THE HISTORY OF MENTAL ILLNESS

Section Learning Objectives

 Describe prehistoric and ancient beliefs about mental illness.

 Describe Greco-Roman thought on mental illness.
 Describe thoughts on mental illness during the Middle Ages.
 Describe thoughts on mental illness during the Renaissance.
 Describe thoughts on mental illness during the 18th and 19th
centuries.
 Describe thoughts on mental illness during the 20th and 21st
centuries.
 Describe the status of mental illness today.
 Outline the use of psychoactive drugs throughout time and their
impact.
 Clarify the importance of managed health care for the treatment
of mental illness.
 Define and clarify the importance of multicultural psychology.
 State the issue surrounding prescription rights for
psychologists.
 Explain the importance of prevention science.

As we have seen so far, what is considered abnormal behavior is

often dictated by the culture/society a person lives in, and
unfortunately, the past has not treated the afflicted very well. In
this section, we will examine how past societies viewed and dealt
with mental illness.

1.4.1. Prehistoric and Ancient Beliefs

Prehistoric cultures often held a supernatural view of abnormal

behavior and saw it as the work of evil spirits, demons, gods, or
witches who took control of the person. This form of demonic
possession often occurred when the person engaged in behavior
contrary to the religious teachings of the time. Treatment by cave
dwellers included a technique called trephination, in which a stone
instrument known as a trephine was used to remove part of the
skull, creating an opening. Through it, the evil spirits could escape,
thereby ending the person’s mental affliction and returning them to
normal behavior. Early Greek, Hebrew, Egyptian, and Chinese
cultures used a treatment method called exorcism in which evil
spirts were cast out through prayer, magic, flogging, starvation,
having the person ingest horrible tasting drinks, or noisemaking.

1.4.2. Greco-Roman Thought

Rejecting the idea of demonic possession, Greek physician

Hippocrates (460-377 B.C.) said that mental disorders were akin to
physical ailments and had natural causes. Specifically, they arose
from brain pathology, or head trauma/brain dysfunction or disease,
and were also affected by heredity. Hippocrates classified mental
disorders into three main categories – melancholia, mania, and
phrenitis (brain fever) – and gave detailed clinical descriptions of
each. He also described four main fluids or humors that directed
normal brain functioning and personality – blood which arose in the
heart, black bile arising in the spleen, yellow bile or choler from the
liver, and phlegm from the brain. Mental disorders occurred when
the humors were in a state of imbalance such as an excess of yellow
bile causing frenzy and too much black bile causing melancholia or
depression. Hippocrates believed mental illnesses could be treated
as any other disorder and focused on the underlying pathology.

Also noteworthy was the Greek philosopher Plato (429-347 B.C.),

who said that the mentally ill were not responsible for their actions
and should not be punished. It was the responsibility of the
community and their families to care for them. The Greek physician
Galen (A.D. 129-199) said mental disorders had either physical or
psychological causes, including fear, shock, alcoholism, head
injuries, adolescence, and changes in menstruation.

In Rome, physician Asclepiades (124-40 BC) and philosopher Cicero

(106-43 BC) rejected Hippocrates’ idea of the four humors and
instead stated that melancholy arises from grief, fear, and rage; not
excess black bile. Roman physicians treated mental disorders with
massage or warm baths, the hope being that their patients would
be as comfortable as they could be. They practiced the concept
of contrariis contrarius, meaning opposite by opposite, and
introduced contrasting stimuli to bring about balance in the
physical and mental domains. An example would be consuming a
cold drink while in a warm bath.

1.4.3. The Middle Ages – 500 AD to 1500 AD

The progress made during the time of the Greeks and Romans was
quickly reversed during the Middle Ages with the increase in power
of the Church and the fall of the Roman Empire. Mental illness was
yet again explained as possession by the Devil and methods such as
exorcism, flogging, prayer, the touching of relics, chanting, visiting
holy sites, and holy water were used to rid the person of demonic
influence. In extreme cases, the afflicted were exposed to
confinement, beatings, and even execution. Scientific and medical
explanations, such as those proposed by Hippocrates, were
discarded.

Group hysteria, or mass madness, was also seen when large

numbers of people displayed similar symptoms and false beliefs.
This included the belief that one was possessed by wolves or other
animals and imitated their behavior, called lycanthropy, and a
mania in which large numbers of people had an uncontrollable
desire to dance and jump, called tarantism. The latter was believed
to have been caused by the bite of the wolf spider, now called the
tarantula, and spread quickly from Italy to Germany and other
parts of Europe where it was called Saint Vitus’s dance.

Perhaps the return to supernatural explanations during the Middle

Ages makes sense given events of the time. The black death
(bubonic plague) killed up to a third, or according to other
estimates almost half, of the population. Famine, war, social
oppression, and pestilence were also factors. The constant
presence of death led to an epidemic of depression and fear. Near
the end of the Middle Ages, mystical explanations for mental illness
began to lose favor, and government officials regained some of
their lost power over nonreligious activities. Science and medicine
were again called upon to explain psychopathology.

