through the body—and cheerful and optimistic, though
The Biological Tradition insomnia and delirium were thought to be caused by excessive
blood in the brain. Melancholic, of course, refers to a depressive
Physical causes of mental disorders have been sought since early personality (depression was thought to be caused by black bile
in history. Important to the biological tradition are a man, Hippoc- flooding the brain). A phlegmatic personality (from the humor
rates; a disease, syphilis; and the early consequences of believing phlegm) indicates apathy and sluggishness but can also mean
that psychological disorders are biologically caused. being calm under stress. A choleric person (from yellow bile or
choler) is hot tempered (Maher & Maher, 1985a).
Excesses of one or more humors were treated by regulating the
Hippocrates and Galen
environment to increase or decrease heat, dryness, moisture, or
The Greek physician Hippocrates (460–377 b.c.e.) is considered cold, depending on which humor was out of balance. One reason
the father of modern medicine. He and his associates left a body of King Charles VI’s physician moved him to the less stressful
work called the Hippocratic Corpus, written between 450 b.c.e. countryside was to restore the balance in his humors (Kemp,
and 350 b.c.e. (Maher & Maher, 1985a), in which they suggested 1990). In addition to rest, good nutrition, and exercise, two treat-
that psychological disorders could be treated like any other disease. ments were developed. In bleeding or bloodletting, a carefully
They did not limit their search for the causes of psychopathology measured amount of blood was removed from the body, often
to the general area of “disease,” because they believed that psycho- with leeches. In the other, vomiting was induced; indeed, in a
logical disorders might also be caused by brain pathology or head well-known treatise on depression published in 1621, Anatomy of
trauma and could be influenced by heredity (genetics). These were Melancholy, Burton recommended eating tobacco and a half-
remarkably astute deductions for the time, and they have been boiled cabbage to induce vomiting (Burton, 1621/1977). Three
supported in recent years. Hippocrates considered the brain to be hundred years ago, under the influence of early biological trad-
the seat of wisdom, consciousness, intelligence, and emotion. itions, Jody might have been diagnosed with an illness, a brain
Therefore, disorders involving these functions would logically be disorder, or some other physical problem and given the proper
located in the brain. Hippocrates also recognized the importance of medical treatments of the day, including bed rest, a healthful diet,
psychological and interpersonal contributions to psychopathology, exercise, and other ministrations as indicated.
such as the sometimes negative effects of family stress; on some Hippocrates also coined the word hysteria to describe a concept
occasions, he removed patients from their families. he learned about from the Egyptians, who had identified what we
The Roman physician Galen (ca. 129–198 c.e.) later adopted now call the somatoform disorders (see Chapter 6). In these disor-
the ideas of Hippocrates and his associates and developed them ders, the physical symptoms appear to be the result of an organic
further, creating a powerful and influential school of thought pathology for which no organic cause can be found, such as
19th century by two factors: the discovery of the nature and cause

of syphilis, and strong support from the well-respected American
psychiatrist John P. Grey.
Syphilis
Behavioural and cognitive symptoms of what we now know as
advanced syphilis include believing that everyone is plotting
against you (delusion of persecution) or that you are God (delu-
sion of grandeur), as well as other bizarre behaviours. Although
these symptoms are very similar to those of psychosis, research-
ers recognized that a subgroup of apparently psychotic patients
deteriorated steadily, becoming paralyzed and dying within five
years of onset. This course of events contrasted with that of most
psychotic patients, who remained fairly stable. In 1825, the
condition was designated a disease, general paresis, because it
had consistent symptoms (presentation) and a consistent course
that resulted in death. The relationship between general paresis
and syphilis was only gradually established. Louis Pasteur’s germ
theory of disease, around 1870, facilitated the identification of the
specific bacterial micro-organism that caused syphilis. Pasteur
stated that all the symptoms of a disease were caused by a germ
(bacterium) that had invaded the body.
Of equal importance was the discovery of a cure for general
paresis. Physicians observed a surprising recovery in patients who
National Library of Medicine had contracted malaria and deliberately injected others with
blood from a soldier who was ill with malaria. Many recovered,
because the high fever “burned out” the syphilis bacteria.
Obviously, this type of experiment would not be ethically possible
today. Ultimately, clinical investigators discovered that penicillin
cures syphilis, but the malaria cure convinced many for the first
▲ Bloodletting, the extraction of blood from patients, was intended to
restore the balance of humors in the body.
time that “madness” and associated behavioural and cognitive
symptoms could be traced directly to a curable infection. Many
mental health professionals then assumed that comparable causes
paralysis and some kinds of blindness. Because these disorders
and cures might be discovered for all psychological disorders.
occurred primarily in women, the Egyptians (and Hippocrates)
mistakenly assumed that they were restricted
to women. They also presumed a cause: The
empty uterus wandered to various parts of
the body in search of conception (the Greek
for “uterus” is hysteron). Numerous physical
symptoms reflected the location of the
wandering uterus. The prescribed cure might
be marriage or, occasionally, fumigation of
the vagina to lure the uterus back to its
natural location (Alexander & Selesnick,
1966). Knowledge of physiology eventually
disproved the wandering uterus theory;
however, the tendency to stigmatize dramatic
women as “hysterical” continued unabated
well into the 1970s, when mental health
professionals became sensitive to the preju-
National Library of Medicine
dicial stereotype the term implied.
The 19th Century

The biological tradition waxed and waned
during the centuries after Hippocrates and ▲ In the 19th century, psychological disorders were attributed to mental or emotional stress,
Galen, but was reinvigorated in the so patients were often treated sympathetically in a restful and hygienic environment.
NEL The Biological Tradition 13

John P. Grey During the 1950s, the first effective drugs for severe psychotic
The champion of the biological tradition in North America was a disorders were developed in a systematic way, and they were
very influential psychiatrist named John P. Grey, who was appointed introduced to Canada by psychiatrist Heinz Lehman. Before that
superintendent of a large hospital in New York in 1854 (Bockoven, time, a number of medicinal substances, including opium (derived
1963). Grey also became editor of the American Journal of Insan- from poppies), had been used as sedatives, along with countless
ity, the precursor of the current American Journal of Psychiatry, herbs and folk remedies (Alexander & Selesnick, 1966). With the
and the flagship publication of the American Psychiatric Associa- discovery of Rauwolfia serpentina (later renamed reserpine) and
tion. Grey’s position was that insanity always has physical causes. another class of drugs called neuroleptics (major tranquilizers),
Therefore, the mentally ill patient should be treated as physically ill. for the first time hallucinatory and delusional thought processes
The emphasis was once again on rest, diet, and proper room could be diminished; these drugs also controlled agitation and
temperature and ventilation, approaches used for centuries by previ- aggressiveness. Other discoveries included benzodiazepines
ous therapists in the biological tradition. Grey even invented the (minor tranquilizers), which seemed to reduce anxiety. By the
rotary fan in order to ventilate his large hospital. 1970s, the benzodiazepines (known by such brand names as
Under Grey’s leadership, the conditions in hospitals greatly Valium and Librium) were among the most widely prescribed
improved, and they became more humane, livable institutions. drugs in the world. As drawbacks and side effects of tranquilizers
But in subsequent years they also became so large and impersonal became apparent, along with their limited effectiveness, the
that individual attention was not possible. number of prescriptions decreased somewhat (we discuss the
In fact, leaders in psychiatry at the end of the 19th century benzodiazepines in more detail in Chapters 5 and 11).
were alarmed at the increasing size and impersonality of mental Throughout the centuries, as Alexander and Selesnick (1966,
hospitals and recommended that they be downsized. It was almost p. 287) point out, “The general pattern of drug therapy for mental
100 years before the community mental health movement was illness has been one of initial enthusiasm followed by disappoint-
successful in reducing the population of mental hospitals with the ment.” For example, bromides, a class of sedating drugs, were used
very controversial policy of deinstitutionalization, in which at the end of the 19th and the beginning of the 20th centuries to treat
patients were released into their communities. Unfortunately, this anxiety and other psychological disorders. By the 1920s they were
practice had as many negative consequences as positive ones, reported as being effective for many serious psychological and
including a large increase in the number of patients with chronic emotional symptoms. By 1928, one of every five prescriptions in the
disabilities left homeless on the streets of our cities. United States was for bromides. When their side effects, including
various undesirable physical symptoms, became widely known, and
experience began to show that their overall effectiveness was rela-
The Development of Biological Treatments
tively modest, bromides largely disappeared from the scene.
On the positive side, renewed interest in the biological origin of Neuroleptics were also used less when attention focused on
psychological disorders led, ultimately, to an increased understanding their many side effects, such as tremors and shaking. However, the
of the biological contributions to psychopathology and to the develop- positive effects of these drugs on some patients’ psychotic symp-
ment of new treatments. In the 1930s, the physical interventions of toms of hallucinations, delusions, and agitation revitalized both
electric shock and brain surgery were often used. Their effects, and the the search for biological contributions to psychological disorders
effects of new drugs, were discovered quite by accident. For example, and the search for new and more powerful drugs, a search that has
insulin was occasionally given to stimulate appetite in psychotic paid many dividends, as documented in later chapters.
patients who were not eating, but it also seemed to calm them down.
In 1927, a Viennese physician, Manfred Sakel, began using higher and
Consequences of the Biological Tradition
higher dosages until, finally, patients convulsed and became temporar-
ily comatose (Sakel, 1958). Some actually recovered their mental In the late 19th century, John P. Grey and his colleagues, ironic-
health, much to the surprise of everybody, and their recovery was ally, reduced or eliminated interest in treating patients with mental
attributed to the convulsions. The procedure became known as insulin illnesses because they thought mental disorders were due to some
shock therapy, but it was abandoned because it was too dangerous, as yet undiscovered brain pathology and were therefore incurable.
often resulting in prolonged coma or even death. Other methods of The only available course of action was to hospitalize these
producing convulsions had to be found. patients. In fact, around the turn of the 20th century, some nurses
In the 1920s, Joseph von Meduna observed that schizophrenia documented clinical success in treating mental patients with
was very rarely found in epileptics (which ultimately did not prove psychological methods but were prevented from treating others for
to be true). Some of his followers concluded that induced brain seiz- fear of raising hopes of a cure among family members. In place of
ures might cure schizophrenia. Following suggestions on the possible treatment, interest centred on diagnosis, legal questions concern-
benefits of applying electric shock directly to the brain—notably, by ing the responsibility of patients for their actions during periods of
two Italian physicians, Cerletti and Bini, in 1938—a surgeon in insanity, and the study of brain pathology itself.
London treated a depressed patient by sending six small shocks Emil Kraepelin (1856–1926) was the dominant figure during
directly through his brain, producing convulsions (Hunt, 1980). The this period and one of the founding fathers of modern psychiatry.
patient recovered. Though greatly modified, shock treatment is still He was extremely influential in advocating the major ideas of the
with us today. The controversial modern uses of electroconvulsive biological tradition, but he was little involved in treatment,
therapy (ECT) are described in Chapter 7. It is interesting that even reflecting the belief that disorders were due to brain pathology.
now we have very little knowledge of how ECT works. His lasting contribution was in the area of diagnosis and
classification, which we discuss in detail in Chapter 3. Kraepelin psychological factors but also on social and cultural ones. Other
(1913) was one of the first to distinguish among various psycho- well-known early philosophers, including Aristotle, also empha-
logical disorders, seeing that each may have a different age of sized the influence of the social environment and early learning
onset and course, with somewhat different clusters of presenting on later psychopathology. These philosophers wrote about the
symptoms and probably a different cause. Many of his descrip- importance of fantasies, dreams, and cognitions and thus antici-
tions of schizophrenic disorders are still useful today. pated, to some extent, later developments in psychoanalytic
By the end of the 19th century, a scientific approach to psycho- thought and cognitive science. They also advocated humane and
logical disorders and their classification had begun with the search responsible care for people with psychological disturbances.
for biological causes. Furthermore, treatment was based on humane
principles. However, there were many drawbacks, the most
Moral Therapy
unfortunate being that active intervention and treatment were all
but eliminated in some settings, despite the fact that some very During the first half of the 18th century, a strong psychosocial
effective approaches were available. It is to these that we now turn. approach to mental disorders called moral therapy became influ-
ential (Taubes, 1998). The term moral really meant “emotional”
or “psychological” rather than a code of conduct. Its basic tenets
Concept Check 1.3 included treating institutionalized patients as normally as possible
in a setting that encouraged and reinforced normal social inter-
For thousands of years, humans have tried to understand
action (Bockoven, 1963; Taubes, 1998), thus providing them with
and control abnormal behaviour. Check your understanding
many opportunities for appropriate social and interpersonal
of these historical theories and match them to the treatments
contact. Relationships were carefully nurtured. Individual atten-
used to “cure” abnormal behaviour: (a) marriage; fumiga-
tion clearly emphasized positive consequences for appropriate
tion of the vagina; (b) hypnosis; (c) bloodletting; induced
interactions and behaviour; the staff made a point of modelling
vomiting; (d) patient placed in socially facilitative environ-
this behaviour. Lectures on various interesting subjects were
ments; and (e) exorcism; burning at the stake.
provided, and restraint and seclusion were eliminated.
1. Supernatural causes; evil demons took over the victims’ Once again, these are old ideas. The principles of moral ther-
bodies and controlled their behaviours. ________________ apy date back to Plato and beyond. But moral therapy as a system
2. The humoral theory reflected the belief that normal func- originated with the well-known French psychiatrist Philippe Pinel
tioning of the brain required a balance of four bodily (1745–1826; Zilboorg & Henry, 1941). A former patient, Pussin,
fluids, or humors. ________________ long since recovered, was working in the Parisian hospital La
3. Maladaptive behaviour was caused by poor social and cul- Bicêtre when Pinel took over. Pussin had already instituted
tural influences within the environment. ________________ remarkable reforms, remembering, perhaps, being shackled as a
patient himself. Pussin persuaded Pinel to go along with the
The Psychological
Tradition
It is a long leap from evil spirits to brain
pathology as causes of psychological disor-
ders. In the intervening centuries, where
was the body of thought that put psycho-
logical development, both normal and
abnormal, in an interpersonal and social
context? In fact, this approach has a long
and distinguished tradition. Plato, for
example, thought that the two causes of
maladaptive behaviour were the social and
cultural influences in a person’s life and the
learning that took place in that environment.
If something was wrong in the environment,
such as abusive parents, a person’s impulses
and emotions would overcome reason. The
best treatment was to reeducate the individual
Stock Montage
through rational discussion so that the power

