Richard P. Halgin
University of Massachusetts at Amherst
At a social gathering of fellow graduate students in the early 1970's a heated debate erupted about the cause of mental illness. On one side of the argument were my antagonists who insisted that all behavior results from learning, and that it is reasonable to conclude that psychiatric disturbances result from unfortunate life experiences. With an air of disbelief, I challenged my colleagues with pointed questions. Do people learn the symptoms of schizophrenia? If so, how and why? Are the euphoric episodes of mania conditioned responses? It just didn't make sense to me to view all mental disorders in terms of behavior theory. Although I didn't realize it at the time, this friendly disagreement would serve as a foundation block upon which I would build a career devoted to understanding the causes of mental disorder and the treatment of people with various forms of disturbance. During this past quarter century I believe that I have expanded my knowledge about mental disorders and treatments. Yet, as I prepare to venture into the new century I realize that I still have so much more to learn. I also realize that many of the seemingly brilliant research findings of earlier decades now seem unsophisticated and at times erroneous. I wonder where the fields of psychopathology and intervention will be twenty five years from now.
As any good soothsayer will attest, predicting the future is not an easy task. People who are proficient at speculation are usually those who have a good grasp of the present and an astute understanding of the past. In this chapter, I will attempt to venture some educated guesses about the future of psychopathology by considering the current state of the field, while also being sensitive to theories and hypotheses that were viewed as tenable in the recent past. I find it helpful to take a critical look at beliefs that once seemed reasonable but are now regarded as facetious. For example, psychopathologists of the 1970s delineated psychotic mental disorders as either 'functional' or 'organic.' In DSM-II (American Psychiatric Association, 1968), schizophrenia was listed in a section entitled 'Psychoses Not Attributed to Physical Conditions.' Although the authors of DSM-II did not offer etiological hypotheses regarding the cause of disorders such as schizophrenia, the notion was widely held at the time that people could develop this disorder from being raised by a 'schizophrenogenic mother.' In fact, in the debate with my friend, he pointed to this notion in support of his premise that life experiences are sufficient for explaining the development of even the most severe forms of disturbance. I wish that I could revisit that debate now that thousands of research studies have led psychopathologists to replace such ill-founded theories with hypotheses that give biology a central role in many etiological explanations.
Psychopathology research is presently at an interesting turning point, with the emergence of biology as one of the defining factors in the etiology of many disorders. However, as we will see, biology rarely tells the whole story; rather, most disorders arise from a complex set of factors. Integrative approaches that bring together biological, psychological, and social influences are emerging as the tools with which psychopathologists are constructing tenable theories and clinicians are developing effective treatments for the new millennium. The term 'biopsychosocial' aptly captures the essence of this integrative perspective.
The diathesis-stress model is an important foundation block upon which biopsychosocial approaches are built. This model proposes that people have a predisposition, or diathesis, that places them at risk for developing a mental disorder. Presumably this vulnerability is genetic, although some theorists have proposed that the vulnerability may also be acquired very early in life as the result of certain life events, such as traumas, diseases, or birth complications (Zubin & Spring, 1977).
In order to appreciate the complexity of this integrative perspective, it is helpful to take a look at the multifaceted state of the contributing subfields. In the following sections, I will discuss the current views of biologists, psychologists, and other social scientists regarding the causes and treatments of mental disorders.
The Biological Perspective
Students in psychopathology courses are usually able to understand the connection between aberrant bodily and emotional functioning by considering the connection in their own experience between certain psychological phenomena and physical events in the body. For example, they know that going without food or sleep for extended periods can cause emotional havoc; a high fever can evoke hallucinations; ingested substances can provoke psychotic-like symptoms. During the past decade advances in biological psychiatry have opened many doors to understanding the ways in which psychological functioning is affected by the nervous system, the endocrine system, and genetics.
In the realm of nervous system research, promising clues to understanding mental disorders have emerged from studies of neurotransmitters, such as acetylcholine, gamma-aminobutyric acid, dopamine, norepinephrine, enkephalins, and serotonin. For example, during the past decade, special attention has been given to serotonin, which researchers now realize is involved in a variety of disorders including obsessive-compulsive disorder, mood disorders, and eating disorders. In the decade to come, researchers will certainly intensify their efforts to understand some of the ways in which neurotransmitters cause people to act, think, and feel in ways that others regard as abnormal.
Researchers will also expand their inquiry into the role of the endocrine system in causing mental disorders. In what ways do hormones cause people to act and feel abnormally? Astute clinicians recognize the importance of conducting assessments that are sensitive to this question. For example, researchers have proposed that certain 'stress' hormones become activated in cases involving melancholic depression, leading to the experience of anxiety and fearfulness (Schulkin, 1994). Experts also know that many people with mood disorders have abnormal levels of thyroid hormones, leading them to speculate about the relationship between rate of metabolism and the occurrence of manic or depressive symptoms (Sokolov, Kutcher, & Joffe, 1994). As we venture toward the next century, an increasing number of disorders will be explained in terms of endocrinological dysfunction. It is conceivable that clinicians will be able to use hormonal testing to predict the onset of some psychological problems months or years before the emergence of symptoms.
Genetic make-up is yet another biological determinant of mental disorder. Polygenic models of genetic inheritance have been proposed to explain the ways in which many genes participate in the process of determining behavioral characteristics. Scientists have developed sophisticated procedures for estimating heritability in their efforts to assess the extent of genetic influence on various characteristics. Even though genetic influences have been shown to play a prominent role in the determination of several disorders, such as schizophrenia and mood disorder, experts realize that these genetics do not tell the entire etiological story. Using a diathesis-stress approach, researchers have begun to make quantitative estimates of the relative contributions of genes and the environment to the development of a mental disorder (Buchsbaum, 1994). As genetic research becomes more sophisticated in the years to come, clinicians may be able to make predictions, perhaps prenatally, about the statistical likelihood of an individual becoming psychologically disordered.
As biological research continues to advance, and more precise modes of predicting the development of mental disorders emerge, experts in the fields of psychopathology and intervention will face many profound ethical and social dilemmas. Should we tell the 18-year-old young woman that she is destined to develop major depressive disorder twenty years from now? Should we inform the 50-year-old man that a decade hence he will be suffering from Alzheimer's Disease? Moving beyond the issues of predicting and informing, researchers in the field will be driven to formulate preventive measures so that the 18-year-old woman and the 50-year-old man can go through their lives unburdened by the frightening scenarios that would otherwise be portrayed. Perhaps medications or psychosurgical procedures will be developed that can change the course of bodily development for people carrying biological predispositions for mental disorders.
The Psychological Perspective
In recent decades psychopathologists have moved away from reliance on narrow theories to explain the etiology and treatment of psychological disorders, and have moved toward integrative models that tap the empirically validated contributions of divergent schools of thought. Tapping various models, including psychodynamic, behavioral, humanistic, and family systems, astute clinicians develop formulations and treatment plans from a multitheoretical perspective (Halgin, 1989).
A few decades ago there were many psychotherapists who spoke ardently about the effectiveness of particular clinical techniques, while discrediting the benefits of other approaches. Behaviorists and psychoanalysts commonly demeaned the efforts of each other, and humanistic therapists ridiculed the techniques of both these models. During the second half of the20th century, thousands of research studies have failed to demonstrate conclusively the superiority of any single model. In fact, in a meta-analysis of outcome psychotherapy studies, Wampold and his colleagues (1997) concluded that the efficacy of bona fide treatments is roughly equivalent. Perhaps this growing realization has been influential in the choice of increasing numbers of therapists to explain and treat mental disorders by turning to the tenets and techniques of more than one model. As Norcross (1997) noted, 'informed pluralism and psychotherapy integration are the Zeitgeist of the new millennium' (p. 86).
In order to understand the psychological aspects of mental illness, we turn to the major theoretical models that have been influential during the past several decades including psychodynamic, behavioral, and family systems. Although relatively less influential in the recent past, humanistic approaches have added a valuable dimension as well.
Psychoanalysis has been broadened and reformulated in recent decades to such an extent that adherents are more likely to use the label psychodynamic and to include a wide range of concepts to explain and treat mental disorders. Particularly prominent among the contributions of psychodynamic adherents is the emergence of object relations theory and technique. Object relations theorists have proposed that various mental disorders arise from an individual's failure to form an integrated self early in life because of disturbed or inadequate relations with a primary caregiver. Researchers adapted the concept of infant attachment style to understand the ways that individuals relate as adults to significant others in their lives (Bartholomew & Horowitz, 1991; Hazan & Shaver, 1994). Such investigations opened doors to understanding emotional problems that involve pathological interpersonal styles in adulthood (Sable, 1997). Experts also applied attachment theory to psychotherapy by incorporating the tenets of this approach into clinical interventions with various kinds of clients suchas disturbed families, bereaved individuals, and distressed children (Biringen, 1994). When working with an especially hostile client, for example, an object relations clinician would give particular attention to the client's early experiences with caregivers in an effort to understand how the individual developed such a distancing interpersonal style.