1.4.4. The Renaissance – 14th to 16th centuries

The most noteworthy development in the realm of philosophy

during the Renaissance was the rise of humanism, or the worldview
that emphasizes human welfare and the uniqueness of the
individual. This perspective helped continue the decline of
supernatural views of mental illness. In the mid to late 1500s,
German physician Johann Weyer (1515-1588) published his
book, On the Deceits of the Demons, that rebutted the Church’s
witch-hunting handbook, the Malleus Maleficarum, and argued that
many accused of being witches and subsequently imprisoned,
tortured, and/or burned at the stake, were mentally disturbed and
not possessed by demons or the Devil himself. He believed that like
the body, the mind was susceptible to illness. Not surprisingly, the
book was vehemently protested and banned by the Church. It
should be noted that these types of acts occurred not only in
Europe, but also in the United States. The most famous example,
the Salem Witch Trials of 1692, resulted in more than 200 people
accused of practicing witchcraft and 20 deaths.

The number of asylums, or places of refuge for the mentally ill

where they could receive care, began to rise during the 16th
century as the government realized there were far too many people
afflicted with mental illness to be left in private homes. Hospitals
and monasteries were converted into asylums. Though the intent
was benign in the beginning, as the facilities overcrowded, the
patients came to be treated more like animals than people. In 1547,
the Bethlem Hospital opened in London with the sole purpose of
confining those with mental disorders. Patients were chained up,
placed on public display, and often heard crying out in pain. The
asylum became a tourist attraction, with sightseers paying a penny
to view the more violent patients, and soon was called “Bedlam” by
local people; a term that today means “a state of uproar and
confusion” (https://www.merriam-webster.com/dictionary/bedlam).

1.4.5. Reform Movement – 18th to 19th centuries

The rise of the moral treatment movement occurred in Europe in

the late 18th century and then in the United States in the early
19th century. The earliest proponent was Francis Pinel (1745-
1826), the superintendent of la Bicetre, a hospital for mentally ill
men in Paris. Pinel stressed respectful treatment and moral
guidance for the mentally ill while considering their individual,
social, and occupational needs. Arguing that the mentally ill were
sick people, Pinel ordered that chains be removed, outside exercise
be allowed, sunny and well-ventilated rooms replace dungeons, and
patients be extended kindness and support. This approach led to
considerable improvement for many of the patients, so much so,
that several were released.

Following Pinel’s lead, William Tuke (1732-1822), a Quaker tea

merchant, established a pleasant rural estate called the York
Retreat. The Quakers believed that all people should be accepted
for who they are and treated kindly. At the retreat, patients could
work, rest, talk out their problems, and pray (Raad & Makari,
2010). The work of Tuke and others led to the passage of the
Country Asylums Act of 1845, which required that every county
provide asylum to the mentally ill. This sentiment extended to
English colonies such as Canada, India, Australia, and the West
Indies as word of the maltreatment of patients at a facility in
Kingston, Jamaica spread, leading to an audit of colonial facilities
and their policies.

Reform in the United States started with the figure largely

considered to be the father of American psychiatry, Benjamin Rush
(1745-1813). Rush advocated for the humane treatment of the
mentally ill, showing them respect, and even giving them small
gifts from time to time. Despite this, his practice included
treatments such as bloodletting and purgatives, the invention of the
“tranquilizing chair,” and reliance on astrology, showing that even
he could not escape from the beliefs of the time.

Due to the rise of the moral treatment movement in both Europe

and the United States, asylums became habitable places where
those afflicted with mental illness could recover. Regrettably, its
success was responsible for its decline. The number of mental
hospitals greatly increased, leading to staffing shortages and a lack
of funds to support them. Though treating patients humanely was a
noble endeavor, it did not work for some patients and other
treatments were needed, though they had not been developed yet.
Staff recognized that the approach worked best when the facility
had 200 or fewer patients, but waves of immigrants arriving in the
U.S. after the Civil War overwhelmed the facilities, and patient
counts soared to 1,000 or more. Prejudice against the new arrivals
led to discriminatory practices in which immigrants were not
afforded the same moral treatments as native citizens, even when
the resources were available to treat them.

The moral treatment movement also fell due to the rise of

the mental hygiene movement, which focused on the physical well-
being of patients. Its leading proponent in the United States was
Dorothea Dix (1802-1887), a New Englander who observed the
deplorable conditions suffered by the mentally ill while teaching
Sunday school to female prisoners. Over the next 40 years, from
1841 to 1881, she motivated people and state legislators to do
something about this injustice and raised millions of dollars to build
over 30 more appropriate mental hospitals and improve others. Her
efforts even extended beyond the U.S. to Canada and Scotland.

Finally, in 1908 Clifford Beers (1876-1943) published his book, A

Mind that Found Itself, in which he described his struggle with
bipolar disorder and the “cruel and inhumane treatment people
with mental illnesses received. He witnessed and experienced
horrific abuse at the hands of his caretakers. At one point during
his institutionalization, he was placed in a straitjacket for 21
consecutive nights” (https://www.mhanational.org/our-history). His
story aroused sympathy from the public and led him to found the
National Committee for Mental Hygiene, known today as Mental
Health America, which provides education about mental illness and
the need to treat these people with dignity. Today, MHA has over
200 affiliates in 41 states and employs 6,500 affiliate staff and over
10,000 volunteers.

“In the early 1950s, Mental Health America issued a call to asylums
across the country for their discarded chains and shackles. On April
13, 1953, at the McShane Bell Foundry in Baltimore, Md., Mental
Health America melted down these inhumane bindings and recast
them into a sign of hope: the Mental Health Bell.

Now the symbol of Mental Health America, the 300-pound Bell

serves as a powerful reminder that the invisible chains of
misunderstanding and discrimination continue to bind people with
mental illnesses. Today, the Mental Health Bell rings out hope for
improving mental health and achieving victory over mental
illnesses.”