of reason would predominate (Maher &
Maher, 1985a). This approach was very
much a precursor to modern psychosocial ▲ Patients with psychological disorders were freed from chains and shackles as a result of the
approaches, which focus not only on influence of Philippe Pinel (1745–1826), a pioneer in making mental institutions more humane.
NEL The Psychological Tradition 15

changes. Much to Pinel’s credit, he did, first at La Bicêtre and institution was 200 or fewer,
Library of Congress Prints and Photographs Division Washington, D.C.

then at the women’s hospital Salpétrière (Maher & Maher, 1985b; allowing for a great deal of indi-
Weiner, 1979), where a humane, socially facilitative atmosphere vidual attention. However,
produced “miraculous” results. patient loads in existing hospi-
After William Tuke (1732–1822) followed Pinel’s lead in tals increased to 1000, 2000,
England, Benjamin Rush (1745–1813), often considered the founder and more with the enormous
of North American psychiatry, introduced moral therapy to the New waves of immigrants arriving in
World. It then became the treatment of choice in the leading hospi- North America at the time.
tals. Asylums had appeared in the 16th century in Europe, with the A second reason for the
intent of providing places of refuge for the confinement and care of decline of moral therapy has
people with mental illnesses. However, these early asylums were an unlikely source. The great
more like prisons than hospitals. Many housed beggars as well as crusader Dorothea Dix (1802–
20540 USA
people with a variety of mental illnesses, conditions were often 1887) campaigned endlessly
deplorable, and little was provided to patients in the way of treat- for reform in the treatment of
ment regimens. It was the rise of moral therapy in Europe and North the insane throughout Canada ▲ Dorothea Dix (1802–1887)
America that made institutions habitable and even therapeutic. and the United States. A school- began the mental hygiene
Sussman (1998) provides a description of the history of the teacher who had worked in movement and spent much of
her life campaigning in the
development of asylums in Canada in the 19th century. He notes various institutions, she had
United States and Canada for
that institutionalizing people with mental illnesses in Canada firsthand knowledge of the
reform in the treatment of
began with humane intentions, to relieve the suffering and neglect deplorable conditions imposed people with mental illnesses.
of these individuals who had previously been placed in jails or on people with mental
poorhouses, or left to care for themselves in the community. The disorders, and she made it her
provinces proceeded relatively independently to develop separate life’s work to inform the public and their leaders of these abuses.
and more adequate provisions for people with mental illness in Her work became known as the mental hygiene movement.
the form of mental hospitals or “asylums” (see Table 1.2 for a According to Hurd, Drewry, Dewey, Pilgrim, Blumer, and
summary). Asylum development in most provinces was influ- Burgess (1916), Dix visited Canada in 1843 and 1844 and discov-
enced to a great extent by systems and movements in Great ered appalling conditions involving the incarceration of “lunatics”
Britain and to a lesser extent by those in the United States. The at Beauport in Québec and in the Toronto Jail. She was involved
involvement of religious orders in the care of people with mental in the construction of the asylum in St. John’s, Newfoundland, in
illnesses in Québec was influenced by practices occurring in 1854. Probably most notable of her contributions to the mental
France. According to Sussman (1998), the development of hygiene movement in Canada was her appeal to the Nova Scotia
asylums through the moral therapy movement did bring some Legislature in January 1850, when she described the deplorable
relief to many people with mental illnesses. conditions for people with mental illnesses at the time and argued
for the development of an asylum in Nova Scotia:
In imagination, for a short time, place yourselves in their stead:
Asylum Reform and the Decline
enter the horrid, noisome cell, invest yourselves with the foul,
of Moral Therapy
tattered garments which scantily serve the purposes of decent
Unfortunately, after the mid-19th century, humane treatment declined protection; cast yourselves upon the loathsome pile of filthy straw;
because of a convergence of factors. First, it was widely recognized find companionship in your own cries and groans, or in the
that moral therapy worked best when the number of patients in an wailings and gibberings of wretches miserable like yourselves; call
TABLE 1.2 Development of the First Asylums in Canada
Province Date Notes
Québec 1845 Beauport, or the Québec Lunatic Asylum, was opened.
New Brunswick 1847 The Provincial Lunatic Asylum was erected.
Ontario 1850 The Provincial Lunatic Asylum in Toronto admitted patients.

Vintage Postcards of Hamilton, Ontario by Janet
Forjan-Freedman www.hamiltonpostcards.com
Newfoundland 1854 An asylum was erected and admitted its first patients.
Nova Scotia 1857 The first patients were admitted to the Provincial Hospital for the Insane.
Prince Edward Island 1877 The Prince Edward Island Hospital for the Insane was built.
Manitoba 1886 The Selkirk Lunatic Asylum admitted patients.
Saskatchewan 1911 The Saskatchewan Provincial Hospital admitted its first patients.
Alberta 1914 The Insane Asylum in Ponoka was opened.
Source: Adapted from Table 1 of: Sussman, S. “The First Asylums in Canada: A Response to Neglectful Community Care and Current Trends.” Canadian Journal of
Psychiatry 1998; 43(3):260-264.
for help and release, for blessed words or soothing and kind offices A final blow to the practice
Association 1918-1988 by John D. Griffin MD, MA, DPM(E), FRCP(C).