Recognizing that the traditional techniques of long-term psychoanalysis are not viable in the contemporary clinical world, clinicians have adapted some psychodynamic tenets in the development of short-term models of intervention. Binder, Strupp and Henry (1995) formulated time-limited dynamic psychotherapy (TLDP) in which the psychotherapeutic process is viewed as a set of interpersonal transactions in which 'the therapist uses the relationship with the patient as the primary medium for bringing about change' (p. 53). In TLDP change comes about through the 'recognition of patterns of interactions with others that continuously reinforce maladaptive attitudes and feelings about oneself and others' (p. 54).
Behavioral and Cognitive Contributions
Behaviorally based models of understanding and treating mental disorders generated considerable excitement as theorists moved beyond the narrow behaviorism of the first half of the 20th century and formulated innovative approaches, such as social learning, cognitive-behaviorism, and behavioral medicine, during the latter decades of the century. Social learning theorists demonstrated the ways in which maladaptive behaviors are learned through observing other people being reinforced for engaging in those behaviors. For example, children raised by violent parents are likely to model violent behavior when they are frustrated. Social learning principles, such as those pertaining to modeling, can be applied in situations in which the observation of healthy and appropriate behavior is particularly important. For example, children can be taught to manage stressful situations by observing others dealing effectively with potentially upsetting circumstances.
Within cognitively based approaches, theorists emphasized the central role that thought processes play in the acquisition and treatment of various disorders. During the 1980s and 1990s many behaviorists redefined their approach as cognitive-behavioral or simply 'cognitive' (Craighead, Craighead, Kazdin, & Mahoney, 1994), thereby emphasizing the thoughts and unobservable processes that determine behavior. The cognitive approach developed most comprehensively with efforts to understand and treat depression (e.g., Beck, 1991; Ellis, 1998), but impressive advances were also achieved in the realm of anxiety disorders (Barlow & Brown, 1998; Steketee, 1998). What is particularly exciting about the work of cognitive-behaviorists is the notion that many symptoms, previously viewed as uncontrollable by the patient, have been brought under control by teaching individuals ways to change their thoughts and thereby change maladaptive emotions. As a result of the efforts of cognitive behaviorists, clinicians can look beyond antianxiety and antidepressant medications in formulating treatments for various conditions. For example, Barlow and Brown (1998) comment that the psychosocial treatment of panic disorder is one of our profession's success stories. The refinement of cognitively based approaches in the years ahead should add to the excitement generated by those professionals who have demonstrated ways of using the powers of the mind to resolve emotional and behavioral dysfunction.
Behavioral medicine is an approach in which clinicians combine behavioral, cognitive, and physiological techniques in the treatment of many medical conditions. As the line that divides medical and psychological intervention becomes increasingly blurred, the benefits of behavioral medicine will become even more evident. For example, experts recognize the fact that many physical conditions, such as heart problems, respiratory difficulties, pain conditions, and even cancer can be exacerbated by stress and alleviated by behavioral and cognitive-behavioral methods. The emerging field of psychoneuroimmunology has focused attention on the connections among psychological stress, nervous system functioning, and the immune system. Although it is a common response to turn to medication for the relief of medical problems, in the years ahead investigators will strive to tap the inner curative powers that play such an important role in personal health.
Family Systems Contributions
The family perspective developed in the late 1960s within the emerging framework of systems theory (Haley, 1976). The underlying premise of this perspective is that the individual's personality is inseparable from the pattern of interactions and relationships within the family. Within this view, disturbance may arise from disturbed communication patterns in the family, problematic family structure, or dysfunction in the family system. For example, a man's alcoholism may be understood, not just as his problem, but rather as a problem in which all the family members play a role in maintaining (Rohrbaugh, Shoham, Spungen, & Steinglass, 1995). Adherents of this approach support interventions that involve all those in the system; so rather than treating just the individual, they involve all the members of the family.
Particularly challenging for family systems theorists is the changing definition of the American family. As we approach the next millennium, clinicians will be confronted with challenges of understanding and treating problems within the contexts of families that differ from previous family structures involving two biological parents. Single-parent households are becoming more common, especially among some groups such as African Americans (Heaton & Jacobson, 1994). It is also more common to find children being raised by gay couples, grandparents, or others with the responsibilities once held almost exclusively by two biological parents. Divorce has become so common in American society that the blended family comprised of children from two or more marital relationships is becoming commonplace. Family researchers and clinicians will devote increasing attention to the impact of new family structures on psychological development as they strive to develop interventions that are responsive to a changing American family.
Although few psychopathologists would suggest that humanistic psychology plays a central role in contemporary approaches to understanding and treating psychological disorders, the client-centered techniques of Rogers and the self-actualization theory of Maslow have had a lasting impact on the work of many clinicians. For example, Hans Strupp (1997), one of the most prominent psychotherapy researchers of the century notes that 'irrespective of its theoretical underpinnings, psychotherapy is anchored in, and fundamentally inseparable from, a human relationship' (p. 92). Effective clinicians recognize that techniques per se are meaningless unless there is a working alliance between the helper and the client.
As I think about the ways in which psychological theorists have contributed to the understanding and treatment of people with mental disorders, I am reminded of why I chose to pursue a career in clinical psychology rather than medicine. I have always been drawn to the curative powers of the human relationship. As I noted above, I recognize that biological contributions play an important roles in helping clinicians understand and treat mental disorders; at the same time, it is my belief that the most powerful medications in the world are limited in efficacy unless accompanied by a therapeutic relationship. In the years to come, I hope to continue to investigate the curative powers of the working alliance between client and clinician, with more focused attention to the specific aspects of a clinician's interpersonal style that are most important in helping clients derive therapeutic benefit.
The Sociocultural Perspective
The racial demographics of American society have changed drastically over the past several decades, and psychopathologists are recognizing the importance of viewing mental disorder through lenses that are sensitive to cultural differences. As the fabric of society changes, so also must definitions of mental disorder and interventions that are culturally sensitive. In a diverse society, experienced clinicians know that they must be broad in their understanding of ethnic and cultural contributions to mental disorder. There is considerable potential for bias in the assessment and treatment of people from groups who have not been members of the majority in society. For example, in the realm of psychological testing and assessment, experts have exhorted mental health professionals to develop '...more culturally sensitive ways of assessing individuals from diverse racial and ethnic backgrounds' (Suzuki, Meller, & Ponterotto, 1995, p. 680).
When diagnosing people from minority groups, it is imperative that clinicians attend to issues of cultural identity. DSM-IV (American Psychiatric Association, 1994) provides a systematic outline for attending to cultural issues in the diagnostic and treatment process. This approach prompts clinicians to consider the degree of involvement with the client's culture of origin, possible cultural explanations for the problem, and the ways in which the problem may be explained or interpreted within the individual's cultural framework.
Although advances have been made in sensitizing clinicians to the importance of attending to cultural issues in assessment and diagnosis, Casas (1995) contends that much more work is needed in the intervention realm. He points out that efforts have been made to revise traditional theories in order to increase their effectiveness with racial/ethnic minority groups, but many of these efforts have lacked a connection to theory or validation by means of controlled experimentation. In the decades to come, researchers and clinicians must sharpen their focus on these complex issues in order to respond to a society whose complexion, language, and cultural heritage will continue to change.
Understanding and Treating Mental Disorders
In addition to broad theoretical advances and refinements, we can also expect specific developments in how particular mental disorders are understood and treated. In this section I focus on several major diagnostic categories and offer some hypotheses about future directions that are informed by emerging trends.
Personality disorders involve long-lasting patterns of inner experience and behavior in which maladaptation is evidenced by disturbance in at least two of the following realms: (a) cognition, (b) affectivity, (c) interpersonal functioning, and (d) impulse control. This pattern is a rigid aspect of the individual and is pervasive in most situations of a person's life. People with these disorders are likely to suffer from intense inner distress or problems in most aspects of their life.
This group of disorders is comprised of a range of maladaptive personality patterns including paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorder. What factors distinguish these various conditions? This question is actually a central concern to researchers who study people with personality disorders. One of the most frustrating aspects of research on the topic of personality disorders is the lack of sharp distinctions within this group. In other words, diagnostic reliability and validity are problematic, leading to wide ranges of estimates of prevalence for several of these disorders. In the past, researchers have used various criteria in defining personality disorders and have relied on imprecise assessment instruments. Consequently, there is considerable diagnostic overlap among the disorders.
