  Chapter 

The study of abnormal psychology is the study of people who suffer from mental, emotional and often physical pain; which is often called psychopathology. Sometimes these experiences are very different from what an average person would experience; but more often it is the case that people with psychopathological problems experience things that everyone would experience from time to time, but in a much more extreme way.

What is abnormality?

Some behaviors that seem abnormal from our perspective are however considered normal in other cultures or situations. When we are determining whether something is normal, we must therefore look at the context or the circumstances in which the behavior occurs. In addition to the context, there are a number of criteria that must be taken into account when determining whether certain behavior is abnormal.

How does abnormality differ among cultures?

Cultural relativism is a theory that states that there are no universal standards or rules for judging behavior as abnormal. Instead, behavior can only be labeled as abnormal according to the prevailing cultural norms. So there are different definitions of abnormality in different cultures.

Opponents of cultural relativism think it can be dangerous if cultural norms dictate what is normal and abnormal. For example, some societies in history have labeled certain individuals and groups as abnormal in order to justify to exert control on these groups. Think for example of what Hitler did to the Jews. Another example is when you consider the time of slavery: slaves who tried to escape, for example, would be diagnosed with drapetomania; a disease that presumably caused them to want freedom.

Gender also influences whether something is labeled as abnormal. For example, men who show sadness or anxiety, or who choose to stay at home for the children while their wives are at work, are often seen as abnormal. Women who are aggressive or who do not want children, for example, are often subject to the same prejudice. On the other hand, aggression in men and chronic anxiety in women are seen as more 'normal', as this is to be expected on the basis of gender.

In any case, it is clear that culture and gender have a number of influences on the expression of abnormal behavior and the way in which these behaviors are treated. Furthermore, culture and gender can influence the type of treatment that is found acceptable when abnormal behavior occurs.

When is behavior considered to be unusual?

A second standard that is used to judge behaviors as abnormal is the unusualness of the behavior. Behavior that is  unusual, is considered abnormal, while typical behaviors are considered normal. This is in a certain sense linked to the cultural relativistic criterion, because the unusual nature of behavior is partly dependent on cultural norms.

This criterion also comes with certain problems. For example, how unusual must a behavior be to be called abnormal? Is behavior considered abnormal if less than 10% of the population exhibits it, or less than 1%? In addition, many rare behaviors can have a positive influence on the individual or society, making it strange to call such behaviors abnormal. People who display such rare but positive behavior are often called eccentric.

When is behavior seen as discomforting (distressing)?

The distress criterion states that behavior can be seen as abnormal when a person feels distress (discomfort) as a result of the behavior. According to this criterion, behavior is therefore not considered abnormal when it only violates cohabitation norms, but does not cause discomfort to the individual. Opponents of this theory state that people are not always aware of the problems that their behavior causes to themselves and others. In addition, it may be that certain behavior causes a lot of discomfort to others, even though it does not harm the individual itself. In such a case, we should actually call the behavior abnormal, even though it does not cause any discomfort to the individual.

How does behavior relate to the psyche?

Some people feel that we should not label behavior as abnormal unless it is part of a mental illness. This implies that a disease process, just like with high blood pressure or diabetes, is the cause of the behavior. However, so far, no biological test has been designed that can diagnose one of the types of abnormality discussed in this book. Many theorists believe that this is because mental health problems are not due to some abnormal genes or disease processes and that we can therefore never develop a simple or definitive test to determine whether someone has a mental disorder. A diagnosis for such a disorder is simply a label for a set of symptoms, so this diagnosis does not refer to an identifiable physical process found in all people who have these symptoms.

What are the four dimensions of abnormality?

Modern assessments of abnormality are not based on one of the previous criteria, but are influenced by a combination of four dimensions, often called the four D's: Dysfunction, Distress, Deviance and Dangerousness .

  • Behavior and feelings are dysfunctional if they impair someone's ability to function in daily life. The more dysfunctional the behavior, the greater the chance that it is considered abnormal.