Reprinted with permission of the Canadian Mental Health Association
of care, till the dull walls are weary in sending back the echo of of moral therapy, mentioned
From In Search of Sanity: A Chronicle of the Canadian Mental Health

your moans; then, if self-possession is not overwhelmed under the earlier, was the decision, in
imaginary miseries of what are the actual distresses of the insane, the middle of the 19th century,
return to the consciousness of your sound intellectual health, and that mental illness was caused
answer if you will longer refuse or delay to make adequate by brain pathology and, there-
appropriations for the establishment of a provincial hospital for fore, was incurable.
those who are deprived of reason, and thereby of all that gladdens The psychological tradition
life or makes existence a blessing. (Hurd et al., 1916, p. 493) lay dormant for a time, only
to reemerge in several very
In addition to improving the standards of care, Dix worked different schools of thought
hard to make sure that everyone who needed care received it, in the 20th century. The first
including homeless people. Through her efforts, humane treat- major approach was psycho-
ment became more widely available in North American institu- analysis, based on Sigmund
tions. As her career drew to a close, she was rightly acknowledged Freud’s (1856–1939) elaborate ▲ Clarence Hincks (1885–1964)
as a hero of the 19th century. was an early crusader for the
theory of the structure of the
mental hygiene movement in
Unfortunately, an unforeseen consequence of Dix’s heroic mind and the role of uncon-
Canada. He cofounded the
efforts was a substantial increase in the number of mental scious processes in determin- Canadian National Committee
patients. This influx led to a rapid transition from moral therapy ing behaviour. The second was for Mental Hygiene in 1918—a
to custodial care because hospitals were inadequately staffed. Dix behaviourism, associated with precursor to today’s Canadian
reformed asylums and single-handedly inspired the construction John B. Watson, Ivan Pavlov, Mental Health Association.
of numerous new institutions. But even her tireless efforts and and B. F. Skinner, which
advocacy could not ensure sufficient staffing to allow the individ- focuses on how learning and adaptation affect the development of
ual attention necessary for effective moral therapy. Unfortunately, psychopathology.
institutionalization in Canada eventually “became a synonym for
an inhumane response to mentally ill people” (Sussman, 1998,
Psychoanalytic Theory
p. 262), often because resources were insufficient to provide
adequate care. Have you ever felt as if someone had cast a spell on you? Have
An important mental health reformer and crusader who you ever been mesmerized by a look across a room from an
followed Dix’s example was Clarence Hincks, a University of attractive woman or man, or a stare from a rock musician as you
Toronto medical school graduate who cofounded the Canadian sat in front at a concert? If so, you have something in common
Committee for Mental Hygiene in 1918. Early in his career, he with the patients of Austrian physician Anton Mesmer (1734–
toured mental institutions throughout Manitoba. In his unpublished 1815) and with millions of people since his time who have been
autobiography and his report to the Manitoba government, Hincks hypnotized. Mesmer suggested to his patients that their problem
documented continued appalling conditions for the people with was due to an undetectable fluid found in all living organisms
mental illnesses in these institutions (Griffin, 1989; Roland, called “animal magnetism” that could become blocked. Mesmer
1990). Hincks often found that those working in institutions— had his patients sit in a dark room around a large vat of chemicals
including the superintendents—had no special psychiatric with rods extending from it and touching the patients. Dressed in
training. In one case there was only one doctor in charge of 700 flowing robes, he might then identify and tap various areas of
patients, and he also acted as the superintendent. In one institution their bodies where their animal magnetism was blocked while
in Portage La Prairie, Hincks encountered a woman who had suggesting strongly that they were being cured. Because of his
been left in a closet for two years, and had only been allowed out rather unusual techniques, Mesmer was considered an oddity and
once, and then within the confines of a cage. Hincks noted that maybe a charlatan and was strongly opposed by the medical
some of the institutions were not even meant for those with establishment (Winter, 1998).
mental illness, but had come to house them anyway despite Benjamin Franklin put animal magnetism to the test by
having no methods for caring for them. At another Manitoban conducting a brilliant experiment in which patients received
institution, he discovered that mentally ill patients were locked either magnetized water or nonmagnetized water with strong
into coffin-like boxes at night to sleep, and in another, “mentally suggestions that they would get better. Neither the patient nor the
defective” children were rolled in long strips of cotton at night, therapist knew which water was which, making it a “double-
with their arms and legs bound, and then placed on shelves to blind” experiment (see Chapter 4). When both groups got better,
sleep. Hincks had himself experienced and recovered from a bout Franklin concluded that animal magnetism, or mesmerism, was
of major depression while in university. His personal experience nothing more than strong suggestion (Gould, 1990; McNally,
in recovering from depression led him to advocate for the idea 1999). Nevertheless, Mesmer is widely regarded as the father of
that mental illness was treatable. Hincks’s position stood in hypnosis, a state in which suggestible subjects sometimes appear
contrast to the prevailing view at the time that mental illness was to be in a trance.
incurable. In fact, one Manitoba institution that Hincks visited in Many distinguished scientists and physicians were very
1918 in Portage La Prairie was named the “Home for Incurables” interested in Mesmer’s powerful methods of suggestion. One
(Roland 1990). of the best known, Jean Charcot (1825–1893), was head of the

problems, conflicts, and fears

in as much detail as they could.
Breuer observed two extremely
important phenomena during
this process. First, patients
often became extremely emo-
tional as they talked and felt
quite relieved and improved
after emerging from the

hypnotic state. Second, seldom
would patients have gained an
understanding of the relation-
Erich Lessing/Art Resource, NY

ship between their emotional
problems and their psycho-
▲ Josef Breuer (1842–1925)
logical disorder. In fact, it was
worked on the celebrated case
difficult or impossible for of Anna O. and, with Freud,
them to recall some of the developed the theory of
details they had described psychoanalysis.
▲ Anton Mesmer (1734–1815) and other early therapists used strong under hypnosis. In other words,
suggestions to cure their patients, who were often hypnotized. the material seemed to be beyond the awareness of the patient.
With this observation, Breuer and Freud had “discovered” the
unconscious mind and its apparent influence on the production
Salpétrière Hospital in Paris, where Philippe Pinel had intro- of psychological disorders. This discovery is one of the
duced psychological treatments several generations earlier. A most important developments in the history of psychology as a
distinguished neurologist, Charcot demonstrated that some of whole.
the techniques of mesmerism were effective with several A close second was their discovery that recalling and reliv-
psychological disorders, and he did much to legitimize the ing emotional trauma that has been made unconscious and
fledgling practice of hypnosis while doing away with the flow- releasing the accompanying tension is therapeutic—a process
ing robes and chemicals. Significantly, in 1885 a young man that became known as catharsis. A fuller understanding of the
named Sigmund Freud came from Vienna to study with relationship between current emotions and earlier events is
Charcot. called insight. As we see throughout this book, particularly in
After returning from France, Freud teamed up with Josef Breuer Chapters 5 and 6 on anxiety and somatoform disorders, the
(1842–1925), who had experimented with a somewhat different existence of unconscious memories and feelings and the
hypnotic procedure. While his patients were in the highly importance of processing emotion-laden information have been
suggestible state of hypnosis, Breuer asked them to describe their verified and reaffirmed.
Freud and Breuer’s theories were based
on systematic case observations. An excel-
lent example is Breuer’s classic description
of his treatment of “hysterical” symptoms in
Anna O. in 1895 (Breuer & Freud, 1957).
Anna O. was a young woman who was
perfectly healthy until she turned 21. Shortly
before her problems began, her father
developed a serious chronic illness that led
to his death. Throughout his illness, Anna O.
had cared for him, spending hours at his
bedside. Five months after her father became
ill, Anna noticed that during the day her
vision blurred and periodically she had diffi-
culty moving her right arm and both legs.
Erich Lessing/Art Resource, NY
Soon, she began to experience some diffi-

culty speaking, and her behaviour became
very erratic. Shortly thereafter, she consulted
Breuer.
In a series of treatment sessions, Breuer
dealt with one symptom at a time through
▲ Jean Charcot (1825–1893) studied hypnosis and influenced Sigmund Freud to consider hypnosis and subsequent “talking through,”
psychosocial approaches to psychological disorders. tracing each symptom to its hypothetical
causation in circumstances be fully aware of their mean-

surrounding the death of ing. The id is the source of our
Anna’s father. One at a time strong sexual and aggressive
her “hysterical” ailments energies or our instinctual
disappeared, but only after drives—the “animal” within
treatment was administered to us. The positive energy or drive
each respective behaviour. within the id is the libido. Even
This process of treating one today some people explain low
behaviour at a time fulfills a sex drive as an absence of
basic requirement for drawing libido. A less important source
Bettmann/Corbis Canada
scientific conclusions about of energy is the death instinct,
the effects of treatment in an or thanatos. Much like matter
individual case study, as we and antimatter, these two basic
see in Chapter 4. drives toward life and domin-
Freud took these basic obser- ance and fulfillment on the one ▲ Sigmund Freud (1856–1939)
vations and expanded them into hand, and death and destruc- is considered the founder of
the psychoanalytic model, the tion on the other, are continu- psychoanalysis.
most comprehensive theory yet ally in opposition.
constructed on the development The id operates according to the pleasure principle, with an
▲ Bertha Pappenheim (1859– and structure of our personal- overriding goal of maximizing pleasure and eliminating any asso-
1936), famous as Anna O., was ities. He also speculated on ciated tension or conflicts. The goal of pleasure, which is particu-
described as “hysterical” by where this development could larly prominent in childhood, often conflicts with social rules and
Breuer. go wrong and produce psycho- regulations, as we see later. The id has its own characteristic way
logical disorders. of processing information; referred to as primary process, this type
Although most of it remains unproven, psychoanalytic theory of thinking is very emotional, irrational, illogical, led with fanta-
has had a strong influence, and it is important to be familiar with sies, and preoccupied with sex, aggression, selfishness, and envy.
its basic ideas; what follows is a brief outline of the theory. We Fortunately for all of us, in Freud’s view, the id’s selfish and
focus on its three major facets: (1) the structure of the mind and sometimes dangerous drives do not go unchecked. In fact, only a
the distinct functions of personality that sometimes clash with few months into life, we know we must adapt our basic demands to
one another; (2) the defence mechanisms with which the mind the real world; we must find ways to meet our basic needs without
defends itself from these clashes or conflicts; and (3) the stages of offending everyone around us. The part of our mind that ensures we
early psychosexual development that provide grist for the mill of act realistically is called the ego, and it operates according to the
our inner conflicts. reality principle instead of the pleasure principle. The cognitive
operations or thinking styles of the ego, characterized by logic and
The Structure of the Mind reason, are referred to as the secondary process, as opposed to the
The mind, according to Freud, has three major parts or functions: illogical and irrational primary process of the id.
the id, ego, and superego (see ■ Figure 1.4). These terms, like many The third important structure within the mind, the superego, or
from psychoanalysis, have found their way into our common what we might call the conscience, represents the moral principles
vocabulary, and although you may have heard them, you may not instilled in us by our parents and our culture. It is the voice within
us that nags at us when we know we’re
doing something wrong. Because the
Type of thinking Driven by purpose of the superego is to counteract the
Moral aggressive and sexual drives of the id that
Superego Conscience are potentially dangerous, the basis for
principles
conflict is readily apparent.
Intrapsychic Ego Logical; Reality The role of the ego is to mediate conflict
conflicts Mediator rational principle between the id and the superego, juggling
Illogical;
their demands with the realities of the world.
Pleasure The ego is often called the executive or
Id emotional;
principle
irrational manager of our minds. If it mediates success-
fully, we can go on to the higher intellectual
and creative pursuits of life. If it is unsuccess-
ful, and the id or the superego becomes too
■ FIGURE 1.4 Freud’s structure of the mind strong, conflict will overtake us and psycho-
logical disorders will develop. Because these
Go to www.abnormalpsych3e.nelson.com to access an interactive version conflicts are all within the mind, they are
of this figure. called intrapsychic conflicts. Finally, Freud
believed the id and the superego are almost

