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Abnormal Psychology

Abnormal Psychology

In a Changing World (Chapter 1 in Book )

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Historical Perspectives on Abnormal Behavior

Throughout the history of Western culture, concepts of abnormal behavior have been shaped, to some degree, by the prevailing worldview of a particular era. For hundreds of years, beliefs in supernatural forces, demons, and evil spirits held sway. (As you’ve just seen, these beliefs still hold true in some societies.) Abnormal behavior was often taken as a sign of possession. In modern times, the predominant—but by no means universal—worldview has shifted toward beliefs in science and reason. In Western culture, abnormal behavior has come to be viewed as the product of physical and psychosocial factors, not demonic possession.

The Demonological Model

1. 1.4 Describe the demonological model of abnormal behavior.

Why would anyone need a hole in the head? Archaeologists have unearthed human skeletons from the Stone Age with egg-sized cavities in the skull. One interpretation of these holes is that our prehistoric ancestors believed abnormal behavior was caused by the inhabitation of evil spirits. These holes might be the result of trephination —drilling the skull to provide an outlet for those irascible spirits. Fresh bone growth indicates that some people did survive this “medical procedure.”

Just the threat of trephining may have persuaded some people to comply with tribal norms. Because no written accounts of the purpose of trephination exist, other explanations are possible. For instance, perhaps trephination was simply a form of surgery to remove shattered pieces of bone or blood clots that resulted from head injuries ( Maher & Maher, 1985 ).

The notion of supernatural causes of abnormal behavior, or demonology, was prominent in Western society until the Age of Enlightenment. The ancients explained nature in terms of the actions of the gods: The Babylonians believed the movements of the stars and the planets expressed the adventures and conflicts of the gods, and the Greeks believed that the gods toyed with humans, that they unleashed havoc on disrespectful or arrogant humans and clouded their minds with madness.

In ancient Greece, people who behaved abnormally were sent to temples dedicated to Aesculapius, the god of healing. The Greeks believed that Aesculapius would visit the afflicted while they slept in the temple and offer them restorative advice through dreams. Rest, a nutritious diet, and exercise were also part of the treatment. Incurables were driven from the temple by stoning. Origins of the Medical Model: In “Ill Humor”

1. 1.5 Describe the origins of the medical model of abnormal behavior.

Not all ancient Greeks believed in the demonological model. The seeds of naturalistic explanations of abnormal behavior were sown by Hippocrates and developed by other physicians in the ancient world, especially Galen.

Hippocrates (ca. 460–377 B.C.E.), the celebrated physician of the Golden Age of Greece, challenged the prevailing beliefs of his time by arguing that illnesses of the body and mind were the result of natural causes, not possession by supernatural spirits. He believed the health of the body and mind depended on the balance of humors , or vital fluids, in the body: phlegm, black bile, blood, and yellow bile. An imbalance of humors, he thought, accounted for abnormal behavior. A lethargic or sluggish person was believed to have an excess of phlegm, from which we derive the word phlegmatic. An overabundance of black bile was believed to cause depression, or melancholia. An excess of blood created a sanguine disposition: cheerful, confident, and optimistic. An excess of yellow bile made people bilious and choleric—quick-tempered.

Though scientists no longer subscribe to Hippocrates’s theory of bodily humors, his theory is important because of its break from demonology. It foreshadowed the modern medical model, the view that abnormal behavior results from underlying biological processes. Hippocrates also made other contributions to modern thought and, indeed, to modern medical practice. He classified abnormal behavior patterns into three main categories, which still have equivalents today: melancholia to characterize excessive depression, mania to refer to exceptional excitement, and phrenitis (from the Greek for inflammation of the brain) to characterize the bizarre behavior that might today typify schizophrenia. To this day, medical schools honor Hippocrates by having students swear an oath of medical ethics that he originated—the Hippocratic oath.

Galen (ca. 130–200 C.E.), a Greek physician who attended Roman emperor–philosopher Marcus Aurelius, adopted and expanded on the teachings of Hippocrates. Among Galen’s contributions was the discovery that arteries carry blood—not air, as had been formerly believed.

Medieval Times

1. 1.6 Describe the treatment of mental patients during medieval times.