  • Behavior and feelings that cause distress in the individual and the people around him / her are also often considered abnormal.

  • Strongly deviant behaviors, such as chronic lying and stealing, lead to assessments of abnormality.

  • Behavior that is dangerous for the individual; such as self-harm, or for others; such as severe aggression, is also seen as abnormal.

Together, these four D's form the professional definition on the basis of which behaviors are assessed as abnormal or maladaptive. Although these criteria provide much clarity, questions still remain. How much emotional pain or damage does a person have to experience? To what extent should the behavior hinder one's performance? We assume that each of the four D's is on a continuum; so, there is no clear dividing line between what is normal and what is abnormal.

What are the historical perspectives on abnormality?

There are three types of theories that attempt to describe the causes of abnormal behavior. The biological theories perceive abnormal behavior in the same way as physical illnesses caused by problems in physical systems. The supernatural theories perceive abnormal behavior occurs as a result of a divine intervention, curses, demonic possession or sin. The psychosocial theories believe that abnormal behavior occurs as a result of a trauma; such as the death of a loved one, or chronic stress.

Ancient theories

Our understanding of the beliefs about abnormal behavior of prehistoric people is based on deductions from archaeological findings. From the moment that written language emerged, people have been written about abnormal behavior.

Expelling evil spirits

Historians speculate that even prehistoric man already had a concept of insanity, probably rooted in supernatural beliefs. Someone who acted strangely was said to be possessed by evil spirits. The treatment for this was exorcism; expelling the evil spirit from the body. This was done by making the body unsuitable for the mind to live in, often through extreme measures such as starving or beating the person. Sometimes, possessed people were even killed. Other times, holes would be drilled into their skull, through which the evil spirits could escape.

Ancient China: the balance of Yin and Yang

The ancient Chinese medicine theories were based on the concept of yin and yang. The human body would contain a positive force (yang) and a negative force (yin) that confronted and complemented each other. When the two forces were in perfect balance, the individual would be healthy. If not, illness (including insanity) could occur.

Another theory was that human emotions were controlled by the internal organs. When the breath of life flowed through one of these organs, the individual experienced a certain emotion. The heart was related to experiencing pleasure, the lungs to sadness and the liver to anger. This theory encouraged people to live in an orderly and harmonious way to promote the good movement of the breath of life. Although these explanations are primarily biological, more religious interpretations of abnormal behavior also emerged when Buddhism emerged.

Ancient Egypt, Greece and Rome: Biological theories dominate

Ancient scriptures from Egypt have been found that contain a list of disorders and the treatment that would be used for them. Disorders in women were often attributed to a 'wandering womb'. It was assumed that the uterus could loosen and move through the body, disrupting the other organs. The later Greeks followed the same theory and called it hysteria (from hystera, which means uterus). Today, the term hysteria refers to physiological symptoms that are most probably the result of psychological processes.

Most Greeks and Romans perceived craziness as a disorder of the gods. The sick retreated to temples of the god Aesculapius, where priests would perform healing ceremonies. Greek doctors, however, usually rejected supernatural explanations of abnormal behavior. Hippocrates, for example, stated that abnormal behavior was just like other body diseases. According to him, the body consisted of four basic fluids: blood, mucus, yellow bile and black bile. All diseases, including abnormal behavior, were caused by a poor balance of these four fluids. Hippocrates classified abnormal behavior into four categories: epilepsy, mania, melancholy and brain fever. Treatments were aimed at bringing these four liquids back into balance.

At this time the state took no responsibility for the insane, there were no institutions or institutions to care for them. Basic rights would be withheld from these people, such as the right to marry or the right to decide on their own property.

Medieval perspectives

Although the Middle Ages are often seen as a time when people were obsessed with the supernatural, this was not the case until the late Middle Ages. Before that, many people did believe in the supernatural, but there is also strong evidence that doctors and governments related abnormal behavior to physical causes or trauma and not to witchcraft or demons.