entirely unconscious. We are fully aware only of the secondary Vaillant, 1986). For example, different psychological disorders
processes of the ego, which is a relatively small part of the mind. seem to be associated with different defence mechanisms (Pollack
& Andrews, 1989), which might be important in planning treat-
Defence Mechanisms ment. Vaillant (1976) noted that healthy defence mechanisms,
The ego fights a continual battle to stay on top of the warring id such as humour and sublimation, were correlated with psycho-
and superego. Occasionally, their conflicts produce anxiety that logical health. Thus, the concept of defence mechanisms—
threatens to overwhelm the ego. The anxiety is a signal that alerts “coping styles,” in contemporary terminology—continues to be
the ego to marshal defence mechanisms, unconscious protective important to the study of psychopathology.
processes that keep primitive emotions associated with conflicts
in check so the ego can continue its coordinating function. Psychosexual Stages of Development
Although Freud first conceptualized defence mechanisms, it was Freud also theorized that during infancy and early childhood, we
his daughter, Anna Freud, who developed the ideas more fully. pass through several psychosexual stages of development that
We all use defence mechanisms at times—sometimes they are have a profound and lasting impact, thus providing the first
adaptive and sometimes they are maladaptive. For example, have you developmental perspective on abnormal behaviour. The stages—
ever done poorly on a test because the professor was unfair in the oral, anal, phallic, latency, and genital—represent distinctive
grading? And then when you got home, you yelled at your brother or patterns of gratifying our basic needs and satisfying our drive for
perhaps at your dog? This is an example of the defence mechanism of physical pleasure. For example, the oral stage, typically extending
displacement. The ego adaptively “decides” that expressing primitive for approximately two years from birth, is characterized by a
anger at your professor might not be in your best interest. Because central focus on the need for food. In the act of sucking, necessary
your brother and your dog don’t have the authority to affect you in an for feeding, the lips, tongue, and mouth become the focus of libid-
adverse way, your anger is displaced to one of them. Indeed, the inal drives and, therefore, the principal source of pleasure. Freud
DSM-IV-TR includes an axis of defence mechanisms in the appendix. hypothesized that, if we did not receive appropriate gratification
Here are some examples of defence mechanisms (adapted from the during a specific stage or if a specific stage left a particularly strong
DSM-IV-TR, American Psychiatric Association, 2000a): impression (which he termed fixation), an individual’s personality
would reflect the stage throughout adult life. For example, fixation
■ Denial: Refuses to acknowledge some aspect of objective at the oral stage might result in excessive thumb sucking and
reality or subjective experience that is apparent to others (e.g., emphasis on oral stimulation through eating, chewing pencils, or
a person not facing the fact that a romantic relationship is biting fingernails. Adult personality characteristics theoretically
over). associated with oral fixation include dependency and passivity or,
■ Displacement: Transfers a feeling about, or a response to, an in reaction to these tendencies, rebelliousness and cynicism.
object that causes discomfort onto another, usually less threat- One of the more controversial and frequently mentioned
ening, object or person (e.g., kicking the dog when actually psychosexual conflicts occurs during the phallic stage (from age
angry with a teacher). three to age five or six), which is characterized by early genital
■ Projection: Falsely attributes own unacceptable feelings, self-stimulation. This conflict is the subject of the Greek tragedy
impulses, or thoughts to another individual or object (e.g., a Oedipus Rex, in which Oedipus is fated to kill his father and,
man with sexual feelings toward a certain woman thinks that unknowingly, to marry his mother. Freud asserted that all young
woman is “coming on” to him). boys relive this fantasy when genital self-stimulation is accom-
■ Rationalization: Conceals the true motivations for actions, panied by images of sexual interactions with their mothers. These
thoughts, or feelings through elaborate reassuring or self- fantasies, in turn, are accompanied by strong feelings of envy and
serving but incorrect explanations (e.g., after not getting into a perhaps anger toward their fathers, with whom they identify but
certain graduate school, an aspiring graduate student decides whose place they want to take. Furthermore, strong fears develop
that school was not really where she wanted to study after all). that the father may punish that lust by removing the son’s penis—
■ Reaction formation: Substitutes behaviour, thoughts, or feel- thus, the phenomenon of castration anxiety. This fear helps the
ings that are the direct opposite of unacceptable ones (e.g., a boy keep his lustful impulses toward his mother in check. The
man with sexual feelings toward children crusades against battle of the lustful impulses on the one hand and castration
child pornography). anxiety on the other creates a conflict that is internal, or intra-
■ Repression: Blocks disturbing wishes, thoughts, or experi- psychic, called the Oedipus complex. The phallic stage passes
ences from conscious awareness (e.g., a person “forgets” about uneventfully only if several things happen. First, the child must
an embarrassing experience). resolve his ambivalent relationship with his parents and reconcile
■ Sublimation: Directs potentially maladaptive feelings or impulses the simultaneous anger and love he has for his father. If this
into socially acceptable behaviour (e.g., redirecting energy from happens, he may go on to channel his libidinal impulses into
underlying conflict into artistic expression and achievement). heterosexual relationships while retaining harmless affection for
his mother. Development of the superego is another consequence
Defence mechanisms have actually been subjected to scientific of successfully resolving this conflict.
study, and some evidence indicates they may be of potential The counterpart conflict in girls, called the Electra complex, is
importance in the study of psychopathology and health even more controversial. Freud viewed the young girl as wanting
(MacGregor, Davidson, Rowan, Barksdale, & MacLean, 2003; to replace her mother and possess her father. Central to this
McGregor, Zanna, Holmes, & Spencer, 2001; Vaillant, Bond, & possession is the girl’s desire for a penis, so as to be more like her
father and brothers—hence the term penis envy. According to field of ego psychology or self-psychology. Her book Ego and
Freud, the conflict is partially resolved when females develop the Mechanisms of Defense (1946) is still influential. According
healthy heterosexual relationships and look forward to having a to Anna Freud, the individual slowly accumulates adaptational
baby, which he viewed as a healthy substitute for having a penis. capacities, skill in reality testing, and defences. Abnormal behav-
It is the partial resolution of the Electra complex, resulting in a iour develops when the ego is deficient in regulating such func-
less highly developed superego, that makes females (in Freud’s tions as delaying and controlling impulses, or in marshalling
theory) less highly developed psychologically than are males. appropriate normal defences to strong internal conflicts.
Needless to say, this particular theory has provoked marked A related area that is quite popular today is referred to as object
consternation over the years as being sexist and demeaning. It is relations. In this school of thought are theorists Melanie Klein and
important to remember that it is theory, not fact; no systematic Otto Kernberg. Kernberg’s work on borderline personality disor-
research exists to support it. der, in which some behaviour borders on being out of touch
In Freud’s view, all nonpsychotic psychological disorders with reality and thus psychotic, has been widely applied (see
resulted from underlying unconscious conflicts, the anxiety that Chapter 12). Object relations is the study of how children incor-
resulted from those conflicts, and the implementation of ego porate the images, memories, and sometimes the values of a
defence mechanisms. Freud called such disorders neuroses, or person who was very important to them and to whom they were
neurotic disorders, from an old term referring to disorders of the (or are) emotionally attached. Object in this sense refers to these
nervous system. important people, and the process of incorporation is called intro-
jection. Introjected objects can become an integrated part of the
Later Developments in Psychoanalytic Thought ego or may assume conflicting roles in determining the identity, or
Freud’s original psychoanalytic theories have been greatly modi- self. For example, your parents may have conflicting views on
fied and developed in many different directions, mostly by his relationships or careers, which, in turn, may be different from
students or followers. your own partly developed point of view. To the extent that these
Anna Freud (1895–1982), Freud’s daughter, concentrated on varying positions have been incorporated, the potential for conflict
the way in which the defensive reactions of the ego determine our arises. One day you may feel one way about your career direction,
behaviour. In so doing, she was the first proponent of the modern and the next day you may feel quite differently. According to
object relations theory, you tend to see the world through the eyes
of the person incorporated into your self. Object relations theor-
ists focus on how these disparate images come together to make
up a person’s identity, and on the conflicts that may emerge.
Carl Jung (1875–1961) and Alfred Adler (1870–1937) were
students of Freud who came to reject his ideas and form their own
schools of thought. Unlike Freud, both Jung and Adler believed
that the basic quality of human nature is positive and that people
have a strong drive toward self-actualization. Jung and Adler
believed by removing barriers to both internal and external
growth, the individual would naturally improve and flourish.
Others took psychoanalytical theorizing in different directions,
emphasizing development over the life span and the influence of
culture and society on personality. Karen Horney (1885–1952),
Erich Fromm (1900–1980), and Erik Erikson (1902–1994) are
associated with these ideas. For example, Horney reanalyzed
Freud’s male-oriented views of women’s psychological develop-
ment, and developed her own feminine psychology in which she
recognized the influences of societal factors (e.g., Horney, 1967).
Erikson’s greatest contribution was his theory of development
across the life span, in which he described in some detail the
crises and conflicts that accompany eight specific psychosocial
stages. For example, in the last of these stages, the mature age,
beginning at about age 65, individuals review their lives and
Hulton-Deutsch Collection/Corbis Canada
attempt to make sense of them, experiencing both the satisfaction

of having completed some lifelong goals and despair at having
failed at others. Scientific developments have borne out the
wisdom of considering psychopathology from a developmental
point of view.
Psychoanalytic Psychotherapy
▲ Anna Freud (1895–1982), here with her father, contributed the Many techniques of psychoanalytic psychotherapy, or psycho-
concept of defence mechanisms to the field of psychoanalysis. analysis, are designed to reveal the nature of unconscious mental

