The Case of Danielle’

The Case of Danielle’
THE CASE OF DANIELLE Danielle, who has just turned 26 years old, presented herself to a university-based psychology clinic with complaints of problems with her work and marriage, as well as just being generally unhappy. A structured interview and several psychological tests were administered. What emerged was a picture of a young woman who had suffered from a variety of phobias as well as varying degrees of depression and anxiety throughout most of her life. Yet, from most perspectives, she had usually functioned within the normal range on most dimensions. She had a normal childhood, and both Danielle and her parents would have characterized her as reasonably well adjusted and happy. Her grades were above average throughout grade school and high school, and although Danielle struggled academically in college, she did manage to graduate with a business degree, with a major in marketing. She started to work on her MBA but felt “just burnt out” with school. So she quit to take a lower-echelon job in the marketing department of a large firm in a major city about 300 miles from the area where she grew up and went to college. Danielle was introduced to her future husband shortly after moving to that city, and they were married after a brief but intense courtship of four months. This intensity waned almost immediately after the marriage ceremony, and they settled into a routine marked neither by contentment nor by obvious problems. They seldom fought openly, but they developed increasingly “parallel lives,” wherein interactions (including sexual ones) were pleasant but minimal. Embedded in this overall life structure were the difficulties that had moved Danielle to come to the clinic. Ever since she had been little, Danielle had been afraid of snakes and insects, especially spiders, and from her high CA S E S T U DY school years onward, she became anxious if closed in for any length of time in a small room (claustrophobia). She also reported that she occasionally experienced periods during which she would feel anxious for no reason that she could put her finger on (“free-floating anxiety”) and then, more rarely, would become depressed. Once, when she was in college, the depression became severe enough that she considered suicide. Fortunately, her roommate was sensitive to the crisis. She made sure Danielle went over to the campus counseling center, and Danielle’s upset diminished quickly enough for her to quit therapy after three sessions. More recently, Danielle had experienced the episodes of anxiety and depression more consistently, and it was clear that her husband didn’t have much interest in hearing about all this. Also, she still had the phobias. She could live with the fears of the snakes and spiders, although they substantially reduced her ability to enjoy outdoor activities. But the claustrophobia had worsened, making some of the meetings required by her job very difficult for her. Danielle’s history was not grossly abnormal in any dimension, but there were aspects that could be related to her developing problems. Although Danielle’s birth was normal, she was noted to be a “fussy” child and seemed to startle more easily than did her two younger brothers. Also, her mother was a rather anxious person and on a few occasions had taken to her bed, obviously somewhat depressed, blaming it on “female problems.” Both parents obviously loved and cared for all the children, but Danielle’s father was not one to show affection very often. He demanded good performance, in both the academic and social areas, and a lack of performance usually meant some form of direct punishment as well as emotional distance from him. Case Analysis An analysis of this case will be made from the perspective of each of the major theories, and some other more specific details that emerged in Danielle’s case will be discussed as appropriate. The discussion of each of these theoretical perspectives on etiology and treatment will not be presented in great detail. Also, the most commonly accepted theories and treatments for anxiety and depression will be discussed again in the later sections of this book that focus on those problems. THE PSYCHOANALYTIC-PSYCHODYNAMIC PERSPECTIVE Psychoanalysis is the approach originally devised by Sigmund Freud and then elaborated by his early and more orthodox followers (Larson, Graham, & Baker, 2007). As changes in theory or technique were introduced by persons who still followed the essential points of Freudian theory, these splinter schools (developed first by individuals such as Adler and Jung and later by Klein, Horney, and Sullivan and more recently by Kernberg, Gill, Bion, Ricoeur, Arieti, Silverman, Shafer, Kohut, Mahler, and others) were usually termed psychodynamic (Kring, Johnson, Davidson, & Neale, 2010; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996; Wachtel, 1997; Weston, 1998). However, virtually all of those theorists would see Danielle’s problems as developing out of an inadequate resolution of conflicts that could have developed in one of the hypothesized stages of development that each person, as represented through the “ego,” must proceed through to reach maturity (the oral, anal, phallic, latency, and genital stages). Conflicts in the Oedipal phase (a prelude to the genital stage), interpreted as the male child’s desire to sexually possess the mother and get rid of the father (the Electra phase is analogous in the female), are seen as crucial to a number of patterns. (See the discussion in Chapter 3 of Little Hans.) Underlying tension leaves the person anxious without an explanation for this feeling (Fenichel, 1945), the free-floating anxiety experienced by Danielle. Regarding depression, Karl Abraham’s early classic papers (Abraham, 1916) provided the basis for the orthodox psychoanalytic view. He theorized that depressed individuals, unable to love, project their frustrated