The Middle Ages, or medieval times, cover the millennium of European history from about 476 C.E. through 1450 C.E. After the passing of Galen, belief in supernatural causes and especially the doctrine of possession increased in influence and eventually dominated medieval thought. The doctrine of possession held that abnormal behaviors were a sign of possession by evil spirits or the Devil. This belief was part of the teachings of the Roman Catholic Church, the central institution in Western Europe after the decline of the Roman Empire. Although belief in possession preceded the Church and is found in ancient Egyptian and Greek writings, the Church revitalized it. The Church’s treatment of choice for possession was exorcism. Exorcists were employed to persuade evil spirits that the bodies of the “possessed” were no longer habitable. Methods of persuasion included prayer, incantations, waving a cross at the victim, and beating and flogging, even starving, the victim. If the victim continued to display unseemly behavior, there were yet more persuasive remedies, such as the rack, a torture device. No doubt, recipients of these “remedies” desperately wished the Devil would vacate them immediately.

Exorcism.

This medieval woodcut illustrates the practice of exorcism, which was used to expel the evil spirits that were believed to have possessed people.

Description

The Renaissance—the great revival of classical learning, art, and literature—began in Italy in the 1400s and spread throughout Europe. Ironically, although the Renaissance is considered the transition from the medieval to the modern world, the fear of witches also reached its height during this period.

Witchcraft

The late 15th through the late 17th centuries were especially bad times to annoy your neighbors. These were times of massive persecutions, particularly of women, who were accused of witchcraft. Church officials believed that witches made pacts with the Devil, practiced satanic rituals, ate babies, and poisoned crops. In 1484, Pope Innocent VIII decreed that witches be executed. Two Dominican priests compiled a notorious manual for witch-hunting, called the Malleus Maleficarum (The Witches’ Hammer), to help inquisitors identify suspected witches. Many thousands would be accused of witchcraft and put to death over the next two centuries.

Witch-hunting required innovative “diagnostic” tests. For the water-float test, suspects were dunked in a pool to certify they were not possessed by the Devil. The test was based on the principle of smelting, during which pure metals settle to the bottom and impurities bob up to the surface. Suspects who sank and drowned were ruled pure. Suspects who kept their heads above water were judged to be in league with the Devil. As the saying went, you were “damned if you do and damned if you don’t.” This so-called test was one way in which medieval authorities sought to detect possession and witchcraft. Managing to float above the waterline was deemed a sign of impurity. In the lower right corner, you can see the bound hands and feet of one poor unfortunate who failed to remain afloat, but whose drowning would have cleared any suspicions of possession.

Description

Modern scholars once believed these so-called witches were actually people with psychological disorders who were persecuted because of their abnormal behavior. Many suspected witches did confess to bizarre behaviors, such as flying or engaging in sexual intercourse with the Devil, which suggests the types of disturbed behavior associated with modern conceptions of schizophrenia. However, these confessions must be discounted because they were extracted under torture by inquisitors who were bent on finding evidence to support accusations of witchcraft ( Spanos, 1978 ). We know today that the threat of torture and other forms of intimidation are sufficient to extract false confessions. Although some who were persecuted as witches probably did show abnormal behavior patterns, most did not (Schoenman, 1984). Rather, it appears that accusations of witchcraft were a convenient means of disposing of social nuisances and political rivals, of seizing property, and of suppressing heresy ( Spanos, 1978 ). In English villages, many of the accused were poor, unmarried elderly women who were forced to beg for food from their neighbors. If misfortune befell the people who declined to give help, the beggar might be accused of having cast a curse on the household. If the woman was generally unpopular, an accusation of witchcraft was likely to follow.

Demons were believed to play roles in both abnormal behavior and witchcraft. However, although some victims of demonic possession were perceived to be afflicted as retribution for their own wrongdoing, others were considered to be innocent victims—possessed by demons through no fault of their own. Witches were believed to have renounced God and voluntarily entered into a pact with the Devil. Witches generally were seen as more deserving of torture and execution ( Spanos, 1978 ).

Historical trends do not follow straight lines. Although the demonological model held sway during the Middle Ages and much of the Renaissance, it did not completely supplant belief in naturalistic causes. In medieval England, for example, demonic possession was only rarely invoked in cases in which a person was held to be insane by legal authorities ( Neugebauer, 1979 ). Most explanations for unusual behavior involved natural causes, such as physical illness or trauma to the brain. In England, in fact, some disturbed people were kept in hospitals until they were restored to sanity (Allderidge, 1979). The Renaissance Belgian physician Johann Weyer (1515–1588) also took up the cause of Hippocrates and Galen by arguing that abnormal behavior and thought patterns were caused by physical problems.