For more information on MHA, please

visit: https://www.mhanational.org/

1.4.6. 20th – 21st Centuries

The decline of the moral treatment approach in the late 19th

century led to the rise of two competing perspectives – the
biological or somatogenic perspective and the psychological or
psychogenic perspective.

1.4.6.1. Biological or Somatogenic Perspective. Recall that Greek

physicians Hippocrates and Galen said that mental disorders were
akin to physical disorders and had natural causes. Though the idea
fell into oblivion for several centuries, it re-emerged in the late
19th century for two reasons. First, German psychiatrist Emil
Kraepelin (1856-1926) discovered that symptoms occurred
regularly in clusters, which he called syndromes. These syndromes
represented a unique mental disorder with a distinct cause, course,
and prognosis. In 1883 he published his textbook, Compendium der
Psychiatrie (Textbook of Psychiatry), and described a system for
classifying mental disorders that became the basis of the American
Psychiatric Association’s Diagnostic and Statistical Manual of
Mental Disorders (DSM) that is currently in its 5th edition Text
Revision (published in 2022).

Secondly, in 1825, the behavioral and cognitive symptoms of

advanced syphilis were identified to include a belief that everyone
is plotting against you or that you are God (a delusion of grandeur),
and were termed general paresis by French physician A.L.J. Bayle.
In 1897, Viennese psychiatrist Richard von Krafft-Ebbing injected
patients suffering from general paresis with matter from syphilis
spores and noted that none of the patients developed symptoms of
syphilis, indicating they must have been previously exposed and
were now immune. This led to the conclusion that syphilis was the
cause of the general paresis. In 1906, August von Wassermann
developed a blood test for syphilis, and in 1917 a cure was found.
Julius von Wagner-Jauregg noticed that patients with general
paresis who contracted malaria recovered from their symptoms. To
test this hypothesis, he injected nine patients with blood from a
soldier afflicted with malaria. Three of the patients fully recovered
while three others showed great improvement in their paretic
symptoms. The high fever caused by malaria burned out the
syphilis bacteria. Hospitals in the United States began
incorporating this new cure for paresis into their treatment
approach by 1925.

Also noteworthy was the work of American psychiatrist John P.

Grey. Appointed as superintendent of the Utica State Hospital in
New York, Grey asserted that insanity always had a physical cause.
As such, the mentally ill should be seen as physically ill and treated
with rest, proper room temperature and ventilation, and a nutritive
diet.

The 1930s also saw the use of electric shock as a treatment

method, which was stumbled upon accidentally by Benjamin
Franklin while experimenting with electricity in the early 18th
century. He noticed that after suffering a severe shock his
memories had changed, and in published work, he suggested
physicians study electric shock as a treatment for melancholia.
 1.4.6.2. Psychological or Psychogenic
Perspective. The psychological or psychogenic perspective states
that emotional or psychological factors are the cause of mental
disorders and represented a challenge to the biological perspective.
This perspective had a long history but did not gain favor until the
work of Viennese physician Franz Anton Mesmer (1734-1815).
Influenced heavily by Newton’s theory of gravity, he believed that
the planets also affected the human body through the force of
animal magnetism and that all people had a universal magnetic
fluid that determined how healthy they were. He demonstrated the
usefulness of his approach when he cured Franzl Oesterline, a 27-
year-old woman suffering from what he described as a convulsive
malady. Mesmer used a magnet to disrupt the gravitational tides
that were affecting his patient and produced a sensation of the
magnetic fluid draining from her body. This procedure removed the
illness from her body and provided a near-instantaneous recovery.
In reality, the patient was placed in a trancelike state which made
her highly suggestible. With other patients, Mesmer would have
them sit in a darkened room filled with soothing music, into which
he would enter dressed in a colorful robe and pass from person to
person touching the afflicted area of their body with his hand or a
rod/wand. He successfully cured deafness, paralysis, loss of bodily
feeling, convulsions, menstrual difficulties, and blindness.

His approach gained him celebrity status as he demonstrated it at

the courts of English nobility. However, the medical community
was hardly impressed. A royal commission was formed to
investigate his technique but could not find any proof for his theory
of animal magnetism. Though he was able to cure patients when
they touched his “magnetized” tree, the result was the same when
“non-magnetized” trees were touched. As such, Mesmer was
deemed a charlatan and forced to leave Paris. His technique was
called mesmerism, better known today as hypnosis.

The psychological perspective gained popularity after two

physicians practicing in the city of Nancy in France discovered that
they could induce the symptoms of hysteria in perfectly healthy
patients through hypnosis and then remove the symptoms in the
same way. The work of Hippolyte-Marie Bernheim (1840-1919) and
Ambroise-Auguste Liebault (1823-1904) came to be part of what
was called the Nancy School and showed that hysteria was nothing
more than a form of self-hypnosis. In Paris, this view was
challenged by Jean Charcot (1825-1893), who stated that hysteria
was caused by degenerative brain changes, reflecting the biological
perspective. He was proven wrong and eventually turned to their
way of thinking.