hostility onto others and believe themselves to be hated and rejected by other people. Abraham related depression to orality and explained loss of appetite and related symptoms in terms of an unconscious desire to devour the introjected love object. Thus, introjection (rather than the projection that psychoanalysts see as central to the paranoid process) is the psychopathological process, and the depressive’s self-reproach can therefore be seen as an attempt to punish those newly incorporated components of the self. Psychoanalytic treatment involves techniques like (1) “free association” (having the person say whatever comes into mind, without censoring it—a more difficult task than it may initially appear); (2) analysis of dreams; (3) analysis of the feelings the client develops toward the therapist (transference); and (4) attempts to develop insight into the sources of the anxiety and depression (Johnson, 2011). All of this is directed toward gaining a rational, objective attitude toward the self, with symptom relief or happiness as secondary and possibly not realizable goals. Orthodox analytic treatment, which is practiced by very few therapists today, would have the analyst sitting behind the client, who is on a couch, seldom either confronting or responding to the client at any length. To the degree that the therapy is less orthodox, and thus more likely to be termed psychodynamic, the therapist is more likely to face the client, confront issues more directly, and in general interact more. The insights that are attained, along with the accompanying release of emotion (catharsis), theoretically act to decrease the anxiety and depression and thus allow the development of more mature and effective coping patterns. The perspective inherited from Freud has been rightly criticized for being difficult (and sometimes impossible) to empirically validate. However, in a landmark paper, Weston (1998) has described findings in various disciplines such as developmental, social, and cognitive psychology that support psychoanalytic theory in general. He has described several of Freud’s central postulates that have received substantial empirical support, including the following: (1) The preponderance of feelings, motives, and thoughts are unconscious; (2) childhood and early development play a critical role in personality and adult relationships; (3) mental processes, including emotion and affect, often operate in parallel, and can be in direct opposition to each other; (4) mental representations of the self and others influence social interactions and may generate psychological symptoms; and (5) mature personality development involves learning to regulate sexual and aggressive impulses, and from a dependent to an independent state. THE BEHAVIORAL PERSPECTIVE Early efforts by behaviorists to explain the development of anxiety and phobias were essentially efforts to translate psychoanalytic thought into the language of learning theory. However, beginning with John Watson and Mary Cover Jones (see the discussions of Little Albert and Little Peter in Chapter 3), early practitioners such as Joseph Wolpe and Arnold Lazarus and later theorists such as Clark Hull and B. F. Skinner, the explanation of the development of anxiety and phobias was in terms of conditioning principles. Thus, anxiety is a learned response that now is unpleasant but that was appropriate at the time of learning. However, the avoidance inherent in the response prevents the corrective learning of newer, more adaptive responses. From the behavioral perspective, the two major ways in which the anxiety responses and phobic patterns (and the depressive responses) are learned are modeling and direct experience learning, which are then amplified by mental and behavioral rehearsal. An examination of Danielle’s history revealed that modeling played a significant role in the development of her anxiety and phobic responses with regard to snakes and insects. As is the case with most people who have such fears, there was no actual, naive traumatic encounter with one of these creatures. Rather, Danielle’s mother, as well as her aunt who often babysat her, would shriek with horror at the sight of a spider, or even the suggestion that a snake might be in the vicinity. At some level of consciousness, Danielle assumed that if these gigantic and all-powerful adults (from the perspective of a small child) were so afraid of these beings, she ought to be, too. Her responses, copied from her model, were accepted and reinforced by those around her. Note that the differential stereotypical reaction to such responses in boys may explain why such patterns are not so usually evident in males. Also, boys are more likely to be encouraged to have actual encounters with these potential phobia sources. In any case, although modeling can often be an efficient way of learning, as it does save the time and possible pain of trial-and-error learning, sometimes, as with Danielle, modeled patterns may promote maladaptive behavior. The simple phobias, of which Danielle’s fears of snakes and spiders are good examples, often have simple and specific targets. Since some of these fears likely had an evolutionary value for the human species (e.g., avoidance of poisonous snakes), some theorists believe this is evidence that there is a greater preparedness to associate anxiety responses to these stimuli, and this contributes (along with the modeling) to the overall learning process here. On the other hand, direct experience learning was critical to the origin of Danielle’s claustrophobic pattern. When she was young, her usual punishments were spanking, being made to stand in the corner, or a withdrawal of reinforcers (staying up late, watching TV, etc.). However, if she really upset her mother, Danielle would be forced to stay in a small, dark closet until she was quiet and her mother felt calmed down. On a couple of occasions this