Responding to the fuzzy diagnostic situation of the recent past, some researchers have embarked on an ambitious journey to redefine the field by focusing on the relationship between personality disorders and what are referred to as the Big Five factors of personality. The Big Five consists of five broad factors of personality ' extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience. As Dyce (1997) noted in his review of relevant studies, interest in this approach has intensified of late, even though the Big Five have been identified for nearly half a century. Instead of placing individuals into artificial discrete categories, proponents suggest a dimensional approach in which personality characteristics are viewed along a continuum ranging from normal to abnormal. A personality disorder would represent an extension of a set of normal personality traits that have exceeded an empirically determined level (Livesley, Schroeder, Jackson, & Jang, 1994; Millon, 1994; Widiger, & Ford-Black, 1994).
In the decades to come, investigators will strive to capture the essence of personality disorders as they move away from simplistic categories on which we have relied to capture a complex set of intrapersonal and interpersonal characteristics. Dyce (1997) contended that researchers will augment the Big Five with attention to nonpersonality factors, such as cognitive distortions, dysfunctional beliefs, and personal evaluations.
Psychopathologists will also intensify efforts to understand how and why people develop these maladaptive patterns. Central to such investigations will be exploration of spectrum models in which certain maladaptive patterns will be linked to other clinical conditions currently beyond the boundaries of the personality disorders category. For example, the hypothesized link between schizotypal personality disorder and schizophrenia may become clearer, as will the relationship between borderline personality disorder and mood disorder.
Biology is certain to provide a prominent clue to solving the puzzle of personality disorders. Researchers will determine with greater precision some of the ways in which the brain of a personality disordered individual differs from that of a person without this maladaptive pattern. For example, for decades theorists have been convinced that the brain of a person with antisocial personality disorder is somehow different from the norm. It has been presumed that these individuals have certain neuropsychological deficits that are reflected in abnormal patterns of learning and attention. But what are the differences, and what are their causes? Studies of family inheritance patterns have provided preliminary evidence in support of the heritability of criminality and psychopathy (Nigg & Goldsmith, 1994).
The study of early life experiences has also yielded clues to understanding the development of personality disorders. Of particular importance has been the effect of abuse and trauma on the emergence of a disturbed personality in adulthood (Millon, 1998). As the horrors of childhood abuse continue to come to light, we are more capable, sadly enough, of understanding what might lead so many people to lives of inner torment and interpersonal dissatisfaction. Even though a cause and effect relationship seems apparent, caution is imperative when drawing conclusions. As Paris (1997) asserts, 'Life events are rarely the cause of any mental disorder. At best, they are risk factors for psychopathology.' (p. 34) He points out that reliance on retrospective designs is a limitation of all studies of trauma in personality disordered patients. He urges researchers to examine the impact of trauma in a multidimensional framework.
In addition to the biological and interpersonal contributors to personality disorder, it will be important to consider societal influences. Millon (1998) attributes the increased prevalence of conditions such as borderline personality disorder to 'broad and pervasive sociocultural forces' (p. 19). He contends that when society's values and practices are fluid and inconsistent, as he regards them to be in contemporary Western culture, people are more likely to develop deficits in psychic solidity and stability.
Within the biopsychosocial framework, researchers will attempt to refine the understanding of personality disorders by zeroing in on the fabric and functioning of the nervous system, the role of early life experiences, and the impact of societal change. Clinicians treating personality-disordered individuals will turn to the findings of these researchers in their attempts to provide sound treatment.
Anxiety, a normal part of human experience, becomes a source of clinical concern when it reaches such an intense level that it interferes with a person's ability to function in daily life. Intense, irrational, and incapacitating experiences form the basis of anxiety disorders. Included in this group are the conditions of panic disorder, agoraphobia, phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and generalized anxiety disorder.
Although this category shares the common feature of inordinate anxiety, the group is oddly heterogeneous when it comes to etiology. For example, it is a widely held notion that certain anxiety disorders, such as panic disorder and obsessive-compulsive disorder, are genetically loaded conditions with measurable physiological correlates (Pini, Goldstein, Wickramaratne, & Weissman, 1994). On the other hand, post-traumatic stress disorder is by definition a reactive condition in which an individual experiences an incapacitating response to a stressful life event (Meichenbaum, 1998).
Although the causes of the anxiety might differ, its manifestation in the various anxiety disorders is both physiological and emotional. In other words, people suffering a panic attack experience intense physical discomfort associated with shortness of breath, hyperventilation, dizziness, choking, heart palpitations, trembling, sweating, stomach distress, and so on. Researchers have long suspected that changes in the body trigger the sensation of panic. These changes may be the result of an underlying biochemical abnormality that may be inherited. For example, certain individuals with panic disorder seem to have higher levels of brain lactate, a normal bodily chemical whose production can be stimulated by such behaviors as aerobic exercise. And, Papp and his colleagues (1997) demonstrated that patients with panic disorder are abnormally sensitive to the anxiety producing effects of CO2 inhalation.
Even though the role of biology in understanding and treating anxiety disorders has been a central focus of some researchers, it would be naive to conclude that we could solve the puzzle of anxiety disorders by looking solely at body chemistry. During the past two decades David Barlow and his colleagues have changed the way mental health professionals understand what goes on in the whole organism of a person tormented by anxiety. Barlow and Brown (1998) have gone beyond the biochemistry of anxiety and have focused on the cognitions of a person with an anxiety disorder. Recognizing the fact that panic attacks represent brain or biochemical dysfunction, which can be activated by CO2 inhalation or injection of sodium lactate, Barlow and his colleagues focused on the individual's response to these substances as influenced mainly by psychological factors. As a result of extensive research, Barlow concluded that 'strong evidence exists that anxiety focused on future panic and the sensations associated with panic combine as a strong force in maintaining panic disorder' (p. 51).
A multitheoretical approach also makes sense for the other anxiety disorders. For example, physiological correlates of obsessive-compulsive disorder have been evident for years. Since the 1800s it has been known that obsessions and compulsions exist in people with neurological disorders, such as epilepsy and Parkinson's disease. Nearly a decade ago Judith Rapoport (1989) noted the connection between neurological conditions involving the basal ganglia and obsessive-compulsive symptoms, and she has focused on the relationship between serotonin and OCD symptoms. More recently other researchers (Robinson et al., 1995) have found anatomical differences in brain structure that suggest malfunctioning circuitry in the connections between the subcortical and cortical motor control centers. At the same time that advances have been made in understanding the biology of OCD, other researchers have progressed in their understanding of the psychology of the condition. Steketee (1998) has developed behavioral interventions involving exposure to feared obsessions and prevention of rituals that accompany the obsessions, and she has demonstrated impressive effectiveness of these psychological techniques. In fact, she notes that she would only bring in serotonergic medications prior to behavioral treatment with 'clients who have difficulty engaging in exposure treatment because their anxiety or depressed mood is extremely high' (p. 69). Steketee's work highlights the fact that for some conditions, therapeutic change can be achieved by helping clients use their own behavior-changing resources.
The category of dissociative disorders is comprised of dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative identity disorder. These disorders involve anxiety or conflict so extreme that part of the individual's personality becomes separated from the rest of conscious functioning. The person with a dissociative disorder experiences a temporary alteration in consciousness involving a loss of personal identity or decreased awareness of immediate surroundings. These conditions have fascinated mental health professionals for most of the 20th century and have generated considerable debate among those who study and treat people with dissociative disorders.
The phenomenon of dissociation, especially in the form of dissociative identity disorder, has been at the heart of tremendous controversy in recent years (Waller & Ross, 1997). Experts have debated the validity of the diagnosis. Prior to DSM-IV this condition was called multiple personality disorder. The label was changed to dispel some of the misunderstandings associated with the term 'multiple personality' (Hacking, 1995). Once considered an extremely rare clinical condition, diagnosis of this disorder became commonplace during the final few decades of the century. In the 50 years prior to 1970 only a handful of cases had been reported, but since 1970 there have been thousands of reports. Some experts maintain that the increase in reported prevalence of multiple personality is due to more accurate diagnosis of the disorder. On the other side of the debate are individuals who maintain that the increase in diagnosis can be attributed to the notoriety of several popular first-person characterizations and media attention. Spanos (1994) asserted that this condition had become a way for some people to understand and express their failures and frustrations, and a tactic for manipulating others for some attention and concern.
The debate over the validity of dissociative identity disorder intensifies when the topic of its relationship with childhood abuse is brought into the discussion. Researchers have noted that most clients with dissociative identity disorder report experiences of having been physically or sexually abused as children. Compounding the issue, however, are questions about the reliability of some recollections of childhood abuse. The most intense controversy in recent years has focused on the phenomenon of recovered memories, especially those that emerge during the course of psychotherapy (Bowers & Farvolden, 1996). Alarm has been expressed about the potential that some psychotherapists inadvertently plant the suggestion that an individual might have been exploited as a child. As Bowers and Farvolden (1996) note, 'we know now that suggestions of various kinds can powerfully alter belief, behavior, and memory' (p. 375). Just as clients may be led to believe that unremembered traumatic events actually occurred, they may also be led to believe that they have more than one personality.