Witchcraft

Some historians argue that people accused of witchcraft were probably mentally ill. They probably suffered from delusions (false beliefs) or hallucinations; signs of some psychological disorder. However, it may also be that they made these confessions because of torturing or in exchange for a postponement of their execution. The theory that 'witches' were actually mentally ill was contradicted by the church at that time.

Psychic epidemics

A psychic epidemic is a phenomenon in which a large number of people exhibit unusual behavior that appears to have a psychological cause. In the Middle Ages, for example, there were dance frenzies in during which people would dance wildly around the house, on the streets, and in the church, while calling out the names of demons, without consideration of the fact that other people were looking at them. These people were often labeled as being possessed by the devil.

Today, these psychic epidemics still happen. In 1991, a great panic at a school in Rhode Island occurred, because many students and teachers thought they were breathing in toxic gases. They were actually starting to show physical symptoms. As a result, great chaos occurred: everyone was evacuated and many people were brought to the emergency room. However, no toxic gasses were found and the final conclusion was that it was an outbreak of mass hysteria caused by the public fear of chemical warfare during the Persian Gulf War.

The distribution of institutions

Around the eleventh or twelfth century, the first facilities in hospitals were created for people who exhibited abnormal behaviors. In these hospitals, the mentally ill were often held against their will and found themselves in very severe, inhumane conditions. The law stated that family members and friends of a mentally ill person were obliged to keep this person in a house, to tie them up or to chain them, to beat him or to take any other action to keep him under control so that he would not hurt anybody or himself. It was not until 1774 that a law was introduced in England that aimed to improve the terrible conditions in which people lived in these institutions. However, a medical theory that was considered to be true at that time stated that the mentally ill could be treated by taking huge amounts of blood from their bodies in order to restore the balance between body and mind.

Moral treatment in the eighteenth and nineteenth century

Fortunately, in the eighteenth and nineteenth century, a much more humane treatment method was developed for people with mental problems. The theory held that people developed problems due to stress of the rapidly changing social situation in that period. The treatment consisted of relaxation in a serene and physically attractive environment. The patients were free to walk around in the asylum and were given clean and sunny rooms and good food. The approach was exceptionally successful, and many people who had been locked up for years got their behavior under control again and were able to live reasonably normal again. Some of them could even leave the asylum.

Unfortunately, the moral treatment movement grew too quickly. As more people were admitted to the new asylums, the practitioners no longer had enough time to give each patient the personal attention they needed. As a result, the earlier major successes were replaced by more modest successes and sometimes even by failures. By the time the twentieth century dawned, many of the old asylums were back: facilities for the mentally ill. Really effective treatments did not arise until well into the twentieth century.

Which perspectives arose at the beginning of the twentieth century?

Despite the poor treatment of the mentally ill at the time, there was considerable progress in scientific research towards these disorders in the early twentieth century. This research laid the foundation for the biological, psychological and social theories of abnormality that we still use today.

The beginning of modern biological perspectives

In 1845, Wilhelm Griesinger published 'The Pathology and Therapy of Psychic Disorders', a paper in which he stated that all psychological disorders could be explained on the basis of brain pathology. In 1883, one of Griesinger's followers, Emil Kraepelin, published a book in which he developed a scheme for classifying symptoms in discrete disorders. This has been the basis for the classification systems that we still use today.

An important discovery was that syphilis appeared to be the cause of some form of insanity. This discovery gave a lot of weight to the idea that biological factors could be the cause of abnormal behavior.

The psychoanalytic perspective

Franz Anton Mesmer developed mesmerism, a method based on animal magnetism. He believed that people had a magnetic fluid in their body that must be well distributed in order to stay healthy. He treated the hysterical disorders by means of a ritual in which the patients sat in the darkness around a container with various chemicals. Then he came in, in a special robe, and while music was playing he touched every patient, with the aim of redistributing their magnetic fluids by his strong magnetic power and presence. Although Mesmer was eventually sentenced as a charlatan, his results continued to lead to discussion. The effects of the treatment are now attributed to the state of trance in which the patients ended up. This was later called hypnosis .