Asylums

By the late 15th and early 16th centuries, asylums, or madhouses, began to appear throughout Europe. Many were former leprosariums, which were no longer needed because of the decline in leprosy after the late Middle Ages. Asylums often gave refuge to beggars as well as the mentally disturbed, but conditions were appalling. Residents were chained to their beds and left to lie in their own waste or to wander about unassisted. Some asylums became public spectacles. In one asylum in London, St. Mary’s of Bethlehem Hospital—from which the word bedlam is derived—the public could buy tickets to observe the antics of the inmates, much as we would pay to see a circus sideshow or animals at the zoo. T / F

TRUTH or FICTION

1. A night’s entertainment in London a few hundred years ago might have included gaping at the inmates at the local asylum.

TRUE A night on the town for the gentry of London sometimes included a visit to a local asylum, St. Mary’s of Bethlehem Hospital, to gawk at the patients. We derive the word bedlam from Bethlehem Hospital.

The Reform Movement and Moral Therapy

1. 1.7 Identify the leading reformers of the treatment of the mentally ill and describe the principle underlying moral therapy and the changes that occurred in the treatment of mental patients during the 19th and early 20th centuries.

The modern era of treatment begins with the efforts of the Frenchmen Jean-Baptiste Pussin and Philippe Pinel in the late 18th and early 19th centuries. They argued that people who behave abnormally suffer from diseases and should be treated humanely. This view was not popular at the time; mentally disturbed people were regarded as threats to society, not as sick people in need of treatment.

From 1784 to 1802, Pussin, a layman, was placed in charge of a ward for people considered “incurably insane” at La Bicêtre, a large mental hospital in Paris. Although Pinel is often credited with freeing the inmates of La Bicêtre from their chains, Pussin was actually the first official to unchain a group of the “incurably insane.” These unfortunates had been considered too dangerous and unpredictable to be left unchained, but Pussin believed that if they were treated with kindness, there would be no need for chains. As he predicted, most of the shut-ins were manageable and calm after their chains were removed. They could walk the hospital grounds and take in fresh air. Pussin also forbade the staff from treating the residents harshly, and he fired employees who ignored his directives.

Bedlam.

The bizarre antics of the patients at St. Mary’s of Bethlehem Hospital in London in the 18th century were a source of entertainment for the well-heeled gentry of the town, such as the two well-dressed women in the middle of the painting.

Description

Pinel (1745–1826) became the medical director for the incurables’ ward at La Bicêtre in 1793 and continued the humane treatment Pussin had begun. He stopped harsh practices such as bleeding and purging, and moved patients from darkened dungeons to well-ventilated, sunny rooms. Pinel also spent hours talking to inmates, in the belief that showing understanding and concern would help restore them to normal functioning.

The philosophy of treatment that emerged from these efforts was labeled moral therapy. It was based on the belief that providing humane treatment in a relaxed and decent environment could restore functioning. Similar reforms were instituted at about this time in England by William Tuke and later in the United States by Dorothea Dix. Another influential figure was the American physician Benjamin Rush (1745–1813)—also a signatory to the Declaration of Independence and an early leader of the antislavery movement. Rush, considered the father of American psychiatry, penned the first American textbook on psychiatry in 1812: Medical Inquiries and Observations Upon the Diseases of the Mind. He believed that madness is caused by engorgement of the blood vessels of the brain. To relieve pressure, he recommended bloodletting, purging, and ice-cold baths. He advanced humane treatment by encouraging the staff of his Philadelphia Hospital to treat patients with kindness, respect, and understanding. He also favored the therapeutic use of occupational therapy, music, and travel ( Farr, 1994 ). His hospital became the first in the United States to admit patients for psychological disorders.

The unchaining of inmates at La Biĉetre by 18th-century French reformer Philippe Pinel.

Continuing the work of Jean-Baptiste Pussin, Pinel stopped harsh practices such as bleeding and purging, and moved inmates from darkened dungeons to sunny, airy rooms. Pinel also took the time to converse with inmates, in the belief that understanding and concern would help restore them to normal functioning.

Description

Dorothea Dix (1802–1887), a Boston schoolteacher, traveled about the country decrying the deplorable conditions in the jails and almshouses where mentally disturbed people were placed. As a result of her efforts, 32 mental hospitals devoted to treating people with psychological disorders were established throughout the United States.

A Step Backward

In the latter half of the 19th century, the belief that abnormal behaviors could be successfully treated or cured by moral therapy fell into disfavor. A period of apathy ensued in which patterns of abnormal behavior were deemed incurable (Grob, 19942009 ). Mental institutions in the United States grew in size but provided little more than custodial care. Conditions deteriorated. Mental hospitals became frightening places. It was not uncommon to find residents “wallowing in their own excrements,” in the words of a New York State official of the time (Grob, 1983). Straitjackets, handcuffs, cribs, straps, and other devices were used to restrain excitable or violent patients.