The use of hypnosis to treat hysteria was also carried out by fellow
Frenchman Pierre Janet (1859-1947), and student of Charcot, who
believed that hysteria had psychological, not biological causes.
Namely, these included unconscious forces, fixed ideas, and
memory impairments. In Vienna, Josef Breuer (1842-1925) induced
hypnosis and had patients speak freely about past events that upset
them. Upon waking, he discovered that patients sometimes were
free of their symptoms of hysteria. Success was even greater when
patients not only recalled forgotten memories but also relived them
emotionally. He called this the cathartic method, and our use of the
word catharsis today indicates a purging or release, in this case, of
pent-up emotion.

By the end of the 19th century, it had become evident that mental
disorders were caused by a combination of biological and
psychological factors, and the investigation of how they develop
began. Sigmund Freud’s development of psychoanalysis followed
on the heels of the work of Bruner, and others who came before
him.

1.4.7. Current Views/Trends

1.4.7.1. Mental illness today. An article published by the

Harvard Medical School in March 2014 called “The Prevalence and
Treatment of Mental Illness Today” presented the results of the
National Comorbidity Study Replication of 2001-2003, which
included a sample of more than 9,000 adults. The results showed
that nearly 46% of the participants had a psychiatric disorder at
some time in their lives. The most commonly reported disorders
were:

 Major depression – 17%

 Alcohol abuse – 13%
 Social anxiety disorder – 12%
 Conduct disorder – 9.5%

Also of interest was that women were more likely to have had
anxiety and mood disorders while men showed higher rates of
impulse control disorders. Comorbid anxiety and mood disorders
were common, and 28% reported having more than one co-
occurring disorder (Kessler, Berglund, et al., 2005; Kessler, Chiu,
et al., 2005; Kessler, Demler, et al., 2005).

About 80% of the sample reported seeking treatment for their

disorder, but with as much as a 10-year gap after symptoms first
appeared. Women were more likely than men to seek help while
whites were more likely than African and Hispanic Americans
(Wang, Berglund, et al., 2005; Wang, Lane, et al., 2005). Care was
sought primarily from family doctors, nurses, and other general
practitioners (23%), followed by social workers and psychologists
(16%), psychiatrists (12%), counselors or spiritual advisers (8%),
and complementary and alternative medicine providers (CAMs;
7%).

In terms of the quality of the care, the article states:

Most of this treatment was inadequate, at least by the standards

applied in the survey. The researchers defined minimum adequacy
as a suitable medication at a suitable dose for two months, along
with at least four visits to a physician; or else eight visits to any
licensed mental health professional. By that definition, only 33% of
people with a psychiatric disorder were treated adequately, and
only 13% of those who saw general medical practitioners.

In comparison to the original study conducted from 1991-1992, the

use of mental health services has increased over 50% during this
decade. This may be attributed to treatment becoming more
widespread and increased attempts to educate the public about
mental illness. Stigma, discussed in Section 1.3, has reduced over
time, diagnosis is more effective, community outreach programs
have increased, and most importantly, general practitioners have
been more willing to prescribe psychoactive medications which
themselves are more readily available now. The article concludes,
“Survey researchers also suggest that we need more outreach and
voluntary screening, more education about mental illness for the
public and physicians, and more effort to treat substance abuse and
impulse control disorders.” We will explore several of these issues
in the remainder of this section, including the use of psychiatric
drugs and deinstitutionalization, managed health care, private
psychotherapy, positive psychology and prevention science,
multicultural psychology, and prescription rights for psychologists.

1.4.7.2. Use of psychiatric drugs and deinstitutionalization .

Beginning in the 1950s, psychiatric or psychotropic drugs were
used for the treatment of mental illness and made an immediate
impact. Though drugs alone cannot cure mental illness, they can
improve symptoms and increase the effectiveness of treatments
such as psychotherapy. Classes of psychiatric drugs include anti-
depressants used to treat depression and anxiety, mood-stabilizing
medications to treat bipolar disorder, anti-psychotic drugs to treat
schizophrenia, and anti-anxiety drugs to treat generalized anxiety
disorder or panic disorder

Frank (2006) found that by 1996, psychotropic drugs were used in

77% of mental health cases and spending on these drugs grew from
$2.8 billion in 1987 to about $18 billion in 2001 (Coffey et al., 2000;
Mark et al., 2005), representing over a sixfold increase. The largest
classes of psychotropic drugs are anti-psychotics and anti-
depressants, followed closely by anti-anxiety medications. Frank,
Conti, and Goldman (2005) point out, “The expansion of insurance
coverage for prescription drugs, the introduction and diffusion of
managed behavioral health care techniques, and the conduct of the
pharmaceutical industry in promoting their products all have
influenced how psychotropic drugs are used and how much is spent
on them.” Is it possible then that we are overprescribing these
mediations? Davey (2014) provides ten reasons why this may be so,
including leading suffers from believing that recovery is in their
hands but instead in the hands of their doctors; increased risk of
relapse; drug companies causing the “medicalization of perfectly
normal emotional processes, such as bereavement” to ensure their
survival; side effects; and a failure to change the way the person
thinks or the socioeconomic environments that may be the cause of
the disorder. For more on this article, please
see: https://www.psychologytoday.com/blog/why-we-worry/201401/
overprescribing-drugs-treat-mental-health-problems. Smith (2012)
echoed similar sentiments in an article on inappropriate
prescribing. He cites the approval of Prozac by the Food and Drug
Administration (FDA) in 1987 as when the issue began and the
overmedication/overdiagnosis of children with ADHD as a more
recent example.