processes and conflicts through catharsis and insight. Freud and efforts are made to identify trauma and active defence mech-
developed techniques of free association, in which patients are anisms, therapists use an eclectic mixture of tactics, with a social
instructed to say whatever comes to mind without the usual and interpersonal focus. Seven tactics that characterize psycho-
socially mandated censoring. Free association is intended to dynamic psychotherapy include (1) a focus on affect and the
reveal emotionally charged material that may be repressed expression of patients’ emotions, (2) an exploration of patients’
because it is too painful or threatening to bring into conscious- attempts to avoid topics or engage in activities that hinder the
ness. Freud’s patients lay on a couch, and he sat behind them so progress of therapy, (3) the identification of patterns in patients’
they would not be distracted. This method is how the couch actions, thoughts, feelings, experiences, and relationships, (4) an
became the symbol of psychotherapy. Other techniques include emphasis on past experiences, (5) a focus on patients’ inter-
dream analysis (still quite popular today), in which the content personal experiences, (6) an emphasis on the therapeutic relation-
of dreams, supposedly reflecting the primary process thinking of ship, and (7) an exploration of patients’ wishes, dreams, or
the id, is systematically related to symbolic aspects of uncon- fantasies (Blagys & Hilsenroth, 2000). Two additional features
scious conflicts. The therapist interprets the patient’s thoughts and characterize psychodynamic psychotherapy. First, it is signifi-
feelings from free association and the content of dreams and cantly briefer than classical psychoanalysis. Second, psycho-
relates them to various unconscious conflicts. This procedure is dynamic therapists de-emphasize the goal of personality
often difficult because the patient may resist the efforts of the reconstruction, focusing instead on relieving the suffering associ-
therapist to uncover repressed and sensitive conflicts and may ated with psychological disorders. Some forms of psychodynamic
deny the interpretations. The goal of this stage of therapy is to psychotherapy have strong scientific evidence for their effective-
help the patient gain insight into the nature of the conflicts. ness, such as interpersonal therapy (IPT) in the treatment of
The relationship between the therapist, called the psychoanalyst, depression (see Chapter 7).
and the patient is very important. In the context of this relationship
as it evolves, the therapist may discover the nature of the patient’s Comments
intrapsychic conflict: In a phenomenon called transference, Pure psychoanalysis is of historical more than current interest,
patients come to relate to the therapist very much as they did and classical psychoanalysis as a treatment has been diminishing
toward important figures in their childhood, particularly their in popularity for years (Robins, Gosling, & Craik, 1999). In 1980,
parents. Patients who resent the therapist but can verbalize no the term neurosis, which specifically implied a psychoanalytic
good reason for it may be reenacting childhood resentment view of the causes of psychological disorders, was dropped from
toward a parent. More often, the patient falls deeply in love with the DSM, the official diagnostic system of the American Psychi-
the therapist, which reflects strong positive feelings that existed atric Association.
earlier for a parent. In the phenomenon of countertransference, A major criticism of psychoanalysis is that it is basically
therapists project some of their own personal issues and feelings, unscientific, relying on reports by the patient of events that
often positive, onto the patient. Therapists are trained to deal with happened years ago. These events have been filtered through the
their own feelings as well as their patients’, whatever the mode of experience of the observer and then interpreted by the psycho-
therapy, and it is strictly against all ethical canons of the mental analyst in ways that certainly could be questioned and might
health professions to accept overtures from patients that might differ from one analyst to the next. Finally, there has been no
lead to relationships outside therapy. careful measurement of any of these psychological phenomena
Classical psychoanalysis requires therapy four to five times a and no obvious way to prove or disprove the basic hypotheses of
week for two to five years to analyze unconscious conflicts, psychoanalysis. This fact is important, because measurement and
resolve them, and restructure the personality to put the ego back the ability to prove or disprove a theory are the foundations of the
in charge. A recent study by Norman Doidge at the Canadian scientific approach.
Institute of Psychoanalysis in Toronto showed that the mean Nevertheless, psychoanalytic concepts and observations have
length of treatment for patients undergoing psychoanalysis in been very valuable, not only to the study of psychopathology and
Canada is 4.8 years, compared to 5.7 years in the United States psychodynamic psychotherapy but also to the history of ideas in
and 6.6 years in Australia (Doidge et al., 2002). In psychoanaly- Western civilization. Careful scientific studies of psycho-
sis, reduction of symptoms (overt manifestations of psychological pathology have supported the observation of unconscious mental
disorders) is seen as relatively inconsequential, because they are processes, that is, the notion that basic emotional responses are
only expressions of underlying intrapsychic conflicts that arise often triggered by hidden or symbolic cues and the understanding
from psychosexual developmental stages. Thus, eliminating a that memories of events in our lives can be repressed and other-
phobia or depressive episode would be of little use unless the wise avoided in a variety of ingenious ways. The relationship of
underlying conflict was dealt with adequately, because another set the therapist and the patient, called the therapeutic alliance, is an
of symptoms would almost certainly emerge (symptom substitu- important area of study across most therapeutic strategies. These
tion). Because of the extraordinary expense of psychoanalysis, concepts, along with the importance of various coping styles or
and the lack of evidence that it is effective in alleviating psycho- defence mechanisms, appear repeatedly throughout this book.
logical disorders, this approach is seldom used today. Freud’s revolutionary idea that pathological anxiety emerges
Classical psychoanalysis is still practised, particularly in some in connection with some of our deepest and darkest instincts
large cities, but many psychotherapists employ a loosely related brought us a long way from witch trials and incurable brain path-
set of approaches referred to as psychodynamic psychotherapy. ology. Before Freud, the source of good and evil and of urges and
Although conflicts and unconscious processes are still emphasized, prohibitions was conceived as external and spiritual, usually in
the guise of demons confronting the forces of good. Since Freud, the relationship as a means to an end (transference), humanistic
we ourselves have become the battleground for these forces, and therapists believed relationships, including the therapeutic rela-
we are inexorably caught up in the battle, sometimes for better tionship, were the single most positive influence in facilitating
and sometimes for worse. human growth. In fact, Rogers made substantial contributions to
the scientific study of therapist–client relationships. And research
by W. H. Coons and colleagues at the Ontario Hospital in Hamil-
Humanistic Theory
ton (Coons, 1957, 1967; Coons & Peacock, 1970) provided
We have already seen that Jung and Adler broke sharply with evidence for the importance of the humanistic concept of empathy
Freud. Their fundamental disagreement concerned the very nature or “the opportunity for interpersonal interaction in a consistently
of humanity. Freud portrayed life as a battleground where we are warm and accepting social environment” (Coons, 1957, p. 1) in
continually in danger of being overwhelmed by our darkest explaining the success of psychotherapy. Proponents of the
forces. Jung and Adler, by contrast, emphasized the positive, opti- humanistic model stress the unique, nonquantifiable experiences
mistic side of human nature. Jung talked about setting goals, of the individual, emphasizing that people are more different than
looking toward the future, and realizing our fullest potential. alike. Thus, it does not come as a surprise that many humanistic
Adler believed that human nature reaches its fullest potential model proponents have not been much interested in doing
when we contribute to other individuals and to society as a whole. research that would discover or create new knowledge. A major
He believed we all strive to reach superior levels of intellectual exception is Carl Rogers himself, who conducted important work
and moral development. Nevertheless, both Jung and Adler on understanding how psychotherapy works, an area known today
retained many of the principles of psychodynamic thought. Their as “psychotherapy process” research.
general philosophies were adopted in the middle of the 20th Frederich (Fritz) Perls developed a therapy known as Gestalt
century by personality theorists and became known as humanistic therapy that has humanistic elements (Levitsky & Perls, 1970;
psychology. Perls, 1969). Like the person-centred therapy approach, Gestalt
Self-actualizing was the watchword for this movement. The therapy focuses on people’s positive and creative potentials.
underlying assumption is that all of us can reach our highest Gestalt therapy helps clients to develop an awareness of their
potential, in all areas of functioning, if only we have the freedom desires and needs, and to understand how they might be blocking
to grow. Inevitably, a variety of conditions may block our actual- themselves from reaching their potential. Unlike psychoanalytic
ization. Because every person is basically good and whole, most therapy, Gestalt therapy does not involve delving into past experi-
blocks originate outside the individual. Difficult living conditions ences—instead, it is very focused on the present. Relative to
or stressful life or interpersonal experiences may move you away person-centred therapy, which does not emphasize technique,
from your true self. Abraham Maslow (1908–1970) was most Gestalt therapists are trained in the use of specific techniques.
systematic in describing the structure of personality. He postu- These include “I language,” in which the therapist encourages the
lated a hierarchy of needs, beginning with our most basic physical client to refer to “I” rather than to “it” to take more responsibility
needs for food and sex and ranging upward to our needs for self- for emotions and behaviour, and the use of metaphor, in which the
actualization, love, and self-esteem. Social needs such as friend- therapist uses stories or scenarios to illustrate and make a problem
ship fall somewhere in between. Maslow hypothesized that we clearer to a client.
cannot progress up the hierarchy until we have satisfied the needs Where is the humanistic movement today? As Maslow noted,
at lower levels. traditional person-centred therapy found its greatest application
Carl Rogers (1902–1987) is, from the point of view of therapy, among individuals without psychological disorders. The applica-
the most influential humanist. Rogers originated client-centred tion of person-centred therapy to more severe psychological
therapy, later known as person-centred therapy (Rogers, 1961). disorders has decreased substantially over the decades, although
In this approach, the therapist takes a passive role, making as few certain variations have periodically arisen in some areas of
interpretations as possible. The point is to give the individual a psychopathology. For example, Les Greenberg and his colleagues
chance to develop during the course of therapy, unfettered by at York University in Toronto have developed experiential and
threats to the self. Humanist theorists have great faith in the abil- emotion-focused therapies that have their roots in both person-
ity of human relations to foster this growth. Unconditional centred and Gestalt approaches (Goldman, Greenberg, & Angus,
positive regard, the complete and almost unqualified acceptance 2006; Greenberg, 2004; Greenberg, Elliott, & Lietaer, 2003;
of most of the client’s feelings and actions, is critical to the Greenberg & Watson, 2005). These variations of traditional
humanistic approach. Empathy is the sympathetic understanding humanistic therapy are well researched and have demonstrated
of the individual’s particular view of the world. The hoped-for effectiveness in treating certain forms of psychopathology, such
result of person-centred therapy is that clients will be more as certain mood and anxiety disorders (see Chapters 5 and 7).
straightforward and honest with themselves and will access their
innate tendencies toward growth.
The Behavioural Model
Like psychoanalysis, the humanistic approach has had a
substantial effect on theories of interpersonal relationships. For As psychoanalysis swept the world at the beginning of the 20th
example, the human potential movements so popular in the 1960s century, events in Russia and North America eventually provided
and 1970s were a direct result of humanistic theorizing. This an alternative psychological model that was just as powerful. The
approach also emphasized the importance of the therapeutic rela- behavioural model brought the systematic development of a more
tionship in a way quite different from Freud’s. Rather than seeing scientific approach to psychological aspects of psychopathology.