On the other side of the debate are experts, such as Richard Kluft, who endorse the increased prevalence of dissociative identity disorder, but define the diagnosis much more broadly than the classic definition. Kluft (1998) contends that most individuals with dissociative identity disorder have dissociative experiences that are not evident to others; only a very small percentage show dramatic behaviors that would be symptoms of disturbance obvious to other people.
Looking toward future research on this diagnosis, Waller and Ross (1997) assert that the overinclusive use of the term dissociation has hampered efforts to understand the etiology and course of the dissociative disorders. They believe that 'progress in dissociation research will accrue much faster after investigators distinguish between normative and pathological dissociative states' (p. 508). Also needed is additional study of the processes of memory and the residual effects of early trauma.
The category of sexual disorders is comprised of sexual dysfunctions, paraphilias, and gender identity disorders. During the 20th century psychologists made significant advances in understanding and treating sexual dysfunctions through the pioneering efforts of Masters and Johnson, and Helen Singer Kaplan. Particularly impressive have been integrative efforts in which clinicians blend divergent techniques in the treatment of people with sexual dysfunctions. For example, Kaplan (1998) brought together psychodynamic and behavioral work in the interventions she recommended. She also promoted a refreshing perspective on sexual problems, viewing neither person in a partnership as the patient; rather she believed that when conducting sex or marital therapy it is important to realize that it is their 'relationship that is ailing and needs to be healed' (p. 141).
As we approach the 21st century, there is less concern with the treatment of sexual dysfunction than there was two decades ago, but much greater attention to the paraphilias which involve the victimization of other people. There is no behavior in contemporary society considered more troubling than pedophilia. The sexual assault of any person, especially a child, is considered an extreme deviation from the standards of acceptable behavior in our society, and vigorous investigative efforts are under way to understand what leads people to engage in such exploitation.
With increasingly sophisticated understanding of the causes of sexual aggression, experts face the daunting task of developing intervention programs that alter the behavior of aggressors. Hall, Shondrick, and Hirschman (1993) promote differential treatments geared to the type of aggressor. For example, they contend that some individuals should be treated with physiological interventions, such as castration, hormonal treatments, and aversion therapy, while others would benefit from cognitive interventions such as victim empathy training.
Essential to the discussion of how society should respond to pedophiles is the issue of incarceration versus treatment. In American society, imprisonment is almost universally mandated, both because of the legal violations involved, and the revulsion of society to the behavior of the perpetrator. Unfortunately, no compelling evidence has emerged to support the notion that time in jail reduces the likelihood of sexually deviant behavior. As ineffective as incarceration may be, efforts to define effective therapeutic interventions have been limited in success.
Some medical interventions proposed for the treatment of pedophiles and other sexual perpetrators have created controversy which must be resolved in the years to come. Castration was a widely used treatment for sex offenders in the 1960s in European countries, but rarely used in the United States. Another invasive surgical intervention has involved psychosurgery in the form of hypothalamotomy, or destruction of the ventromedial nucleus of the hypothalamus. This procedure is intended to change the individual's sexual arousal patterns by targeting the source of these patterns in the central nervous system. In most places surgery has been replaced by other alternatives, such as medication (Berlin, 1997; Marshall, Jones, Ward, Johnston, & Barbaree, 1991).
Primary among the goals for dealing with sexual aggressors is the development of preventive strategies that reduce, ideally eradicate, this form of unacceptable behavior. Perhaps risk factors can be delineated such that parents, educators, and mental health professionals might accurately predict which young people are at greatest risk of moving toward this paraphilia in adolescence and adulthood. In the best of all worlds, corrective measures could be introduced before the problem emerges.
In reality, prevention will be only partially successful, and society will face the challenging questions of how to respond to people who are so intrusive in the lives of those less powerful. Mental health experts may be called upon to develop biological alterations for paraphilias that are far more extreme and long-lasting than any somatic interventions currently in use today.
Mood disturbance is a clinical condition with which every person can relate. At some time or other every person feels depressed, and many people experience symptoms to a degree sufficient to meet the criteria of major depressive disorder. Out of every 100 people, approximately 13 men and 21 women develop this disorder at some point in life (Kessler et al., 1994). Bipolar disorder is much less common than major depressive disorder; only 1.6 percent of Americans developing this condition at some point in life. Nevertheless, the lives of these individuals are thrown into chaos that warrants serious clinical attention.
The study of mood disorder etiology has yielded some of the most compelling findings about the role of genetics. The observation that mood disorders run in families is now well-established (Klein et al., 1995; Winokur, Coryell, Keller, Endicott, & Leon, 1995). Even in the case of suicide, genetic make-up seems to play a powerful role, as demonstrated by some carefully conducted twin research studies (Roy, Segal, & Sarchiapone, 1995).
Research on the biochemistry of mood disorder is still in a developmental stage, as investigators continue to sort out the role of various neurotransmitters. Focus has broadened beyond concern about catecholamines such as norepineprhine and dopamine to include attention to indolamines such as serotonin. Researchers are also looking at neuroanatomical differences, such as blood flow within the brain, in people with mood disorders such as depression (Bench, Frackowiak, & Dolan, 1995).
With all the excitement surrounding findings about the biological causes of depression, there is a risk that the importance of psychological and social factors will be underestimated. Attention has been drawn away from the fact that many people become seriously depressed in reaction to upsetting life events. Cognitive theorists, such as Aaron Beck, Donald Meichenbaum, and Albert Ellis, have been influential in emphasizing the role of disturbed thinking processes in the development and maintenance of depression. In the words of Ellis (1998), '...people largely depress themselves by taking their strong desires for success and relationships and irrationally raising them to absolute musts and demands' (p. 175). Ellis has taken an interesting integrative stance in which he acknowledges the possible causative role of biology in determining depression; however, he goes a step further by pointing out that people with endogenously caused depression may 'denigrate themselves for being depressed' (p. 176) and consequently develop low frustration tolerance.
Several researchers have focused on the powerful impact of disturbed interpersonal relationships in the lives of depressed people. Interpersonal theorists (Weissman & Markowitz, 1994) developed a model of understanding mood disorders that integrates several components. They take into consideration early life experiences that set the stage for intimacy and personal happiness later in life. Connecting the ideas of psychoanalytic theorists with behavioral and cognitive theorists, they look at the ways in which childhood failure to develop satisfying intimate relationships may lead to adult experiences of despair, isolation, and resulting depression.
Turning to the topic of therapeutic intervention for mood disorders, an increasing number of mental health professionals have turned to somatic interventions as components of a treatment plan. Although a minority of practitioners relies exclusively on medication to treat patients with serious depression or bipolar disorder, most recognize the importance of attending to interpersonal and emotional issues in treatment.
In the realm of medication, the advent of selective serotonin erupt inhibitors (SSRI's), such as Prozac, has revolutionalized the treatment of depression and several other disorders. In his 1993 book, Listening to Prozac, Peter Kramer caught the attention of millions of readers with his suggestion that Prozac need not be reserved for people diagnosed with depression. According to Kramer, Prozac (and similar medications) can quickly and easily help people with other conditions, such as low self-esteem or sensitivity to depression. Americans are apparently heeding this advice, as evidenced by annual sales of Prozac in excess of 700 million dollars (Standard & Poor's Industry Survey, 1995). The implications of such widespread prescription of this 'miracle drug' are difficult to assess, but there seems little question about the fact that countless numbers of people are seeking psychological changes and are finding that medications help them make life more pleasant. Will the daily SSRI dose become as commonplace as the morning vitamin?
In this pursuit of a panacea substance, Americans have also turned to herbs. Receiving special attention of late is the herb hypericum perforatum, more commonly known as St. John's Wort (Wills, 1996). In Germany St. John's Wort is prescribed much more widely than Prozac, and European researchers have found it to be more effective than placebo and as effective as mainstream antidepressants with fewer side effects (Klaus et al., 1996). With such promising results, we are led to wonder whether future treatment for mood disturbance will be found in one's garden or pantry.
In addition to the medical use of prescriptive substances, some practitioners are relying more and more on the incorporation of electroconvulsive therapy (ECT) in the treatment of mood disorders. For several decades this intervention was used only in the most extreme cases because of negative public attitudes and images of ECT. That has changed considerably during the 1990s, such that some practitioners actually recommend 'maintenance' ECT in which the treatment is administered over a period of several months to prevent recurrence of depressive symptoms (Steibel, 1995). For several years, practitioners were especially concerned about the possibility that long-lasting adverse effects might result from repeated administration of ECT; however, recent research reports have not provided grounds for such concern (Barnes, Hussein, Anderson, & Powell, 1997). Of continuing concern, however, for many practitioners and patients is the fact that the mechanism of the antidepressant action of ECT remains unknown, although vigorous investigative efforts have been undertaken to explain what happens in the brain as a result of this treatment (Werstiuk, Coote, Griffith, Shannon, & Steiner, 1996).