A result of the use of psychiatric drugs was deinstitutionalization,

or the release of patients from mental health facilities. This shifted
resources from inpatient to outpatient care and placed the spotlight
back on the biological or somatogenic perspective. When people
with severe mental illness do need inpatient care, it is typically in
the form of short-term hospitalization.

1.4.7.3. Managed health care. Managed health care is a term

used to describe a type of health insurance in which the insurance
company determines the cost of services, possible providers, and
the number of visits a subscriber can have within a year. This is
regulated through contracts with providers and medical facilities.
The plans pay the providers directly, so subscribers do not have to
pay out-of-pocket or complete claim forms, though most require co-
pays paid directly to the provider at the time of service. Exactly
how much the plan costs depends on how flexible the subscriber
wants it to be; the more flexibility, the higher the cost. Managed
health care takes three forms:

 Health Maintenance Organizations (HMO) – Typically only pay

for care within the network. The subscriber chooses a primary
care physician (PCP) who coordinates most of their care. The
PCP refers the subscriber to specialists or other health care
providers as is necessary. This is the most restrictive option.
 Preferred Provider Organizations (PPO) – Usually pay more if
the subscriber obtains care within the network, but if care
outside the network is sought, they cover part of the cost.
 Point of Service (POS) – These plans provide the most flexibility
and allow the subscriber to choose between an HMO or a PPO
each time care is needed.
Regarding the treatment needed for mental illness, managed care
programs regulate the pre-approval of treatment via referrals from
the PCP, determine which mental health providers can be seen, and
oversee which conditions can be treated and what type of
treatment can be delivered. This system was developed in the
1980s to combat the rising cost of mental health care and took
responsibility away from single practitioners or small groups who
could charge what they felt was appropriate. The actual impact of
managed care on mental health services is still questionable at
best.

1.4.7.4. Multicultural psychology. As our society becomes

increasingly diverse, medical practitioners and psychologists alike
must take into account the patient’s gender, age, race, ethnicity,
socioeconomic (SES) status, and culture and how these factors
shape the individual’s thoughts, feelings, and behaviors.
Additionally, we need to understand how the various groups,
whether defined by race, culture, or gender, differ from one
another. This approach is called multicultural psychology.

In August 2002, the American Psychological Association’s (APA)

Council of Representatives put forth six guidelines based on the
understanding that “race and ethnicity can impact psychological
practice and interventions at all levels” and the need for respect
and inclusiveness. They further state, “psychologists are in a
position to provide leadership as agents of prosocial change,
advocacy, and social justice, thereby promoting societal
understanding, affirmation, and appreciation of multiculturalism
against the damaging effects of individual, institutional, and
societal racism, prejudice, and all forms of oppression based on
stereotyping and discrimination.” The guidelines from the 2002
document are as follows:

 “Guideline #1: Psychologists are encouraged to recognize that,

as cultural beings, they may hold attitudes and beliefs that can
detrimentally influence their perceptions of and interactions
with individuals who are ethnically and racially different from
themselves.
 Guideline #2: Psychologists are encouraged to recognize the
importance of multicultural sensitivity/responsiveness,
 knowledge, and understanding about ethnically and racially
different individuals.
 Guideline #3: As educators, psychologists are encouraged to
employ the constructs of multiculturalism and diversity in
psychological education.
 Guideline #4: Culturally sensitive psychological researchers are
encouraged to recognize the importance of conducting culture–
centered and ethical psychological research among persons
from ethnic, linguistic, and racial minority backgrounds.
 Guideline #5: Psychologists strive to apply culturally-
appropriate skills in clinical and other applied psychological
practices.
 Guideline #6: Psychologists are encouraged to use
organizational change processes to support culturally informed
organizational (policy) development and practices.”

Source: https://apa.org/pi/oema/resources/policy/multicultural-
guidelines.aspx

This type of sensitivity training is vital because bias based on

ethnicity, race, and culture has been found in the diagnosis and
treatment of autism (Harrison et al., 2017; Burkett, 2015),
borderline personality disorder (Jani et al., 2016), and
schizophrenia (Neighbors et al., 2003; Minsky et al., 2003). Despite
these findings, Schwartz and Blankenship (2014) state, “It should
also be noted that although clear evidence supports a longstanding
trend in differential diagnoses according to consumer race, this
trend does not imply that one race (e.g., African Americans)
actually demonstrate more severe symptoms or higher prevalence
rates of psychosis compared with other races (e.g., Euro-
Americans). Because clinicians are the diagnosticians and
misinterpretation, bias or other factors may play a role in this trend
caution should be used when making inferences about actual rates
of psychosis among ethnic minority persons.” Additionally, white
middle-class help seekers were offered appointments with
psychotherapists almost three times as often as their black
working-class counterparts. Women were offered an appointment
time in their preferred time range more than men were, though
average appointment offer rates were similar between genders
(Kugelmass, 2016). These findings collectively show that though we
are becoming more culturally sensitive, we have a lot more work to
do.

1.4.7.5. Prescription rights for psychologists. To reduce

inappropriate prescribing as described in 1.4.7.2, it has been
proposed to allow appropriately trained psychologists the right to
prescribe. Psychologists are more likely to utilize both therapy and
medication, and so can make the best choice for their patient. The
right has already been granted in New Mexico, Louisiana, Guam,
the military, the Indian Health Services, and the U.S. Public Health
Services. Measures in other states “have been opposed by the
American Medical Association and American Psychiatric
Association over concerns that inadequate training of psychologists
could jeopardize patient safety. Supporters of prescriptive authority
for psychologists are quick to point out that there is no evidence to
support these concerns” (Smith, 2012).