Deplorable hospital conditions remained commonplace through the middle of the 20th century. By the mid-1950s, the population in mental hospitals had risen to half a million. Although some state hospitals provided decent and humane care, many were described as little more than human snake pits. Residents were crowded into wards that lacked even rudimentary sanitation. Mental patients in back wards were essentially warehoused—that is, left to live out their lives with little hope or expectation of recovery or a return to the community. Many received little professional care and were abused by poorly trained and supervised staffs. Finally, these appalling conditions led to calls for reforms of the mental health system. These reforms ushered in a movement toward deinstitutionalization , a policy of shifting the burden of care from state hospitals to community-based treatment settings, which led to a wholesale exodus from state mental hospitals. The mental hospital population across the United States has plummeted from nearly 600,000 in the 1950s to about 40,000 today ( “Rate of Patients,” 2012 ). Some mental hospitals were closed entirely.

Another factor that laid the groundwork for the mass exodus from mental hospitals was the development of a new class of drugs—the phenothiazines. This group of antipsychotic drugs, which helped quell the most flagrant behavior patterns associated with schizophrenia, was introduced in the 1950s. Phenothiazines reduced the need for indefinite hospital stays and permitted many people with schizophrenia to be discharged to halfway houses, group homes, and independent living.

The mental hospital.

Under the policy of deinstitutionalization, mental hospitals today provide a range of services, including short-term treatment of people in crisis or in need of a secure treatment setting. They also provide long-term treatment in a structured environment for people who are unable to function in less-restrictive community settings.

The Role of the Mental Hospital Today

1. 1.8 Describe the role of mental hospitals in the mental health system.

Most state hospitals today are better managed and provide more humane care than those of the 19th and early 20th centuries, but here and there, deplorable conditions persist. Today’s state hospital is generally more treatment-oriented and focuses on preparing residents to return to community living. State hospitals function as part of an integrated, comprehensive approach to treatment. They provide a structured environment for people who are unable to function in a less-restrictive community setting. When hospitalization has restored patients to a higher level of functioning, the patients are reintegrated in the community and given follow-up care and transitional residences, if needed. If a community-based hospital is not available or if they require more extensive care, patients may be rehospitalized as needed in a state hospital. For younger and less intensely disturbed people, the state hospital stay is typically briefer than it was in the past, lasting only until their conditions allow them to reenter society. Older, chronic patients, however, may be unprepared to handle the most rudimentary tasks of independent life (shopping, cooking, cleaning, and so on)—in part because the state hospital may be the only home such patients have known as adults.

The Community Mental Health Movement

1. 1.9 Describe the goals and outcomes of the community mental health movement.

In 1963, the U.S. Congress established a nationwide system of community mental health centers (CMHCs) intended to offer an alternative to long-term custodial care in bleak institutions. CMHCs were charged with providing continuing support and mental health care to former hospital residents released from state mental hospitals. Unfortunately, not enough CMHCs have been established to serve the needs of hundreds of thousands of formerly hospitalized patients and to prevent the need to hospitalize new patients by providing comprehensive, community-based care and structured residential treatment settings, such as halfway houses.

The community mental health movement and the policy of deinstitutionalization were developed in the hope that mental patients could return to their communities and assume more independent and fulfilling lives, but deinstitutionalization has often been criticized for failing to live up to its lofty expectations. The discharge of mental patients from state hospitals left many thousands of marginally functioning people in communities that lacked adequate housing and other forms of support they needed to function. Although the community mental health movement has had some successes, a great many patients with severe and persistent mental health problems fail to receive the range of mental health and social services they need to adjust to life in the community ( Lieberman, 2010 ; Sederer & Sharfstein, 2014 ). As you shall see, one of the major challenges facing the community mental health system is the problem of psychiatric homelessness.

Deinstitutionalization and the Psychiatric Homeless Population

Many of the homeless wandering city streets and sleeping in bus terminals and train stations are discharged mental patients or persons with disturbed behavior who might well have been hospitalized in earlier times, before deinstitutionalization was in place. Lacking adequate support, they often face more dehumanizing conditions on the street than they did in the hospital. Many compound their problems by turning to illegal street drugs such as crack. Some of the younger psychiatric homeless population might have remained hospitalized in earlier times but are now, in the wake of deinstitutionalization, directed toward community support programs when they are available. The problem of psychiatric homelessness is not limited to the United States. A recent study in Denmark showed that about 60% of the homeless population had diagnosable psychiatric disorders ( Nielsen et al., 2011 ).