In the decades to come, the greatest promise for finding a widely accepted treatment for mood disorder would seem to lie in those interventions that can be self-generated efforts to change biological bases of mood. As evidence emerges in support of the therapeutic benefits of diet and exercise, people may take increasing control over their own emotions through behavioral changes that influence the biochemistry of the brain.
A profoundly disturbing and complex mental disorder, schizophrenia is a form of psychosis that causes havoc in the lives of people who suffer from this disorder and their family members. Between one and two percent of Americans have schizophrenia, but the resources needed to care for those whose lives are disrupted by this disorder are tremendous.
Of central importance in professional discussions about this disorder are questions about the nature of schizophrenia. Like several other conditions we have already discussed, schizophrenia is coming to be understood dimensionally rather than categorically. The notable dimensions include positive-negative and process-reactive. The most striking symptoms of schizophrenia are the 'positive' symptoms, such as delusions, hallucinations, disturbed speech, and disturbed behavior. However, experts have increased their attention to negative symptoms that involve functioning that is below that regarded as normal, such as emotional unresponsiveness, deficient communication, and loss of motivation. The process-reactive dimension differentiates schizophrenia according to how symptoms emerge ' either during a course of gradual deterioration or in reaction to stressors.
Implicit in questions about the dimensions of schizophrenia are questions about the definition of this disorder, a definition that has evolved considerably during the past century. Is schizophrenia a singular condition with many facets or a set of different but related disorders? As mentioned above, current thought leans toward the notion of a schizophrenia spectrum, with the psychotic expression of schizophrenia being related to conditions, such as schizoid personality disorder and schizotypal personality disorder.
After many decades of research on the etiology of schizophrenia, investigators have more certainty about the biological bases of this disorder than can be said about most other mental disorders. Experts are clear about the fact that the brains of people with schizophrenia differ from those of others, but investigators continue to lack certainty about the precise differences. As Stevens (1997) has noted, the search for an anatomy of schizophrenia has engendered an enormous mass of data, yet 'no morphological or microscopic abnormality has been found that is either necessary or sufficient for the diagnosis' (p. 373). In response to the heterogeneous biological picture of schizophrenia, experts are moving away from trying to understand this disorder as a single condition, but rather they are focusing their attention on symptom complexes to guide future neuroanatomical investigations (Buchanan & Carpenter, 1997).
As they continue their pursuit for an accurate biological characterization of schizophrenia, investigators will also try to pin down what causes the biological differences. Tremendous efforts have been made to define the genetics of schizophrenia transmission, yet thousands of questions remain. Family patterns of individuals with schizophrenia provide convincing evidence for genetic determinants. The closer a relative is to an individual with schizophrenia, the greater the concordance. For example, the highest concordance rate, 48%, is found in identical twins. However, the fact that the rate is not 100% leads to the conclusion that genetic influences cannot tell the whole story. In the years to come, researchers will try to understand what protects slightly more than half of the twin-siblings from developing the psychosis of their identical twin. By means of complex family studies involving efforts to separate out the role of biology from environment, investigators will continue their inquiry. Through such methods as the assessment of biological markers and genetic mapping, they will try to understand what goes on in the mind and the body of a person who develops this disturbing disorder. In other words, what is the diathesis and what are the stressors? It seems reasonable to expect that within a decade experts will be able to predict with a fair amount of certainty the odds of developing schizophrenia. They should also have a good grasp of what might increase an individual's vulnerability and what protective steps might be taken to reduce this vulnerability.
The realm of intervention for schizophrenia presents many challenges as well. Excitement has grown since the advent of such new antipsychotic medications as clozapine, a serotonin blocker that works on the neurotransmitter systems but has a different biochemical mode than traditional neuroleptics. The use of clozapine has increased substantially since the Food and Drug Administration approved it in 1990 and has been enthusiastically welcomed by the 10 to 20 percent of people with schizophrenia whose symptoms were unaffected by the other antipsychotic medications. Because major medical risks have been associated with clozapine use, pharmaceutical companies have worked diligently to develop similar medications that involve less risk. In the years to come, experts will continue to refine the formula for pharmacological interventions that are effective in quieting the tormenting symptoms of this disorder.
Even with the most effective of pharmacological interventions, experts recognize that psychological interventions will also be needed. At the very least, people who have been emotionally and behaviorally disturbed for years will need help readjusting to life once their symptoms are reduced or eradicated. In addition to social and family interventions, some therapists are promoting 'personal therapy.' In this approach, promoted by Gerard Hogarty and his colleagues, therapists strive to help schizophrenic individuals notice their physical and emotional reactions to stress, so they can learn strategies for coping with stress and relaxing in social situations. Research reports regarding the benefits of personal therapy have been startling (Hogarty et al., 1997). This kind of success serves as an important reminder to clinicians working with schizophrenic individuals that medication provides symptom relief, but not cure. People with schizophrenia need a more comprehensive intervention that returns them to and retains them in the mainstream of society.
The category comprising development-related disorders is large and diverse, consisting of conditions, such as mental retardation, autistic disorder, and learning disorders. Perhaps more than any other development-related disorder, attention-deficit/hyperactivity disorder (ADHD) has received the most research attention. This condition affects between 3% and 5% of the population and approximately 50% of clinical child populations (Cantwell, 1996). Children with ADHD are particularly intriguing to clinicians and educators both because of their deficits as well as their capacities. Some ADHD children are remarkably bright and charming; however, their lives are unhappy because they lack control over their own behaviors. The components of inattention and hyperactivity-impulsivity lead to a childhood or adolescence characterized by unhappiness and impaired functioning. Barkley and Edwards (1998) describe ADHD as a 'developmental disorder of self-regulation and future-directed behavior that adversely affects an individual's self-discipline, social effectiveness, and general adaptive functioning' (p. 232).
Researchers have worked earnestly to understand the biology of this disorder, with special attention to the role of genetics. During the past decade there has been increasing evidence in support of a genetic mechanism underlying ADHD, although researchers have questioned the extent to which the condition is categorical or dimensional (i.e., clearly delineated vs. behavior along a continuum). Levy and her colleagues (1997) support the notion that ADHD has an exceptionally high heritability compared with other behavior disorders; they contend that 'ADHD is best viewed as the extreme of a behavior that varies genetically throughout the entire population rather than as a disorder with discrete determinants' (p. 737).
In the years to come, experts will more precisely define the factors that cause ADHD. To date, they have focused attention on neurological deficits, genetics, birth complications, acquired brain damage, exposure to toxic substances, and infectious diseases. In addition to biological factors, they will attempt to understand the psychological contributors, such as the fact that individuals with ADHD are more likely to have grown up in a disturbed family environment (Biederman et al., 1995).
Controversy has emerged in recent years regarding the prescription of Ritalin (methylphenidate), a medication that has been demonstrated as effective in treating ADHD symptoms. Giving young children medication engenders mixed feelings in most parents, yet experts have demonstrated that most individuals with ADHD experience therapeutic benefits from these medications in which symptoms are reduced and overall adjustment is improved.
Greatest progress has been made in multifaceted treatments that involve work with the family, educators, and the child using behavior modification programs that are maintained for long periods, possibly years (Barkley & Edwards, 1998). Combining directive therapeutic interventions with medication as needed has been shown to be the most effective way of bringing order to the lives of children who feel out of control. Challenges in the decade ahead pertain to the early diagnosis of ADHD and the introduction of educative strategies directed toward caregivers during the earliest stages of ostensible ADHD behavior.
It is no secret that the abuse of substances has reached crisis proportions in contemporary society. Findings from the National Comorbidity Study have revealed that Americans between the ages of 15 and 54 are more affected by dependence on psychoactive substances than by any other psychiatric disturbance (Anthony, Warner, & Kessler, 1994). Over one-quarter of the U.S. population have abused or been dependent on substances at some point in their lifetime (Kessler et al., 1994).
Millions of dollars are being spent to determine why people abuse substances and how they should be treated. The biopsychosocial model (Zucker, Howard, & Boyd, 1994) has been particularly valuable in explaining the determinants of alcoholism. This model originated in part from longitudinal studies in which researchers followed individuals from childhood or adolescence to adulthood. The individuals most likely to become alcohol dependent had a history of antisocial behavior, including aggressive and sadistic behavior, trouble with the law, rebelliousness, lower achievement in school, completion of fewer years of school, and more truancy. They also showed a variety of behaviors possibly indicative of some type of early neural dysfunction, including nervousness and fretfulness as infants, hyperactivity as children, and poor coordination. These characteristics may reflect a genetically based vulnerability that, when combined with environmental stresses, leads to the development of alcohol dependence.