The behavioural model is more commonly referred to today as the Whether the stimulus is food, as in Pavlov’s laboratory, or
cognitive-behavioural (e.g., Meichenbaum, 1995) or social learn- chemotherapy, the classical conditioning process begins with a
ing model (e.g., Bandura, 1973, 1986), given the greater emphasis stimulus that elicits a response in almost anyone and requires no
today on cognitive and social factors involved in learning. These learning; no conditions must be present for the response to occur.
more recent developments to the traditional behavioural model are For these reasons, the food or chemotherapy is called the uncon-
described in Chapter 2. ditioned stimulus (UCS). The natural or unlearned response to
this stimulus—in these cases, salivation or nausea—is called the
Pavlov and Classical Conditioning unconditioned response (UCR). Now the learning comes in. As
In his classic study of the salivation response in dogs, physiolo- we have already seen, any person or object associated with the
gist Ivan Petrovich Pavlov (1849–1936) of St. Petersburg, unconditioned stimulus (food or chemotherapy) acquires the
Russia, learned why dogs salivate before the presentation of power to elicit the same response, but now the response, because
food. This classic experiment initiated the study of classical it was elicited by the conditional or conditioned stimuli (CS), is
conditioning, a type of learning in which a neutral stimulus is termed a conditioned response (CR). Thus, the nurse associated
paired with a response until it elicits that response. The word with the chemotherapy becomes a conditioned stimulus. The
conditioning (or conditioned response) resulted from an acci- nausea, which is almost the same as that experienced during
dent in translation from the original Russian. Pavlov was really chemotherapy, becomes the conditioned response.
talking about a response that occurred only on the “condition” With unconditioned stimuli as powerful as chemotherapy, a
of the presence of a particular event or situation (stimulus)—in conditioned response can be learned in one trial. However, most
this case, the footsteps of the laboratory assistant at feeding learning of this type requires repeated pairing of the unconditioned
time. Thus, “conditional response” would have been more stimulus (e.g., chemotherapy) and the conditioned stimulus (e.g.,
accurate. Conditioning is one way we acquire new information, nurses’ uniforms or hospital equipment). When Pavlov began to
particularly information that is somewhat emotional in nature. investigate this phenomenon, he substituted a metronome for the
This process is not as simple as it first seems, and we continue footsteps of his laboratory assistants so he could quantify the
to uncover many more facts about its complexity (Bouton, stimulus more accurately and, therefore, study the approach more
Mineka, & Barlow, 2001; Rescorla, 1988). But it can be quite precisely. What he also learned is that presentation of the CS
automatic. Let’s look at a powerful contemporary example. (e.g., the metronome) without the food for a long enough period
Psychologists working in oncology units have studied a phenom- would eventually eliminate the conditioned response to the food.
enon well known to many cancer patients, their nurses and physicians, In other words, the dog learned that the metronome no longer
and their families. Chemotherapy, a common treatment for some meant that a meal might be on the way. This process was called
forms of cancer, has side effects that include severe nausea and extinction.
vomiting. But as documented in the research of Patricia Dobkin at Because Pavlov was a physiologist, it was quite natural for him
the University of Montréal and others, these patients often to study these processes in a laboratory and to be quite scientific
experience severe nausea and, occasionally, vomiting, when they about it. This method required precision in measuring and observ-
merely see the medical personnel who administer the chemotherapy ing relationships and in ruling out alternative explanations.
or any equipment associated with the treatment itself, even on Although this approach is common in biology, it was not at all
days when their treatment is not delivered (Morrow & Dobkin, common in psychology at that time. For example, it was impos-
1988). For some patients, this reaction becomes associated with a sible for psychoanalysts to measure unconscious conflicts
wide variety of stimuli that evoke people or things present precisely, or even to observe them. Early experimental psycholo-
during chemotherapy—anybody in a nurse’s uniform or even the gists such as Edward Titchener (1867–1927) emphasized the
sight of the hospital itself. The study of introspection. Subjects simply reported on their inner
strength of the response to simi- thoughts and feelings after experiencing certain stimuli, but the
lar objects or people is usually a results of this armchair psychology were inconsistent and discour-
function of how similar these aging to many experimental psychologists.
objects or people are. This
phenomenon is called stimulus Watson and the Rise of Behaviourism
generalization because the An early American psychologist, John B. Watson (1878–1958), is
response “generalizes” to simi- considered the founder of behaviourism. Strongly influenced by
lar stimuli. In any case, this the work of Pavlov, Watson decided that to base psychology on
particular reaction, obviously, is introspection was to head in the wrong direction, that psychology
very distressing and uncomfort- could be made as scientific as physiology, and that psychology no
able, particularly if it is associ- more needed introspection or other nonquantifiable methods than
ated with a wide variety of did chemistry and physics (Watson, 1913). This point of view is
objects or situations. Psychol- reflected in a famous quotation from a seminal article published
▲ Ivan Pavlov (1849–1936)
ogists have had to develop by Watson in 1913: “Psychology, as the behaviorist views it, is a
identified the process of specific treatments to overcome purely objective experimental branch of natural science. Its theor-
classical conditioning, which is this response (Redd & Andryko- etical goal is the prediction and control of behavior. Introspection
important to many emotional wski, 1982); they are described forms no essential part of its methods” (p. 158). This, then, was
disorders. more fully in Chapter 9. the beginning of behaviourism and, like most revolutionaries,
Watson took his cause to extremes. For example, he wrote that The Beginnings of Behaviour Therapy
“thinking,” for purposes of science, could be equated with The implications of Jones’s research were largely ignored for
subvocal talking and that one need only measure movements two decades, given the fervour associated with more psycho-
around the larynx to study this process objectively. analytic conceptions of the development of fear. But in the late
Most of Watson’s time was spent developing behavioural 1940s and early 1950s, Joseph Wolpe (1915–1997), a pioneer-
psychology as a radical empirical science, but he did dabble briefly ing psychiatrist from South Africa, became dissatisfied with
in the study of psychopathology. In 1920, he and a student, Rosalie prevailing psychoanalytic interpretations of psychopathology
Rayner, presented an 11-month-old boy named Albert with a and began looking for something else. He turned to the work of
harmless fluffy white rat to play with. Albert was not afraid of the Pavlov and became familiar with the wider field of behavioural
small animal and enjoyed playing with it. However, every time psychology. He developed a variety of behavioural procedures
Albert reached for the rat, the experimenters made a loud noise for treating his patients, many of whom have phobias. His best-
behind him. After only five trials, Albert showed the first signs of known technique was termed systematic desensitization. In
fear if the white rat came near. The experimenters then determined principle, it was really very similar to Jones’s treatment of little
that Albert displayed mild fear of any similar white furry object, Peter. Individuals were gradually introduced to the objects or
even a Santa Claus mask with a white fuzzy beard. You may not situations they feared so their fear could extinguish; that is,
think this is surprising, but keep in mind that this was one of the they could test reality and see that nothing bad really happened
first examples ever recorded in a laboratory of actually producing in the presence of the phobic object or scene. Wolpe added
fear of an object not previously feared. Of course, this experiment another element by having his patients do something that was
would be considered unethical by today’s standards. For example, incompatible with fear while they were in the presence of the
Watson and Rayner’s failure to remove (or “recondition”) Albert’s dreaded object or situation. Because he could not always repro-
fear before the end of the experiment, and their insufficient follow- duce the phobic object in his office, Wolpe had his patients
up of the child’s fears after the experiment, would be criticized on carefully and systematically imagine the phobic scene, and the
ethical grounds today (Harris, 1979). response he chose was relaxation, because it was convenient.
Another student of Watson’s, Mary Cover Jones, thought that For example, Wolpe treated a young man with a phobia of dogs
if fear could be learned or classically conditioned in this way, by training him first to relax deeply and then imagine he was
perhaps it could also be unlearned or extinguished. She worked looking at a dog across the park. Gradually, he could imagine
with a boy named Peter, who at two years, ten months old was the dog across the park and remain relaxed, experiencing little
already quite afraid of furry objects. Jones decided to bring a or no fear, and Wolpe then had him imagine he was closer to the
white rabbit into the room where Peter was playing for a short dog. Eventually the young man imagined he was actually
time each day. She also arranged for other children, whom she touching the dog while maintaining a very relaxed, almost
knew did not fear rabbits, to be in the same room. She noted that trance-like state.
Peter’s fear gradually diminished. Each time it diminished, she Wolpe reported success with systematic desensitization, one of
brought the rabbit closer. Eventually Peter was touching and even the first wide-scale applications of the new science of behaviour-
playing with the rabbit (Jones, 1924a, 1924b), and years later the ism to psychopathology. Wolpe, working with fellow pioneers
fear had not returned. Hans Eysenck and Stanley J. Rachman in London, called this
approach behaviour therapy. Wolpe eventually moved to the
United States and Rachman to Canada, while Eysenck remained
in the United Kingdom, which contributed to the dissemination of
behaviour therapy knowledge and techniques throughout North
America and Europe.
B. F. Skinner and Operant

Conditioning
Sigmund Freud’s influence
extended far beyond psycho-
pathology into many aspects
of our cultural and intellectual
Archives of the History of American Psychology
Courtesy of Jack Rachman

history. Only one other behav-
ioural scientist has made a
similar impact, Burrhus Fred-
eric (B. F.) Skinner (1904–
1990). In 1938, he published
The Behavior of Organisms, ▲ Stanley J. Rachman, recently
in which he laid out, in a retired from the University of
comprehensive manner, the British Columbia, is one of the
▲ Mary Cover Jones (1896–1987) was one of the first psychologists principles of operant condi- original founders of the
to use behavioural techniques to free a patient from a phobia. tioning, a type of learning in behaviour therapy approach.