1.4.7.6. Prevention science. As a society, we used to wait for

a mental or physical health issue to emerge, then scramble to treat
it. More recently, medicine and science has taken
a prevention stance, identifying the factors that cause specific
mental health issues and implementing interventions to stop them
from happening, or at least minimize their deleterious effects. Our
focus has shifted from individuals to the population. Mental health
promotion programs have been instituted with success in schools
(Shoshani & Steinmetz, 2014; Weare & Nind, 2011; Berkowitz &
Beer, 2007), in the workplace (Czabała, Charzyńska, & Mroziak,
B., 2011), with undergraduate and graduate students (Conley et al.,
2017; Bettis et al., 2016), in relation to bullying (Bradshaw, 2015),
and with the elderly (Forsman et al., 2011). Many researchers
believe it is the ideal time to move from knowledge to action and to
expand public mental health initiatives (Wahlbeck, 2015). The
growth of positive psychology in the late 1990s has further
propelled this movement forward. For more on positive psychology,
please see Section 1.1.1.
 Key Takeaways
You should have learned the following in this section:

 Some of the earliest views of mental illness saw it as the work of

evil spirts, demons, gods, or witches who took control of the
person, and in the Middle Ages it was seen as possession by the
Devil and methods such as exorcism, flogging, prayer, the
touching of relics, chanting, visiting holy sites, and holy water
were used to rid the person of demonic influence.
 During the Renaissance, humanism was on the rise which
emphasized human welfare and the uniqueness of the individual
and led to an increase in the number of asylums as places of
refuge for the mentally ill.
 The 18th to 19th centuries saw the rise of the moral treatment
movement followed by the mental hygiene movement.
 The psychological or psychogenic perspective states that
emotional or psychological factors are the cause of mental
disorders and represented a challenge to the biological
perspective which said that mental disorders were akin to
physical disorders and had natural causes.
 Psychiatric or psychotropic drugs used to treat mental illness
became popular beginning in the 1950s and led to
deinstitutionalization or a shift from inpatient to outpatient care.

Section 1.4 Review Questions

1. How has mental illness been viewed across time?

2. Contrast the moral treatment and mental hygiene movements.
3. Contrast the biological or somatogenic perspective with that
of the psychological or psychogenic perspective.
4. Discuss contemporary trends in relation to the use of drugs to
treat mental illness, deinstitutionalization, managed health
care, multicultural psychology, prescription rights for
psychologists, and prevention science.
 RESEARCH METHODS IN PSYCHOPATHOLOGY

Section Learning Objectives

 Define the scientific method.

 Outline and describe the steps of the scientific method, defining
all key terms.
 Identify and clarify the importance of the three cardinal features
of science.
 List the five main research methods used in psychology.
 Describe observational research, listing its advantages and
disadvantages.
 Describe case study research, listing its advantages and
disadvantages.
 Describe survey research, listing its advantages and
disadvantages.
 Describe correlational research, listing its advantages and
disadvantages.
 Describe experimental research, listing its advantages and
disadvantages.
 State the utility and need for multimethod research.

1.5.1. The Scientific Method

Psychology is the “scientific study of behavior and mental

processes.” We will spend quite a lot of time on the behavior and
mental processes part throughout this book and in relation to
mental disorders. Still, before we proceed, it is prudent to further
elaborate on what makes psychology scientific. It is safe to say that
most people outside of our discipline or a sister science would be
surprised to learn that psychology utilizes the scientific method at
all. That may be even truer of clinical psychology, especially in light
of the plethora of self-help books found at any bookstore. But yes,
the treatment methods used by mental health professionals are
based on empirical research and the scientific method.
As a starting point, we should expand on what the scientific method
is.

The scientific method is a systematic method for gathering

knowledge about the world around us.

The keyword here is systematic, meaning there is a set way to use

it. What is that way? Well, depending on what source you look at, it
can include a varying number of steps. I like to use the following:

Table 1.1: The Steps of the Scientific Method

Ste
Name Description
p

To study the world around us, you have to wonder

about it. This inquisitive nature is the hallmark
Ask questions and of critical thinking —our ability to assess claims
0 be willing to made by others and make objective judgments that
wonder. are independent of emotion and anecdote and based
on hard evidence —and a requirement to be a
scientist.

Through our wonderment about the world around us

and why events occur as they do, we begin to ask
questions that require further investigation to arrive
Generate a
at an answer. This investigation usually starts with
research question
a literature review, or when we conduct a literature
1 or identify a
search through our university library or a search
problem to
engine such as Google Scholar to see what questions
investigate.
have been investigated already and what answers
have been found, so that we can identify gaps or
holes in this body of work.

2 Attempt to We now attempt to formulate an explanation of why

explain the the event occurs as it does. This systematic
phenomena we explanation of a phenomenon is a theory and our
wish to study. specific, testable prediction is the hypothesis. We
will know if our theory is correct because we have
formulated a hypothesis that we can now test.
 It goes without saying that if we cannot test our
hypothesis, then we cannot show whether our
prediction is correct or not. Our plan of action of how
Test the
3 we will go about testing the hypothesis is called
hypothesis.
our research design. In the planning stage, we will
select the appropriate research method to answer our
question/test our hypothesis.