Children of alcoholic parents are likely to start their pattern of alcohol and drug use early in life, and by the age of 12, about one-fifth show negative consequences of substance abuse or symptoms of dependency (Chassin, Pillow, Curran, Molina, & Barrera, 1993). In addition to the fact that early alcohol use increases the likelihood of subsequent drug abuse, a person can develop a pattern of alcohol dependence by the early to mid-twenties that becomes fully established within two years (Langenbucher & Chung, 1995).
Moving beyond the notion of biological vulnerability, researchers have also focused attention on psychological processes involved in the transition from social drinking to dependence (Stacy, Widaman, & Marlatt, 1990). According to the expectancy model, people acquire the belief that alcohol will reduce stress; will make them feel more competent socially, physically, and sexually; and will give them feelings of pleasure. Young people are understandably drawn to want such experiences. In one longitudinal study of young teens, researchers found those individuals with the highest expectancies for the facilitating effects of alcohol began to drink earliest and heaviest, increasing their rate of drinking faster than teens who did not have strong alcohol expectancies (Smith, Goldman, Greenbaum, & Christiansen, 1995). This finding serves as a interesting segue into the social determinants of drinking behavior. Advertisers know that effective marketing of alcohol involves highlighting the social desirability of drinking. Drinkers are characterized as having fun, being relaxed, and being sexy, and are thus idealized as role models, especially for individuals who have only minimal experience of such pleasant feelings in their lives. As the social crisis regarding substance abuse continues to escalate, society will have to come to terms with the importance of finding less destructive pathways than psychoactive substances for achieving personal happiness and relieving inner psychological distress.
Corresponding to the integrative approach to understanding the causes of substance abuse, clinicians have recognized the importance of taking an integrative approach to the treatment of this problem. Complicating the treatment picture, however, is the fact that many individuals with a history of substance abuse also suffer from other mental and physical disorders. Schuckit (1998) highlights the complications that arise in the realm of dually diagnosed patients. He notes that 'one in three alcohol- or drug-dependent people present for care with temporary symptoms that resemble other Axis I major psychiatric disorders' (p. 262). Schuckit emphasizes the importance of careful diagnosis in which a time line is established in which the clinician considers issues of symptom onset. He also points out the fact that substance abusers are likely to suffer from one or more serious health problems that lead to the shortening of life from heart disease, cancers, suicide, and accidents.
In the realm of biological treatment of alcoholism, some clinicians have recommended the prescription of medications that are intended to alleviate symptoms of depression or anxiety. Schuckit (1998) contends that for the average alcohol-dependent individual not suffering from clearly documented independent depressive episodes, antidepressants are not particularly helpful. As for other medications, he believes that at the present time efficacy reports are preliminary. Antabuse (disulfiram) is a medication that is intended to produce a strongly aversive physiological reaction when a person drinks. Unfortunately, research on this medication has failed to demonstrate its widespread efficacy. Schuckit sees greater promise in the use of naltrexone (Trexan), an opiate antagonist. Clearly, much more research will be needed in the near future to determine which pharmacological agents are effective in reducing craving in people who are intensely addicted.
The greatest hope for effective intervention has been found in self-help contexts with Alcoholics Anonymous serving as a model for helping people who have lost control of their lives because of substance abuse. The 12 steps to recovery form the heart of AA's philosophy. The emphasis on honesty, confrontation, and storytelling are seen as essential elements of the 12-step program (Khantzian & Mack, 1994). Other important components of AA are the constant availability of people who can provide support during times of crisis and the spiritual element upon which the approach rests (Smith, 1994). It is difficult to generate data from controlled studies that self-help groups, such as AA, improve recovery rates, but clinical impressions certainly lead to such a conclusion (Schuckit, 1998).
In addition to the personal impact on the substance abuser of programs such as AA, supplementary interventions that focus on the individual's family and social circle have evolved. For example, Al-Anon provides support for people who are close to alcoholic individuals and who need help to cope with the problems that alcoholism has caused in their lives. Al-A-Teen is specifically designed for teenagers whose lives have been affected by alcoholism in the family.
Even though biological, psychological, and social interventions show promise for ameliorating the terrible emotional and medical crises in the lives of substance abusers, these efforts have had minimal impact on resolving the drug problem in society. The most important task for experts in the area of substance abuse pertains to the challenge of prevention. During the 1980s and 1990s federal, state, and local governments have poured millions of dollars into education and prevention programs directed at elementary and secondary school students. The DARE Program, the most widely tapped of these efforts, has failed to bring about a reduction in the drug problem. In fact, researchers have been dismayed by the finding that young people, who participated in this program a decade ago while in elementary school, are using illicit substances at alarming rates (Murray, 1997). Researchers, clinicians, and educators are desperately looking for ways to bring about long-lasting attitude change in young people so that they will have the wisdom to avoid falling into the catastrophic danger zone of drug abuse.
Other Psychopathological Conditions
In this chapter I focused on some of the major disorders that are of concern to researchers and clinicians in the field of psychopathology. Because of space limitations, it is not possible to discuss all the major conditions in the field despite the fact that tremendous advances are taking place in the way that certain disorders are understood and treated. Brief mention of some significant trends is warranted.
In the category of cognitive disorders, psychologists are giving increasing attention to research endeavors on conditions such as Alzheimer's Disease. All signs are pointing toward the likelihood that in the beginning years of the new millennium researchers will finally grasp the causes for this debilitating disorder of the brain. Methods are likely to be found that will suspend the deterioration that takes place and possibly even recover some of the capacities that are lost. Other forms of dementia will also be better understood. It is possible that the vigorous research efforts on various forms of dementia, such as that commonly found in people with AIDS, will lead to greater understanding of various forms of cognitive impairment. For the time being many clinicians working with patients suffering from dementia are focusing efforts to alleviate the emotional burden borne by caregivers who tend to loved ones afflicted by severe cognitive disabilities (Zarit & Zarit, 1998).
The category of eating disorders presents yet another challenge for researchers and clinicians. An alarming number of young people, mostly girls, have become entangled in patterns of eating disturbance with devastating, often fatal, consequences. Biopsychosocial approaches will serve as the means for deriving an explanation for what takes place in the body, mind, and social world of people who become caught up in a life characterized by dangerously self-destructive behaviors associated with eating. Experts in this area will continue their efforts to demonstrate how interventions such as cognitive-behavioral techniques can bring about demonstrable improvement in individuals whose lives have been ravaged by eating disorders (Agras & Apple, 1998).
Advice to Aspiring Psychopathologists
Each semester when I teach undergraduate courses in abnormal psychology students turn to me for recommendations about possible career paths related to the study of people with mental disorders. These students ask for pragmatic advice ranging from the kind of graduate study to pursue to the specific undergraduate courses they should take. My suggestions are rooted in the integrative approach that I have used to discuss the mental disorders in this chapter.
Of special importance to the aspiring psychopathologist is a sophisticated understanding of the human body. Beginning with the brain, it is essential to know the structure and functioning of the control center of human functioning. Advanced study of neuroscience provides tremendously important tools for understanding human behavior. In addition to focused study of the brain, the wise student studies all other major systems of the body. For example, knowledge of the endocrine system is essential for an investigator studying certain forms of mood disturbance. An appreciation for the emotional correlates of medical conditions, such as diabetes, allergies, and circulatory disease, can alert a researcher or clinician to the multifaceted causes of problems that might seem emotionally caused.
In recent years, psychologists have been debating the issue of whether they should have prescription privileges. This debate has been intense with proponents arguing that the prescription of medication will be an essential function in the work of a clinician. On the other side are those who are committed to maintaining the field of clinical psychology as one that focuses on cognitive, emotional, and psychological phenomena rather than biological and medical functions. In my view, these latter arguments are naive. As we come to grips with the fact that biological and psychological phenomena are inseparable, clinicians must be prepared to intervene somatically. Aspiring psychologists should be prepared for these modes of intervention and should be trained in procedures that involve the integration of somatic and psychotherapeutic interventions. If I were starting out today, I would still choose clinical psychology over medicine, but I would be certain to learn the most current information in the fields of physiology and psychopharmacology.
In addition to a strong foundation in the study of biological aspects of mental disorder, clinicians need to have sound training in the major psychological perspectives. This goal can be achieved by means of careful study of the history of psychology in which students develop a grasp of the tenets of the major schools of thought, with special attention to the contributions of the psychodynamic, behavioral, family systems, and interpersonal approaches. However, they will need more than academic study. The aspiring clinician needs hands-on experience working with different kinds of clients, using a variety of therapeutic techniques, in a diversity of settings. Those who are committed to working exclusively with adult clients in individual therapy should be certain to have training experiences involving the treatment of children, couples, and families. Those committed to working within a behavioral paradigm should look for opportunities to obtain supervision within a more exploratory framework. Through such broad exposure, they will gradually develop their own personal style, and in the process, learn the kind of clinical approach that works for their clients and that provides a sense of personal satisfaction for themselves.