The effect of hypnosis was confirmed by Bernheim and Liebault, led by Charcot, who showed that they could induce symptoms of hysteria by suggesting these symptoms when the patients were under hypnosis. These experiments have contributed a lot to the progress of psychological perspectives on abnormality.

One of Charcot's students was Sigmund Freud. In his work, he became convinced that much of people's mental acitivity takes place outside of consciousness. He collaborated with Breuer on research towards hypnosis and the value of catharsis (a major release of emotions under hypnosis). They found that discussing the problems of the patient is often better under hypnosis because the patient would engage in less censoring. Their research became the basis for psychoanalysis, the study of the subconscious mind.

The roots of behaviorism

While the psychoanalytic theory emerged, the roots of behaviorism were planted in Europe and later on also in America. Ivan Pavlov developed methods and theories for understanding behavior in terms of stimuli and responses, rather than in terms of internal functioning of the subconscious mind. His research into the drooling of dogs when they encountered other stimuli than food is still world famous. From these findings he formulated the theory of classical conditioning . On the basis of this theory, the American John Watson investigated important human behaviors (such as phobias) and explained them entirely based on the theory of conditioning of an individual.

At the same time, Thorndike and Skinner investigated how the consequences of behavior influence the chance that this behavior will be repeated. They stated that behavior that is followed by positive consequences will be repeated more often than behavior that is followed by negative consequences. This became known as operant conditioning .

Behaviorism has had a major impact on psychology and is at the basis of many effective psychological treatments that are used today.

The cognitive revolution

In the 1950s, some argued that the generalizability of behaviorism was limited because the theory did not take into account the internal thought processes that influence the relationship between stimulus and response. It was not until the 1970s that the focus shifted from psychology to studying cognitions; thought processes that influence emotion and behavior. Bandura, for example, stated that the extent to which people think they can influence certain events (self-efficacy beliefs) is crucial for their mental health.

Beck introduced rational emotive therapy. This therapy was controversial, as therapists sometimes really had to challenge their patients to change their irrational thought patterns. The treatment method eventually became very popular and Beck's cognitive therapy has become one of the most used therapies for many disorders.

What has changed in modern mental health care?

Halfway through the 20th century, there were major advances in the medical treatment of some important forms of abnormality. In particular, the discovery of phenothiazines (drugs that can counteract hallucinations and delusions) made it possible for many people who had been in institutions for years to return to normal society. In addition, new forms of psychotherapy have been developed that are very effective in treating a wide range of psychological problems.

Deinstitutionalization

The patients' rights movement arose around 1960. The perspective was that mental patients would be able to recover better when they would be re-integrated into society, with support from treatment within the community. This was called de-institutionalization. This process had a huge effect on the lives of people with serious psychological problems. Many patients experienced a great improvement in their quality of life as a result, and they suddenly had much more freedom.

This can still be seen today. Work in the community is often done by social workers, therapists and doctors. In halfway houses, patients live in a structured environment in which they can get used to life in society, a job and their family and friends. Day treatment centers ensure that people can receive treatment during the day, but can go home and sleep there at night. People with acute problems can go to psychiatric hospitals.

A problem with these developments was that community-based treatment centers could not handle the large numbers of patients who left the asylum. Many ended up in care homes or with family in the house, where they did not receive the right treatment. Another part ended up on the street.

Managed care

Managed care is a collection of methods for coordinating care, ranging from simply keeping an eye on someone to fully checking which care can be given and paid for. The aim is to provide assistance for existing medical problems and to prevent future medical problems. Often, caregivers receive a fixed amount of money per patient per month and then have to determine how they can offer the best care to each patient with that money.

The advantage of this is that finding suitable care no longer has to be done by the patient's family, but that the primary care provider can find the right care and ensure that the patient has access to it. This prevents the patient from missing out on the right treatment. Unfortunately, mental health care is not always (fully) covered by health insurance. In addition, many American states have reduced the mental health care subsidy, which means that poorer people in particular cannot receive the care they actually need.

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