With our research study done, we now examine the

data to see if the pattern we predicted exists. We
need to see if a cause and effect statement can be
made, assuming our method allows for this inference.
More on this in Section 2.3. For now, it is essential to
know that statistics have two forms. First, there
are descriptive statistics which provide a means of
summarizing or describing data and presenting the
Interpret the data in a usable form. You likely have heard of mean
4
results. or average, median, and mode. Along with standard
deviation and variance, these are ways to describe
our data. Second, there are inferential
statistics that allow for the analysis of two or more
sets of numerical data to determine the statistical
significance of the results. Significance is an
indication of how confident we are that our results
are due to our manipulation or design and not
chance.

We need to interpret our results accurately and not

overstate our findings. To do this, we need to be
aware of our biases and avoid emotional reasoning so
Draw conclusions that they do not cloud our judgment. How so? In our
5
carefully. effort to stop a child from engaging in self-injurious
behavior that could cause substantial harm or even
death, we might overstate the success of our
treatment method.

6 Communicate our Once we have decided on whether our hypothesis was

findings to the correct or not, we need to share this information with
broader scientific others so that they might comment critically on our
community. methodology, statistical analyses, and conclusions.
Sharing also allows for replication or repeating the
study to confirm its results. Communication occurs
via scientific journals, conferences, or newsletters
released by many of the organizations mentioned in
Module 1.6.
Science has at its root three cardinal features that we will see play
out time and time again throughout this book. They are:

1. Observation – To know about the world around us, we have to

be able to see it firsthand. When a mental disorder afflicts an
individual, we can see it through their overt behavior. An
individual with depression may withdraw from activities
he/she enjoys, those with social anxiety disorder will avoid
social situations, people with schizophrenia may express
concern over being watched by the government, and
individuals with dependent personality disorder may leave
major decisions to trusted companions. In these examples and
numerous others, the behaviors that lead us to a diagnosis of
a specific disorder can easily be observed by the clinician, the
patient, and/or family and friends.
2. Experimentation – To be able to make causal or cause and
effect statements, we must isolate variables. We must
manipulate one variable and see the effect of doing so on
another variable. Let’s say we want to know if a new
treatment for bipolar disorder is as effective as existing
treatments, or more importantly, better. We could design a
study with three groups of bipolar patients. One group would
receive no treatment and serve as a control group. A second
group would receive an existing and proven treatment and
would also be considered a control group. Finally, the third
group would receive the new treatment and be the
experimental group. What we are manipulating is what
treatment the groups get – no treatment, the older treatment,
and the newer treatment. The first two groups serve as
controls since we already know what to expect from their
results. There should be no change in bipolar disorder
symptoms in the no-treatment group, a general reduction in
symptoms for the older treatment group, and the same or
better performance for the newer treatment group. As long as
patients in the newer treatment group do not perform worse
than their older treatment counterparts, we can say the new
drug is a success. You might wonder why we would get
 excited about the performance of the new drug being the
same as the old drug. Does it really offer any added benefit?
In terms of a reduction of symptoms, maybe not, but it could
cost less money than the older drug and that would be of
value to patients.
3. Measurement – How do we know that the new drug has
worked? Simply, we can measure the person’s bipolar
disorder symptoms before any treatment was implemented,
and then again once the treatment has run its course. This
pre-post test design is typical in drug studies.

1.5.2. Research Methods

Step 3 called on the scientist to test his or her hypothesis.

Psychology as a discipline uses five main research designs. They
are:

1.5.2.1. Naturalistic and laboratory observation. In terms

of naturalistic observation, the scientist studies human or animal
behavior in its natural environment, which could include the home,
school, or a forest. The researcher counts, measures, and rates
behavior in a systematic way and, at times, uses multiple judges to
ensure accuracy in how the behavior is being measured. The
advantage of this method is that you see behavior as it happens,
and the experimenter does not taint the data. The disadvantage is
that it could take a long time for the behavior to occur, and if the
researcher is detected, then this may influence the behavior of
those being observed.

Laboratory observation involves observing people or animals in a

laboratory setting. The researcher might want to know more about
parent-child interactions, and so, brings a mother and her child into
the lab to engage in preplanned tasks such as playing with toys,
eating a meal, or the mother leaving the room for a short time. The
advantage of this method over the naturalistic method is that the
experimenter can use sophisticated equipment to record the
session and examine it later. The problem is that since the subjects
know the experimenter is watching them, their behavior could
become artificial. Clinical observation is a commonly employed
research method to study psychopathology; we will talk about it
more throughout this book.

1.5.2.2. Case studies. Psychology can also utilize a detailed

description of one person or a small group based on careful
observation. This was the approach the founder of psychoanalysis,
Sigmund Freud, took to develop his theories. The advantage of this
method is that you arrive at a detailed description of the
investigated behavior, but the disadvantage is that the findings may
be unrepresentative of the larger population, and thus,
lacking generalizability. Again, bear in mind that you are studying
one person or a tiny group. Can you possibly make conclusions
about all people from just one person, or even five or ten? The
other issue is that the case study is subject to researcher bias in
terms of what is included in the final narrative and what is left out.
Despite these limitations, case studies can lead us to novel ideas
about the cause of abnormal behavior and help us to study unusual
conditions that occur too infrequently to analyze with large sample
sizes and in a systematic way.