which behaviour changes as a governed to some degree by reinforcement, which can be arranged
function of what follows the in an endless variety of ways, in schedules of reinforcement.
behaviour. Skinner observed Skinner wrote a book on different schedules of reinforcement
early on that a large part of our (Ferster & Skinner, 1957). He also believed that using punish-
behaviour is not automatically ment as a consequence is relatively ineffective in the long run and
elicited by an unconditioned that the primary way to develop new behaviour is to positively
stimulus (UCS) and we must reinforce desired behaviour. Much like Watson, Skinner did not
account for this. In the ensu- see the need to go beyond the observable and quantifiable to
ing years, Skinner did not establish a satisfactory science of behaviour. He did not deny the
confine his ideas to the labora- influence of biology or the existence of subjective states of
tories of experimental psych- emotion or cognition; he simply explained these phenomena as
ology. He ranged broadly in relatively inconsequential side effects of a particular history of
his writings, describing, for reinforcement.
▲ B. F. Skinner (1904–1990)
example, the potential appli- The subjects of Skinner’s research were usually animals,
studied operant conditioning, a
cations of a science of behav- mostly pigeons and rats. Using his new principles, Skinner and his
form of learning that is central to
psychopathology. iour to our culture. Some of disciples actually taught the animals a variety of tricks, including
the best-known examples of dancing, playing Ping-Pong, and playing a toy piano. To do this,
his ideas are in the novel he used a procedure called shaping, a process of reinforcing
Walden Two (Skinner, 1948), in which he depicts a fictional soci- successive approximations to a final behaviour or set of behav-
ety run on the principles of operant conditioning. In another well- iours. If you want a pigeon to play Ping-Pong, first you provide it
known work, Beyond Freedom and Dignity (1971), Skinner lays with a pellet of food every time it moves its head slightly toward
out a broader statement of the problems facing our culture and a Ping-Pong ball tossed in its direction. Gradually you require the
suggests solutions based on his own view of a science of pigeon to move its head ever closer to the Ping-Pong ball until it
behaviour. touches it. Finally, receiving the food pellet is contingent on the
Skinner was strongly influenced by Watson’s conviction that a pigeon’s actually hitting the ball back with its head. Pavlov,
science of human behaviour must be based on observable events Watson, and Skinner contributed significantly to behaviour ther-
and relationships among those events. The work of psychologist apy (e.g., Wolpe, 1958), in which scientific principles of psychol-
Edward L. Thorndike (1874–1949) also influenced Skinner. ogy are applied to clinical problems. Many psychologists and
Thorndike is best known for the law of effect, which states that other mental health professionals quickly picked up on behaviour
behaviour is either strengthened (likely to be repeated more therapy techniques and began applying them with their patients in
frequently) or weakened (likely to occur less frequently) the 1950s and 1960s. For example, in an early application of these
depending on the consequences of that behaviour. Skinner took principles at the Lakeshore Psychiatric Hospital in Toronto,
the very simple notions that Thorndike had tested in the animal Richard Steffy and his colleagues describe how they used operant
laboratories, using food as a reinforcer, and developed them in a conditioning techniques to modify the behaviour of a ward of
variety of complex ways to apply to much of our behaviour. For severely aggressive female patients. These researchers docu-
example, if a five-year-old boy starts shouting at the top of his mented how reinforcements could be used by staff to decrease
lungs in McDonald’s, much to the annoyance of the people these patients’ violent activity and to improve their self-care and
around him, it is unlikely his behaviour was automatically elicited social responsiveness (Steffy, Hart, Craw, Torney, & Marlett,
by an unconditioned stimulus (UCS). Also, he will be less likely 1969). Similar results were reported by Teodoro Ayllon and Jack
to do it in the future if his parents scold him, take him out to the Michael (1959) from a study conducted at the Saskatchewan
car to sit for a bit, or consistently reinforce more appropriate Hospital in Weyburn, showing that the use of reinforcements by
behaviour. Then again, if the parents think his behaviour is cute nursing staff could produce substantial reductions in psychiatric
and laugh, chances are he will do it again. patients’ undesirable behaviour and increases in patients’ desir-
Skinner coined the term operant conditioning because behav- able behaviour. The ideas of Pavlov, Watson, and Skinner have
iour “operates” on the environment and changes it in some way. continued to contribute substantially to current psychosocial treat-
For example, the boy’s behaviour affects his parents’ behaviour ments, and so we refer to them repeatedly in this book.
and probably the behaviour of other customers as well. Therefore,
he changes his environment. Most things we do socially provide Comments
the context for other people to respond to us in one way or The behavioural model has contributed greatly to the understand-
another, thereby providing consequences for our behaviour. The ing and treatment of psychopathology, as will be apparent in the
same is true of our physical environment, although the conse- chapters that follow. Nevertheless, this model is incomplete in
quences may be long term (polluting the air eventually will itself and inadequate to account for what we now know about
poison us). Skinner preferred the term reinforcement to reward psychopathology. In the past, behaviourism had little or no room
because it connotes the effect on the behaviour. Skinner once said for biology, because disorders were considered, for the most part,
that he found himself a bit embarrassed to be talking continually environmentally determined reactions. The model also fails to
about reinforcement, much as Marxists used to see class struggle account for development of psychopathology across the life span.
everywhere. But he pointed out that all of our behaviour is Recent advances in our knowledge of how information is
processed, both consciously and subconsciously, have added a influence—biological, behavioural, cognitive, emotional, or
layer of complexity. We also now know that learning can occur social—ever occurs in isolation. Every time we think, feel, or do
indirectly or vicariously through observing others in social inter- something, the brain and the rest of the body are hard at work.
actions (Bandura, Jeffery, & Bachicha, 1974; Bandura & McDon- Perhaps not as obvious, however, is the fact that our thoughts,
ald, 1963; Bandura, Ross, & Ross, 1963). Integrating all these feelings, and actions inevitably influence the function and even
dimensions requires a new model of psychopathology. the structure of the brain, sometimes permanently. In other words,
our behaviour, both normal and abnormal, is the product of the
continual interaction of psychological, biological, and social
influences.
The Present: The Scientific Method and The view that psychopathology is multiply determined had its
an Integrative Approach early adherents. Perhaps the most notable was psychiatrist Adolf
Meyer (1866–1950). Whereas most professionals during the first
As Shakespeare wrote, “What’s past is prologue.” We have just half of the 20th century held narrow views of the cause of psycho-
reviewed three different traditions or ways of thinking about pathology, Meyer steadfastly emphasized the equal contributions
causes of psychopathology: the supernatural, the biological, and of biological, psychological, and sociocultural determinism.
the psychological (further subdivided into two major historical Although Meyer had some proponents, it was a century before the
components: psychoanalytic and behavioural). wisdom of his advice was fully recognized in the field.
Supernatural explanations of psychopathology are still with By 2000, a veritable explosion of knowledge about psycho-
us. Superstitions prevail, including beliefs in the effects of the pathology had occurred. The young fields of cognitive science and
moon and the stars on our behaviour. However, this tradition has neuroscience began to grow exponentially as we learned more
little influence on scientists and other professionals. Biological, about the brain and about how we process, remember, and use
psychoanalytic, and behavioural models, by contrast, continue to information. At the same time, startling new findings from behav-
further our knowledge of psychopathology, as we see in the next ioural science revealed the importance of early experience in
chapter. Even with the many advances in our understanding of determining later development. It was clear that a new model was
mental disorders, no blood test exists for mental illness, and no needed that would consider biological, psychological, and social
specific known cure, as is often the case with physical illness. influences on behaviour. This approach to psychopathology would
This fact helps explain why there are many, sometimes compet- combine findings from all areas with our rapidly growing under-
ing, models for mental disorders today. standing of how we experience life during different develop-
Despite the fact that the biological, psychoanalytic, and behav- mental periods, from infancy to old age. In 2010, the National
ioural models continue to improve our understanding of the vari- Institute of Mental Health (NIMH) instituted a strategic plan to
ous forms of psychopathology, each tradition has failed in at least support further research and development on the interrelationship
one important way. First, scientific methods were not often of these factors with the aim of translating research findings to
applied to the theories and treatments within a tradition, mostly front-line treatment settings (Insel, 2009). In the remainder of this
because methods that would have produced the evidence neces- book, we explore the reciprocal influences among neuroscience,
sary to confirm or disconfirm the theories and treatments had not cognitive science, behaviour science, and developmental science
been developed. Lacking such evidence, various fads and super- and demonstrate that the only currently valid model of psycho-
stitions were widely accepted that ultimately proved untrue or pathology is multidimensional and integrative.
useless. New fads often superseded truly useful theories and treat-
ment procedures. This trend was at work in the so-called discov-
ery of the drug reserpine, which, in fact, had been around for Concept Check 1.4
thousands of years. King Charles VI was subjected to a variety of
procedures, some of which have since been proved useful and Match the treatment with the corresponding psychological
others that were mere fads or even harmful. How we use scientific theory of behaviour: (a) behavioural model, (b) moral
methods to confirm or disconfirm findings in psychopathology is therapy, (c) psychoanalytic theory, and (d) humanistic
described in Chapter 4. Second, health professionals tend to look theory.
at psychological disorders very narrowly, from their own point of 1. Treating institutionalized patients as normally as possible
view alone. John Grey assumed psychological disorders are the and encouraging social interaction and relationship
result of brain disease and that other factors have no influence development. ____________
whatsoever. John Watson assumed that all behaviours, including
2. Hypnosis, psychoanalysis-like free association and
disordered behaviour, are the result of psychological and social
dream analysis, and balance of the id, ego, and superego.
influences and that the contribution of biological factors is
____________
inconsequential.
In the 1990s, two developments came together as never before 3. Person-centred therapy with unconditional positive
to shed light on the nature of psychopathology: (1) the increasing regard. ____________
sophistication of scientific tools and methodology (e.g., more 4. Classical conditioning, systematic desensitization, and
sophisticated medical technology methods such as neuro- operant conditioning. ____________
imaging—see Chapter 3), and (2) the realization that no one
NEL The Present: The Scientific Method and an Integrative Approach 27