In the decade ahead, I will continue to conduct research that I have recently initiated that focuses on helping trainees assess 'clinical style,' the qualities of personality and interpersonal interaction that enhance or impede their work with clients. This research begins by having the trainee characterize his or her therapeutic style along various dimensions (e.g., directive vs. evocative, educative vs. interpretive, confrontative vs. supportive). In addition to self-characterization, data about the trainee's clinical style are collected from supervisors and clients, as well as outcome measures, such as ratings of client satisfaction and clinical benefit. In this research, we will strive to help clinicians develop a greater understanding of the relationship between clinical style and effectiveness in general, as well as effectiveness with certain kinds of clients. My advice to aspiring clinicians is that they begin the process of self-assessment well before entering the field. In addition to intensive personal reflection, they may benefit from a personal therapy in which they explore their motivation for pursuing this career and give consideration to personal attributes that may enhance or impede their clinical work.
My research on clinical style takes place within a changing psychotherapeutic climate that is being defined by changes in the marketplace associated with the expansion of managed care health systems. Increasing emphasis is being placed on effectiveness and efficiency of interventions. For example, insurance companies are calling upon clinicians to use only empirically supported treatments in their practice. In response to such calls, leaders in the field of psychology have been working to formulate treatment recommendations called 'practice guidelines' (Nathan, 1998). Not surprisingly, these efforts have unleashed a storm of controversy, primarily because much of the research upon which these guidelines were formulated took place in laboratory rather than realistic clinical contexts. As the debate continues, educators are struggling with decisions about the content and techniques of psychotherapy training curricula. What is overlooked in many of these discussions is the personality and style of those providing clinical services. As we approach the new millennium, the onus will be on the educators of aspiring clinicians to respond to the challenges imposed by exciting new scientific findings about mental illness, inspiring data about innovative interventions, and powerful changes within health care delivery systems (Halgin, in press). At the same time we must realize that the clinician and his or her personal style will continue to be central factors in the equation. Imaginative research will be needed to understand the nature of this fascinating equation.
Finally, as we approach the 21st century, psychopathologists and clinicians need to understand our society and the forces and pressures that affect people adversely. The fields of sociology, and anthropology for that matter, provide important clues for solving pressing problems in the field. For example, researchers in the field of eating disorders know that they must attend to societal pressures on teenage girls in developing theories and interventions. In a multicultural society, clinicians are repeatedly called upon to explain phenomena and treat people within social contexts about which they have limited understanding. As the fabric of society changes, so also must the training and sensitivity of professionals. Those entering the field must make a determined effort to become educated about people whose backgrounds differ from their own. I urge my students to look for opportunities to meet and learn about people from other religious, ethnic, cultural, or socioeconomic backgrounds. In addition to social and educational pursuits, they should look for work contexts within which to expand their understanding about people.
When students ask me if I would follow the same career path if I had to do it over, I tell them that I am certain that I would. I have been fascinated over the past quarter century by my work with hundreds of clients whose lives I have tried to change for the better. In addition to facilitating changes in their lives, I have experienced change in my own life as a result of my work with these clients. I have developed a greater appreciation of the complexities of human nature. I have refined my clinical style so that I now have a better sense of what is helpful to my clients and with which kinds of clients I am most effective. And I have come to understand myself a great deal more ' my strengths, my limitations, my biases, and my sensitivities. I urge those beginning their careers to prepare for an exciting but arduous journey on which they will encounter an explosion of knowledge about human nature and abnormal behavior. On this journey they are certain also to learn a great deal about themselves. I urge them to engage in the kind of debates that excited me early in my career and to open themselves to evolving areas of investigation.
Agras, W. S., & Apple, R. F. (1998). Sally and her eating disorder: A case of bulimia nervosa. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 38-57). New York: Oxford University Press.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders-IV. Washington, DC: Author.
Anthony, J. C., Warner, L. A., Kessler, R. C. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2, 244-268.
Barkley & Edwards (1998). Missing reference--
Barlow, D. A., & Brown, T. A. (1998). Eric: A case of panic disorder with agoraphobia. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 38-57). New York: Oxford University Press.
Barnes, R. C., Hussein, A., Anderson, D. N., & Powell, D. (1997). Maintenance electroconvulsive therapy and cognitive function. British Journal of Psychiatry, 170, 285-287).
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226-244.
Beck, A. T. (1991). Cognitive therapy: A 30-year retrospective. American Psychologist, 46, 368-375.
Bench, C. J., Frackowiak, R. S., & Dolan, R. J. (1995). Changes in regional cerebral blood flow on recovery from depression. Psychological Medicine, 25, 247-251.
Berlin, F. S. (1997). 'Chemical castration' for sex offenders. The New England Journal of Medicine 336, 1030.
Biederman, J., Faraone, S. V., Mick, E., Spencer, T., Wilens, T., Kiely, K., Guite, J., Ablon, J. S., Reed, E., & Warburton, R. (1995). High risk for attention deficit hyper- activity disorder among children of parents with childhood onset of the disorder: A pilot study. American Journal of Psychiatry, 152, 431-435.
Binder, J. L., Strupp, H. H., & Henry, W. P. (1995). Psychodynamic therapies in practice: Time-limited dynamic psychotherapy. In B. Bongar & L. E. Beutler (Eds.), Comprehensive Textbook of Psychotherapy: Theory and Practice. New York: Oxford University Press.
Biringen, Z. (1994). Attachment theory and research: Application to clinical practice. American Journal of Orthopsychiatry, 64, 404-420
Bowers, K. S., & Farvolden, P. (1996). Revisiting a century-old Freudian slip ' From suggestion disavowed to truth repressed. Psychological Bulletin, 119, 355-380.
Buchanan, R. W., & Carpenter, W. T. (1997). The neuroanatomies of schizophrenia. Schizophrenia Bulletin, 23, 367-372.
Buchsbaum, M. S. (1994). Critical review of psychopathology in twins: Structural and functional imaging of the brain. In J. T. J. Bouchard & P. Propping (Eds.), Twins as a tool of behavioral genetics (pp. 257-271). Chichester, England: Wiley.
Budman, S. H. (1994). Models of brief individual and group psychotherapy. In J. L. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (pp. 231-248), Washington, DC: American Psychiatric Press.
Cantwell, D. (1996). Attention deficit disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 978-987.
Casas, J. M. (1995). Counseling and psychotherapy with racial/ethnic minority groups in theory and practice. In B. Bongar, B. & L. E. Beutler (Eds.), Comprehensive textbook of psychotherapy: Theory and practice (pp. 311-335). New York: Oxford University Press.
Chassin, L., Pillow, D. R., Curran, P. J., Molina, B. S. G., Barrera, M. (1993). Relation of parental alcoholism to early adolescent substance use: A test of three mediating mechanisms. Journal of Abnormal Psychology, 102, 3-19.
Craighead, L. W., Craighead, L. W., Kazdin, A. E., & Mahoney, M. J. (1994). Cognitive and behavioral perspectives: An introduction. In L.W. Craighead, W. E. Craighead, A. E. Kazdin, & M. J. Mahoney (Eds.), Cognitive and behavioral interventions:An empirical aproach to mental health problems (pp. 1-14). Boston: Allyn & Bacon.
Dyce (1997) missing reference
Ellis, A. (1998). Flora: A case of severe depression and treatment with rational emotive behavior therapy. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 166-180). New York: Oxford University Press.
Hacking, I. (1995). Rewriting the soul: Multiple personality and the sciences of memory. Princeton, NJ: Princeton University Press.
Haley, J. (1976). A history of a research project. In C. E. Slukzi & D. C. Ransom (Eds.), The double bind: The foundation of the communicational approach to the family (pp. 59-104). New York: Grune & Stratton.
Halgin (1989) reference missing
Halgin, R. P. (In press). Clinical training: Challenges for a new millennium. In C.E. Watkins (Section Editor), The future of psychotherapy training. Journal of Clinical Psychology.
Hall, G. C. N., Shondrick, D. D., Hirschman, R. (1993). Conceptually derived treatments for sexual aggressors. Professional Psychology: Research and practice, 24, 62-69.
Hazan, C., & Shaver, P. R. (1994). Attachment as an organizational framework for research on close relationships. Psychological Inquiry, 5, 1-22.
Heaton, T. B., & Jacobson, C. K. (1994). Race differences in changing family demographics in the 1980s. Journal of family issues, 15, 456-485
Hogarty, G. E., Kornblith, S. J., Greenwald, D., DiBarry, A. L., Cooley, S., Ulrich, R. F., Carter, M., & Flesher, S. (1997). Three-year trials of personal therapy among schizophrenic patients living with or independent of family, I: Description of study and effects on relapse rates. American Journal of Psychiatry, 154, 1504-1513.
Kaplan, H. S. (1998). Missing reference
Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H., Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-iii-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.