1.5.2.3. Surveys/Self-Report data. This is a questionnaire

consisting of at least one scale with some questions used to assess
a psychological construct of interest such as parenting style,
depression, locus of control, or sensation-seeking behavior. It may
be administered by paper and pencil or computer. Surveys allow for
the collection of large amounts of data quickly, but the actual
survey could be tedious for the participant and social desirability,
when a participant answers questions dishonestly so that they are
seen in a more favorable light, could be an issue. For instance, if
you are asking high school students about their sexual activity, they
may not give genuine answers for fear that their parents will find
out. You could alternatively gather this information via an interview
in a structured or unstructured fashion.

1.5.2.4. Correlational research. This research method

examines the relationship between two variables or two groups of
variables. A numerical measure of the strength of this relationship
is derived, called the correlation coefficient. It can range from -
1.00, a perfect inverse relationship in which one variable goes up
as the other goes down, to 0 indicating no relationship at all, to
+1.00 or a perfect relationship in which as one variable goes up or
down so does the other. In terms of a negative correlation, we
might say that as a parent becomes more rigid, controlling, and
cold, the attachment of the child to parent goes down. In contrast,
as a parent becomes warmer, more loving, and provides structure,
the child becomes more attached. The advantage of correlational
research is that you can correlate anything. The disadvantage is
that you can correlate anything, including variables that do not
have any relationship with one another. Yes, this is both an
advantage and a disadvantage. For instance, we might correlate
instances of making peanut butter and jelly sandwiches with
someone we are attracted to sitting near us at lunch. Are the two
related? Not likely, unless you make a really good PB&J, but then
the person is probably only interested in you for food and not
companionship. The main issue here is that correlation does
not allow you to make a causal statement.

A special form of correlational research is the epidemiological

study in which the prevalence and incidence of a disorder in a
specific population are measured (See Section 1.2 for definitions).

1.5.2.5. Experiments. This is a controlled test of a hypothesis

in which a researcher manipulates one variable and measures its
effect on another variable. The manipulated variable is called
the independent variable (IV), and the one that is measured is
called the dependent variable (DV). In the example under
Experimentation in Section 1.5.1, the treatment for bipolar disorder
was the IV, while the actual intensity or number of symptoms serve
as the DV. A common feature of experiments is a control
group that does not receive the treatment or is not manipulated and
an experimental group that does receive the treatment or
manipulation. If the experiment includes random assignment,
participants have an equal chance of being placed in the control or
experimental group. The control group allows the researcher (or
teacher) to make a comparison to the experimental group and make
a causal statement possible, and stronger. In our experiment, the
new treatment should show a marked reduction in the intensity of
bipolar symptoms compared to the group receiving no treatment,
and perform either at the same level as, or better than, the older
treatment. This would be the initial hypothesis made before
starting the experiment.

In a drug study, to ensure the participants’ expectations do not

affect the final results by giving the researcher what he/she is
looking for (in our example, symptoms improve whether the
participant is receiving treatment or not), we might use what is
called a placebo, or a sugar pill made to look exactly like the pill
given to the experimental group. This way, participants all are
given something, but cannot figure out what exactly it is. You might
say this keeps them honest and allows the results to speak for
themselves.

Finally, the study of mental illness does not always afford us a large
sample of participants to study, so we have to focus on one
individual using a single-subject experimental design. This differs
from a case study in the sheer number of strategies available to
reduce potential confounding variables, or variables not originally
part of the research design but contribute to the results in a
meaningful way. One type of single-subject experimental design is
the reversal or ABAB design. Kuttler, Myles, and Carson (1998)
used social stories to reduce tantrum behavior in two social
environments in a 12-year old student diagnosed with autism,
Fragile-X syndrome, and intermittent explosive disorder. Using an
ABAB design, they found that precursors to tantrum behavior
decreased when the social stories were available (B) and increased
when the intervention was withdrawn (A). A more recent study
(Balakrishnan & Alias, 2017) also established the utility of social
stories as a social learning tool for children with autism spectrum
disorder (ASD) using an ABAB design. During the baseline phase
(A), the four student participants were observed, and data recorded
on an observation form. During the treatment phase (B), they
listened to the social story and data was recorded in the same
manner. Upon completion of the first B, the students returned to A,
which was followed one more time by B and the reading of the
social story. Once the second treatment phase ended, the
participation was monitored again to obtain the outcome. All
students showed improvement during the treatment phases in
terms of the number of positive peer interactions, but the number
of interactions reduced in the absence of social stories. From this,
the researchers concluded that the social story led to the increase
in positive peer interactions of children with ASD.

1.5.2.6. Multi-method research. As you have seen above, no

single method alone is perfect. All have strengths and limitations.
As such, for the psychologist to provide the most precise picture of
what is affecting behavior or mental processes, several of these
approaches are typically employed at different stages of the
research study. This is called multi-method research.

Key Takeaways
You should have learned the following in this section:

 The scientific method is a systematic method for gathering

knowledge about the world around us.
 A systematic explanation of a phenomenon is a theory and our
specific, testable prediction is the hypothesis.
 Replication is when we repeat the study to confirm its results.
 Psychology’s five main research designs are observation, case
studies, surveys, correlation, and experimentation.
 No single research method alone is perfect – all have strengths
and limitations.

Section 1.5 Review Questions

1. What is the scientific method and what steps make it up?

2. Differentiate theory and hypothesis.
3. What are the three cardinal features of science and how do
they relate to the study of mental disorders?
4. What are the five main research designs used by
psychologists? Define each and then state its strengths and
limitations.
5. What is the advantage of multi-method research?