SUMMARY
What Is a Psychological Disorder? ■ Each tradition has its own way of treating individuals who
have psychological disorders. Supernatural treatments
■ A psychological disorder is (1) a psychological dysfunction or include exorcism to rid the body of the supernatural
dyscontrol within an individual that is (2) associated with dis- spirits. Biological treatments typically emphasize physical
tress or impairment in functioning and (3) a response that is care and the search for medical cures, especially drugs.
not typical or culturally expected. Although this definition is Psychological approaches use psychosocial treatments,
the most popular, no one description has yet been identified beginning with moral therapy and including modern
that defines the essence of abnormality. psychotherapy.
■ Sigmund Freud, the founder of psychoanalytic therapy, offered
The Science of Psychopathology an elaborate conception of the unconscious mind, much of
■ The field of psychopathology is concerned with the scientific which is still conjecture. In therapy, Freud focused on tapping
study of psychological disorders. Trained mental health pro- into the mysteries of the unconscious through such techniques
fessionals range from clinical and counselling psychologists to as catharsis, free association, and dream analysis. Though
psychiatrists and psychiatric social workers and nurses. Each Freud’s followers veered from his path in many ways, Freud’s
profession requires a specific type of training. influence can still be felt today.
■ Using scientific methods, mental health professionals can function ■ One outgrowth of Freudian therapy is humanistic psychology,
as scientist-practitioners. They not only keep up with the latest which focuses more on human potential and self-actualizing
findings but also use scientific data to evaluate their own work, and than on psychological disorders. Therapy that has evolved
they often conduct research within their clinics or hospitals. from this approach is known as person-centred therapy; the
■ Research about psychological disorders falls into three basic therapist shows almost unconditional positive regard for the
categories: description, causation, and treatment and out- client’s feelings and thoughts.
comes. ■ The behavioural model moved psychology into the realm of
science, with an emphasis on findings from the laboratories of
The Supernatural, Biological, and Psychological psychology as applied to human behaviour. Therapeutic tech-
Traditions niques derived from this model include systematic desensitiza-
tion, reinforcement, and shaping.
■ Historically, three prominent approaches to abnormal behav-
iour have been used. In the supernatural tradition, abnormal The Present: The Scientific Method and the
behaviour is attributed to agents outside our bodies or social Integrative Approach
environment, such as demons or spirits, or the influence of the
moon and stars; though still alive, this tradition has been ■ With the increasing sophistication of our scientific tools and
largely replaced by biological and psychological perspectives. new knowledge from cognitive science, behavioural science,
In the biological tradition, disorders are attributed to disease or and neuroscience, we now realize that no contribution to
biochemical imbalances; in the psychological tradition, psychological disorders ever occurs in isolation. Our behav-
abnormal behaviour is attributed to faulty psychological iour, both normal and abnormal, is a product of a continual
development and to social context. interaction of psychological, biological, and social influences.
Key Terms
behaviour therapy, 25 extinction, 24 presenting problem, 8 psychosocial, 15
behavioural model, 23 free association, 22 prevalence, 8 reinforcement, 26
behaviourism, 17 id, 19 prognosis, 8 scientist-practitioner, 7
catharsis, 18 incidence, 8 psychoanalysis, 17 self-actualizing, 23
classical conditioning, 24 intrapsychic conflicts, 19 psychoanalyst, 22 shaping, 26
clinical description, 8 introspection, 24 psychoanalytic model, 19 superego, 19
course, 8 mental hygiene movement, 16 psychodynamic systematic desensitization, 25
defence mechanisms, 20 moral therapy, 15 psychotherapy, 22 transference, 22
dream analysis, 22 neurosis (neuroses plural), 21 psychological disorder, 3 unconditional positive
ego, 19 object relations, 21 psychopathology, 6 regard, 23
ego psychology, 21 person-centred therapy, 23 psychosexual stages of unconscious, 18
etiology, 8 phobia, 3 development, 20
Answers to Concept Checks

1.1 1.2 1.3 1.4
1. a, c 2. d 3. b, c 4. b 1. d 2. c 3. a 4. f 5. e 6. b 1. e 2. c 3. d 4. a 1. b 2. c 3. d 4. a
Media Resources
Access an integrated eBook, Abnormal Psychology Videos (formerly Abnormal Psych Live
CD-ROM), chapter-specific interactive learning tools (flashcards, quizzes, learning modules),
and more in your Psychology CourseMate, available at www.abnormalpsych3ce.nelson.com.
Abnormal Psychology Video

Free Abnormal Psychology videos can be viewed on the website www.abnormalpsych3ce
.nelson.com.
■ Roots of Behaviour Therapy: This combined clip shows the historical progression
of classical conditioning and the behavioural model from Pavlov through Watson
and Skinner.
Video Concept Reviews

CourseMate also contains Mark Durand’s Video Concept Reviews on these challenging
topics:
■ Concept Check—Abnormality ■ Prognosis
■ Psychopathology ■ Supernatural Views—Historical
■ Mental Health Professions ■ Supernatural Views—Current
■ The Scientist-Practitioner ■ Emotion Contagion
■ Presenting Problem ■ Hippocrates
■ Prevalence ■ Moral Therapy
■ Incidence ■ Concept Check—Integrative Approach
■ Course
NEL Summary 29
Timeline of Significant Events

400 B.C.E.–1875
National Library of Medicine
Stock Montage
1300s: Superstition runs ram-
400 B.C.E.: Hippocrates sug- pant and mental disorders are 1400–1800: Bloodletting and 1793: Philippe Pinel introduc-
gests that psychological disor- blamed on demons and witch- leeches are used to rid the es moral therapy and makes
ders have both biological and es; exorcisms are performed body of unhealthy fluids and French mental institutions
psychological causes. to rid victims of evil spirits. restore chemical balance. more humane.
400 B.C.E. 1300s 1500s 1825–1875

200 B.C.E.: Galen suggests that 1400s: Enlightened view that 1500s: Paracelsus suggests 1825–1875: Syphilis is dif-
normal and abnormal behaviour insanity is caused by mental that the moon and the stars ferentiated from other types of
are related to four bodily flu- or emotional stress gains affect people’s psychological psychosis in that it is caused
ids, or humors. momentum, and depression functioning, rather than pos- by a specific bacterium; ulti-
and anxiety are again regard- session by the devil. mately, penicillin is found to
ed by some as disorders. cure syphilis.
1930–1968 1950: The first effective drugs

for severe psychotic disorders
are developed. Humanistic 1958: Joseph Wolpe effec-
1930: Insulin shock therapy, psychology (based on ideas tively treats patients with pho-
electric shock treatments, and 1943: The Minnesota of Carl Jung, Alfred Adler, bias using systematic desen-
brain surgery begin to be used Multiphasic Personality and Carl Rogers) gains some sitization based on principles
to treat psychopathology. Inventory is published. acceptance. of behavioural science.
1930 1943 1950 1968

1938: B. F. Skinner publishes 1946: Anna Freud publishes 1952: The first edition of the 1968: DSM-II is published.
The Behavior of Organisms, Ego and the Mechanisms of Diagnostic and Statistical
which describes the principles Defense. Manual (DSM-I) is published.
of operant conditioning.
Imagno/Hulton Archive /Getty Images
NEL
1848–1920
Photographs Division Washington,

Library of Congress Prints and
Munchener Medizinische
Wochenschrift (1926)
D.C. 20540 USA
FPO
1848: Dorothea Dix suc- 1870: Louis Pasteur develops 1913: Emil Kraepelin classifies
cessfully campaigns for his germ theory of disease, various psychological disorders
more humane treatment in which helps identify the bac- 1900: Sigmund Freud pub- from a biological point of view
American mental institutions. terium that causes syphilis. lishes The Interpretation of and publishes work on diagnosis.
Dreams.
1848 1870 1900 1920
1854: John P. Grey, head of 1895: Josef Breuer treats the 1904: Ivan Pavlov receives the 1920: John B. Watson experi-
New York’s Utica Hospital, “hysterical” Anna O., leading Nobel Prize for his work on ments with conditioned fear in
believes that insanity is the to Freud’s development of the physiology of digestion, Little Albert using a white rat.
result of physical causes, thus psychoanalytic theory. which leads him to identify
de-emphasizing psychological conditioned reflexes in dogs.
treatments.
1990s: Increasingly sophisticat-

1980–2000
ed research methods are devel-
oped; no one influence—biologi-
cal or environmental—is found
to cause psychological disorders
1980: DSM-III is published. in isolation from the other. 2000: DSM-IV-TR is published.
1980 1990s 2000

1987: DSM-III-R is published. 1994: DSM-IV is published.
NEL
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Vincent Durand Sherry H Stewart

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A clear and complete insight into the nature of

S T U DE N T LE A RNI NG OU T COM ES*

NEL What Is a Psychological Disorder? 3

■ FIGURE 1.1 The criteria defining a psychological disorder

emotions are not functioning properly. However, if all your friends

CP PHOTO/AP/Charles Rex Arbogast

4 Chapter 1 Abnormal Behaviour in Historical Context NEL

“So Rhoda,” I began laconically, “what do you suppose was wrong

goats,” she said.

NEL What Is a Psychological Disorder? 5

Some controversial figures such as Thomas Szasz and George

6 Chapter 1 Abnormal Behaviour in Historical Context NEL

“psychotherapist” and “therapist” are not regulated by the provin-

Psychiatric nurses 11 000

NEL The Science of Psychopathology 7

A general overview of the categories now will give you a clearer

8 Chapter 1 Abnormal Behaviour in Historical Context NEL

treatment that allow us to function as scientist-practitioners. In

NEL The Supernatural Tradition 9

during the 14th and 15th centuries, people

Mary Evans Picture Library

10 Chapter 1 Abnormal Behaviour in Historical Context NEL

(AIDS) epidemic reflects a very similar belief among some

Mary Evans Picture Library

NEL The Supernatural Tradition 11

within the biological tradition that extended

12 Chapter 1 Abnormal Behaviour in Historical Context NEL

19th century by two factors: the discovery of the nature and cause

dicial stereotype the term implied.

The 19th Century

NEL The Biological Tradition 13

14 Chapter 1 Abnormal Behaviour in Historical Context NEL

through rational discussion so that the power

NEL The Psychological Tradition 15

Library of Congress Prints and Photographs Division Washington, D.C.

Province Date Notes

Québec 1845 Beauport, or the Québec Lunatic Asylum, was opened.

New Brunswick 1847 The Provincial Lunatic Asylum was erected.

Ontario 1850 The Provincial Lunatic Asylum in Toronto admitted patients.

Manitoba 1886 The Selkirk Lunatic Asylum admitted patients.

Alberta 1914 The Insane Asylum in Ponoka was opened.

16 Chapter 1 Abnormal Behaviour in Historical Context NEL

Association 1918-1988 by John D. Griffin MD, MA, DPM(E), FRCP(C).

From In Search of Sanity: A Chronicle of the Canadian Mental Health

NEL The Psychological Tradition 17

problems, conflicts, and fears

Mary Evans Picture Library

Erich Lessing/Art Resource, NY

Soon, she began to experience some diffi-

18 Chapter 1 Abnormal Behaviour in Historical Context NEL

causation in circumstances be fully aware of their mean-

NEL The Psychological Tradition 19