Khantzian, E. J., & Mack, J. E. (1994). How AA works and why it's important for clinicians to understand. Journal of Substance Abuse Treatment, 11, 77-92.
Klein, D. N., Riso, L. P., Donaldson, S. K., Schwartz, J. E., Anderson, R. L., Ouimette, P.C., Lizardi, H., & Aronson, T. A. (1995). Family study of early-onset dysthymia. Archives of General Psychiatry, 52, 487-496.
Klaus, L., et al. (1996). St. John's Wort for depression ' an overview and meta-analysis of randomized clinical trials. British Medical Journal, 313.
Kluft, R. (1998). Joe: A case of dissociative identity disorder. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 90-112). New York: Oxford University Press.
Kramer, P. D. (1993). Listening to Prozac: A psychiatrist explores antidepressant drugs and the remaking of the south. New York: Viking.
Langenbucher, J. W., Chung, T. (1995). Onset and staging of DSM- IV alcohol dependence using mean age and survival hazard methods. Journal of Abnormal Psychology, 104, 346-354.
Levy, F., Hay, D. A., McStephen, M., Wood, C., & Waldman, I. (1997). Attention-deficit hyperactivity disorder: A category or a continuum? Genetic analysis of a large-scale twin study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 737-744.
Livesley, W. J., Schroeder, M. L., Jackson, D., N., & Jang, K. L. (1994). Categorical distinctions in the studies of personality disorder: Implications for classification. Journal of Abnormal Psychology, 103, 6-17.
Marshall, W. L., Jones, R., Ward, T., Johnston, P., Barbaree, H. E. (1991). Treatment outcome with sex offenders. Clinical Psychology Review, 11, 465-485.
Meichenbaum, D. (1998). Sheila and Karen: Two cases of post-traumatic stress disorder. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 72-87). New York: Oxford University Press.
Millon, T.(1994). Manual for the Millon Clinical Multiaxial Inventory-III. Minneapolis: National Computer Systems.
Millon, T. (1998). Ann: My first case of borderline personality disorder. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 8- 22). New York: Oxford University Press.
Murray, B. (1997, September). Why aren't antidrug programs working? APA Monitor, p. 30.
Nathan, P. E. (1998). Practice guidelines: Not yet ideal. American Psychologist, 53, 290-299.
Nigg, J. T., & Goldsmith, H. H. (1994). Genetics of personality disorders: Perspectives from personality and psychopathology research. Psychological Bulletin, 115, 346-380.
Norcross, J. C. (1997). Emerging breakthroughs in psychotherapy integration: Three predictions and one fantasy. Psychotherapy 34, 86-90.
Papp, L. A., Martinez, J. M., Klein, D. F., Coplan, J. D., Norman, R. G., Cole, R., deJesus, M. J., Ross, D., Goetz, R, & Gorman, J. M. (1997). Respiratory psychophysiology of panic disorder: Three respiratory challenges in 98 subjects. American Journal of Psychiatry 154, 1557-1565.
Paris, J. (1997). Childhood trauma as an etiological factor in the personality disorders. Journal of Personality Disorders 11, 34-39.
Pini, S., Goldstein, R. B., Wickramatne, P. J., & Weissman, M. M. (1994). Phenomenology of panic disorder and major depression in a family study. Journal of Affective Disorders, 30, 257-272.
Rapoport, J. L. (1989). The biology of obsessions and compulsions. Scientific American, 83-89.
Robinson, D., Wu, H., Munne, R. A., Ashtari, M., Lavir, J. M. J., Lerner, G., Koreen, A., Cole, K., & Bogerts, B. (1995). Reduced caudate nucleus volume in obsessive-compulsive disorder. Archives of General Psychiatry, 52, 393-398.
Rohrbaugh, M., Shoham, V., Spungen, C., & Steinglass, P. (1995). In B. Bongar & L. E. Beutler (Eds.), Comprehensive textbook of psychotherapy: Theory and practice (pp. 228- 253). New York: Oxford University Press.
Roy, A., Segal, N. L., & Sarchiapone, M. (1995). Attempted suicide among living co-twins of twin suicide victims. American Journal of Psychiatry 152, 1075-1076.
Sable, P. (1997). Disorders of adult attachment. Psychotherapy 34, 286-296.
Schuckit, M. A. (1998). John's alcohol dependence: A casebook report. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 38-57). New York: Oxford University Press.
Schulkin, J. (1994). Melancholic depression and the hormones of adversity. A role for the amygdala. Current Directions in Psychological Science, 3, 41-44.
Smith, D. E. (1994). AA recovery and spirituality: An addiction medicine perspective. Journal of Substance Abuse Treatment, 11, 11-112.
Smith, G. T., Goldman, M. S., Greenbaum, P. E., Christiansen, B. A. (1995). Expectancy for social facilitation from drinking: The divergent paths of high-expectancy and low-expectancy adolescents. Journal of Abnormal Psychology, 104, 32-40.
Sokolov, S. T. H., Kutcher, S. P., & Joffe, R. T. (1994). Basal thyroid indices in adolescent depression and bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 469-475.
Spanos, N. P. (1994). Multiple identity enactments and multiple personality disoreder: A sociocognitive perspective. Psychological Bulletin, 116, 143-165.
Stacy, A. W., Widaman, K. F., & Marlatt, G. A. (1990). Expectancy models of alcohol abuse. Journal of Personality and Social Psychology, 58, 918-928.
Standard & Poor's Industry Surveys, October 1995, Vol. 1 A-L.
Steketee, G. (1998). Judy: A compelling case of obsessive-compulsive disorder. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 58-71). New York: Oxford University Press.
Steibel, V. G. (1995). Maintenance electroconvulsive therapy for chronically mentally ill patients: A case series. Psychiatric Services, 46, 265-268.
Stevens, J. R. (1997). Anatomy of schizophrenia revisited. Schizophrenia Bulletin, 23, 373-379.
Strupp, H. H. (1997). Research, practice, and managed care. Psychotherapy 34, 91-94.
Suzuki, L. A., Meller, P. J., & Ponterotto, J. G. (Eds.) (1995). Handbook of multicultural assessment: Clinical, Psychological, and Educational Applications. San Francisco, Jossey-Bass.
Waller, N. G., & Ross, C. A. (1997). The prevalence and biometric structure of pathological dissociation in the general population: Taxometric and behavior genetic findings. Journal of Abnormal Psychology, 106, 499-510.
Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, 'All must have prizes.' Psychological Bulletin, 122, 203-215.
Weissman, M. M., & Markowitz, J. C. (1994). Interpersonal psychotherapy: Current status. Archives of General Psychiatry, 51(suppl.), 599-606.
Werstiuk, E. S., Coote, M., Griffith, L., Shannon, H., & Steiner, M. (1996). Effects of electroconvulsive therapy on peripheral adrenoceptors, plasma, noradrenaline, MHPG and cortisol in depressed patients. British Journal of Psychiatry, 169, 758-765.
Widiger, T. A., & Ford-Black, M. M. (1994). Diagnosis and disorders. Clinical Psychology: Science and Practice, 1, 84-87.
Wills (1996). Missing reference
Winokur, G., Coryell, W., Keller, M., Endicott, J., Leon, A. (1995). A family study of manic-depressive (bipolar I) disease. Archives of General Psychiatry, 52, 367-373.
Zarit, S. H., & Zarit, J. M. (1998). Esther and Milton: 'Til death do us part: A case of dementia. In R. P. Halgin & S. K. Whitbourne (Eds.), A casebook in abnormal psychology: From the files of experts (pp. 236-252). New York: Oxford University Press.
Zubin, J., & Spring, B. (1977). Vulnerability ' A new view of schizophrenia. Journal of Abnormal Psychology 86, 103-126.
Zucker, R., Howard, J., & Boyd, G. (1994). The development of alcohol problems: Exploring the biopsychosocial matrix of risk. Washington, D.C.: National Institute on Alcohol Abuse and Alcoholism
Richard P. Halgin is a Professor of Psychology in the Clinical Psychology Program at the University of Massachusetts at Amherst and a Visiting Professor of Psychology at Amherst College. He is the co-author of Abnormal Psychology: Clinical Perspectives on Psychological Disorders, Third Edition (McGraw-Hill, 2000), editor of Taking Sides: Clashing Views on Controversial Issues in Abnormal Psychology (Dushkin/McGraw-Hill, 2000), and co-editor of A Casebook in Abnormal Psychology: From the Files of Experts (Oxford University Press, 1998). His list of publications also includes more than fifty articles and book chapters in the fields of psychotherapy, clinical supervision, and professional issues in psychology. He is a Board Certified Clinical Psychologist and has over two decades of clinical, supervisory, and consulting experience. His excellence in teaching has been recognized at the University of Massachusetts, where he was honored with the Distinguished Teaching Award.
The author may be reached at firstname.lastname@example.org