An estimated 20% to 30% of the homeless population suffers from severe psychological disorders, such as schizophrenia (Yager, 2015). Many also have neuropsychological impairments, including significant problems with memory, learning, and concentration, which leaves them disadvantaged in seeking and holding a job (Bousman et al., 2011). As many as 50% of the homeless population also suffer from substance abuse problems that largely go untreated (Yager, 2015).

The lack of available housing, transitional care facilities, and effective case management plays an important role in homelessness among people with psychiatric problems (Rosenheck, 2012Stergiopoulos, Gozdzik, et al., 2015 ). Some homeless people with severe psychiatric problems are repeatedly hospitalized for brief stays in community-based hospitals during acute episodes. They move back and forth between the hospital and the community as though caught in a revolving door. Frequently, they are released from the hospital with inadequate arrangements for housing and community care. Some are essentially left to fend for themselves. Although many state hospitals closed their doors and others slashed the number of beds, states failed to provide sufficient funds to support services needed in the community to replace the need for long-term hospitalization. Many homeless people have severe psychological problems but fall through the cracks of the mental health and social service systems.

The mental health system alone does not have the resources to resolve the multifaceted problems faced by the psychiatric homeless population. Helping the psychiatric homeless escape from homelessness requires matching services to their needs in an integrated effort involving mental health and alcohol and drug abuse programs; access to decent, affordable housing; and provision of other social services (Stergiopoulos, Gozdzik, et al., 2015). Another difficulty is that homeless people with severe psychological problems typically do not seek out mental health services. Many have become disenfranchised from mental health services because of previous bad hospital stays, during which they were treated poorly or felt disrespected, dehumanized, or simply ignored ( Price, 2009 ). We need intensive outreach and intervention efforts to help homeless people connect with the services they need as well as programs that provide a better quality of care to homeless individuals ( Price, 2009 ; Stergiopoulos, Gozdzik, et al., 2015 ). All in all, the problems of the psychiatric homeless population remain complex, vexing problems for the mental health system and society at large.

Deinstitutionalization: A Promise as Yet Unfulfilled

Although the net results of deinstitutionalization may not yet have lived up to expectations, a number of successful community-oriented programs are available. However, they remain underfunded and unable to reach many people needing ongoing community support. If deinstitutionalization is to succeed, patients need continuing care and opportunities for decent housing, gainful employment, and training in social and vocational skills. Most people with severe psychiatric disorders, such as schizophrenia, live in their communities, but only about half of them are currently in treatment ( Torrey, 2011 ).

New, promising services exist to improve community-based care for people with chronic psychological disorders—for example, psychosocial rehabilitation centers, family psychoeducational groups, supportive housing and work programs, and social skills training. Unfortunately, too few of these services exist to meet the needs of many patients who might benefit from them. The community mental health movement must have expanded community support and adequate financial resources if it is to succeed in fulfilling its original promise.

Psychiatric homelessness.

Many homeless people have severe psychological problems but fall through the cracks of the mental health and social service systems.

The mental health system alone does not have the resources to resolve the multifaceted problems faced by the psychiatric homeless population. Helping the psychiatric homeless escape from homelessness requires matching services to their needs in an integrated effort involving mental health and alcohol and drug abuse programs; access to decent, affordable housing; and provision of other social services (Stergiopoulos, Gozdzik, et al., 2015). Another difficulty is that homeless people with severe psychological problems typically do not seek out mental health services. Many have become disenfranchised from mental health services because of previous bad hospital stays, during which they were treated poorly or felt disrespected, dehumanized, or simply ignored ( Price, 2009 ). We need intensive outreach and intervention efforts to help homeless people connect with the services they need as well as programs that provide a better quality of care to homeless individuals ( Price, 2009 ; Stergiopoulos, Gozdzik, et al., 2015 ). All in all, the problems of the psychiatric homeless population remain complex, vexing problems for the mental health system and society at large.

Deinstitutionalization: A Promise as Yet Unfulfilled

Although the net results of deinstitutionalization may not yet have lived up to expectations, a number of successful community-oriented programs are available. However, they remain underfunded and unable to reach many people needing ongoing community support. If deinstitutionalization is to succeed, patients need continuing care and opportunities for decent housing, gainful employment, and training in social and vocational skills. Most people with severe psychiatric disorders, such as schizophrenia, live in their communities, but only about half of them are currently in treatment ( Torrey, 2011 ).

New, promising services exist to improve community-based care for people with chronic psychological disorders—for example, psychosocial rehabilitation centers, family psychoeducational groups, supportive housing and work programs, and social skills training. Unfortunately, too few of these services exist to meet the needs of many patients who might benefit from them. The community mental health movement must have expanded community support and adequate financial resources if it is to succeed in fulfilling its original promise.

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