took several hours. The anxiety and discomfort of the situation, compounded by Danielle’s fear of the dark. and sense of uncertainty about what was going to happen to her, produced a panic response. Panic includes a sense of loss of control, the most anxiety-generating experience of all. Direct experience learning is a potent factor in the development of many phobias. Regarding depression, the general theories of the early behaviorists were first refined into an overall theory by Ferster in 1965; the general concept is that depression can result from either of two processes (Ferster & Culbertson, 1982), which do not necessarily exclude parallel biological issues. In the first, an environmental change (e.g., loss of job, death in the family) sharply lessens the level of incoming reinforcement, and no new methods of obtaining reinforcement have developed (Williams, 2009). Danielle’s college depression immediately followed the breakup with her boyfriend. They had always spent a great deal of time together, so this abrupt loss of reinforcement precipitated the depression in that instance. Behaviorists also note that depression can occur from a pattern of avoidance behavior. This is when a person’s attempts to avoid aversive situations have become so strong that they preclude behaviors that bring reinforcement; that is, these behaviors are used to avoid anxiety. From a treatment perspective, behavior therapists have pioneered some of the most successful treatments for phobias and anxiety, even using such approaches as group therapy (Saiger, Rubenfeld, & Dluhy, 2008). The most commonly used technique, however, has been exposure therapy, especially in the specific form of systematic desensitization therapy (SDT; Head & Gross, 2009). Typically, the therapist first develops a relaxation response, sometimes through drugs but more commonly and controllably through some form of relaxation training. A hierarchy of anxiety-producing stimuli is then produced and presented, and may be enhanced by virtual reality technique—for Danielle, this involved closed spaces, snakes, and spiders (Wolpe, 1973). In each case, Danielle would be asked to describe the most anxiety-arousing situation she could think of in each category. That scene (e.g., “snakes crawling over my body”) would receive a score of 100. A scene that brings on little or no anxiety (e.g., “hearing my professor mention snakes”) would receive a 0. While remaining relaxed, the client is gradually moved through each hierarchy in imagination (in vitro), and then some live tasks (in vivo) may be introduced (e.g., asking Danielle to handle a snake or sit for a period of time in a small closed room). An alternative behavioral technique for phobias or anxiety is flooding, or implosion therapy, which attempts to maximize anxiety rather than minimize it, as is done in SDT. Usually carried out in a few longer-than-usual sessions, the technique asks the person to imagine more and more anxiety-producing scenes (e.g., snakes crawling in and out of body orifices). Virtual reality procedures are being used to enhance this method. The theory is that the anxiety will eventually peak and then extinguish, with the consequence that the phobia gradually lessens. As for Danielle’s depression, modern behavior therapists would emphasize getting her in touch with more interpersonal contacts and sources of positive reinforcement (Horowitz, 2004). For her, this could mean returning to active sports and learning social skills so that she could have more rewarding interpersonal interactions. Since depressives tend to be overwhelmed by tasks, breaking a goal down into subtasks and short-term goals (the “graded-task” approach) is useful. Also, behavior therapists would help Danielle survey her present range of activities. Since depression tends simultaneously to lessen activity in general and increase the percentage of nonpleasurable activities, contracting, modeling, and stimulus-control techniques could help to reverse this process. Morita therapy, developed by a Japanese professor named Morita, is an approach that combines both behavioral and cognitive elements, as is evident in these two quotes from David Reynolds (1984), one of the foremost interpreters of Eastern psychotherapy techniques to Western cultures: Behavior wags the tail of feelings. Behavior can be used sensibly to produce an indirect influence on feelings. Sitting in your bathrobe doesn’t often stimulate the desire to play tennis. Putting on tennis shoes and going to the courts, racket in hand, might. (p. 100) Awareness, awareness, awareness. That is where we live. That is all we know. That is life for each of us. (p. 4) A Morita therapist would (1) attempt to bring a regular routine into Danielle’s life; (2) deemphasize talking about the historical antecedents to her problems; (3) emphasize the growth possibilities in all experiences, including pain and failure; (4) try to get her to begin to function “as if” she was psychologically healthy and competent; and (5) emphasize bringing both attention and awareness into all facets of her day-to-day functioning. THE COGNITIVE-BEHAVIOR PERSPECTIVE Since cognition refers to a person’s thinking pattern, any theorists who talk about disordered thinking patterns as critical to the development of psychopathology can be considered to be cognitive theorists, and now are more commonly referred to as cognitive behavior therapists In that general sense, psychoanalytic and psychodynamic theorists also have a cognitive perspective (Wachtel, 1997). However, a more focused emphasis on cognition as central to the development of anxiety is found in the pioneering works of people such as Albert Ellis and George Kelly and such later therapists as Donald Meichenbaum and Aaron Beck. Kelly’s theory of “personal constructs” notes that people develop certain beliefs, of which they may be consciously unaware, that cause them anxiety. Ellis (2002) similarly has commented on how people adopt such belief-rules as “I must reach a high point of success in whatever I undertake” or “If I ever show aggression or upset to those people close to me, they won’t love me.” (Not surprisingly, no one can ever fully live up to such standards, and anxiety and depression quite naturally ensue.) Aaron Beck, the winner of the 2004 Grawemeyer Award for outstanding contributions to psychology, focused on the development of depression from cognitive beliefs, and the theory evolved from an initial study (Beck & Valin, 1953) that indicated that themes of self-punishment occurred with great frequency in the delusions of psychotically depressed clients. Beck would not disagree with the psychodynamic theorists that an early traumatizing event could predispose an individual to depression. However, the major focus is on distorted thought patterns. Beck and others note that depressives have developed thought processes that simultaneously (1) minimize any positive achievements; (2) magnify problems with “catastrophic expectations” (i.e., “making mountains out of molehills”); (3) tend to view issues in extremes, (i.e., to polarize their ideas, seeing only in black or white, no grays); and (4) overgeneralize to a conclusion based on little data, (e.g., one or two events). These tendencies are often compounded by a sense of “learned helplessness,” a view that one cannot do anything to really control or change one’s world. Low self-esteem, lessened activity, negative mood, and self-punitiveness follow (Alford & Beck, 1997; Barrett & Meyer, 1992; Beck & Valin, 1953; Reinecke, Washburn, & Becker-Weidman, 2008). As for intervention, Albert Ellis, who was functioning as a cognitive-behavior therapist before anyone even used that term, would directly challenge his client’s irrational beliefs. For example, Danielle believed that she could never again be happy, and that if she were to leave the marriage, no one would ever find her attractive again. Ellis (2002) would directly confront these beliefs, exploring what the implications and consequences would be if indeed these irrational hypotheses were true. This would then be followed by challenges to act in accord with the more rational beliefs that the client has now labeled as more likely to happen. Beck also tries to help clients bring their beliefs and expectations into consciousness and/ or clearer focus, although he is a bit less confrontational than Ellis in this process. He then helps them explore new beliefs. Meichenbaum (1986) goes a step further by first helping clients eliminate negative subvocal verbalizations (e.g., “When things in my life do not go the way I want them to, it is bad or terrible”). He then helps the clients develop alternative sets of positive self-statements (e.g., “When things don’t go my way, it may be unpleasant, but it’s not the end of the world. Sometimes things do go my way; sometimes they don’t”) to use by consciously and periodically repeating to themselves. Such therapists readily agree with the clients’ protests that they will not believe what they are saying. However, if they persist, it does have an effect. Helping client engage in positive imaging of successful and competent behaviors, possibly through hypnosis, can help here as well. Increasingly popular, Dialectical Behavior Therapy (DBT), developed by Marsha M. Linehan, is an example of a formalized combination of traditional cognitive behavioral therapy with other approaches. DBT utilizes a cognitive-behavioral framework combined with Buddhist meditative practice aimed at “mindful awareness” (Linehan, 1993a). Treatment focuses on the delicate balance between validating a client’s feelings, thoughts, and behaviors at any given time while also helping clients to acknowledge that not all feelings, thoughts, and behaviors are adaptive. Although it was initially studied for use with clients diagnosed with Borderline Personality Disorder (BPD; Linehan, 1993b, 1999, 2008), research indicates that DBT is also effective in treating individuals who present with mood disorders, trauma, anxiety, and chemical dependency (Janowsky, 1999; Linehan et al., 2006). INFORMATION PROCESSING AND SYSTEMS THEORY Modern variations of the cognitive approach, pioneered by people such as Noam Chomsky, Walter Mischel, George Kelly, and James Grier Miller, are information processing, the sociocultural perspective, and systems theory, and they often overlap. They are obviously influenced by evolving concepts from computer science and from interdisciplinary studies, and they share a belief in two seemingly paradoxical concepts: (1) Emotional disorder is a universal human experience, even in many of its specific manifestations; and (2) the pattern and experience of emotional disorder can be strongly influenced by the amount and types of information that are obtained from the persons, families, and society around that individual, while the diagnosis and treatment are likewise affected by that information. Paradoxically, high use of the Internet has been associated with increased interpersonal withdrawal and depression. Consider this information processing example described by Mischel (1986): A boy drops his mother’s favorite vase. What does it mean? The event is simply that the vase has been broken. Yet ask the child’s psychoanalyst and he may point to the boy’s unconscious hostility. Ask the mother and she tells you how “mean” he is. His father says he is “spoiled.” The child’s teacher may see the event as evidence of the child’s “laziness” and chronic “clumsiness.” Grandmother calls it just an “accident.” And the child himself may construe the event as reflecting his “stupidity.” (pp. 207–208) Information theorists use the terms of computer science—for example, “hardwired for sex” (it is built in genetically) or “brain software” (information provided from the outside that is developed into what George Kelly referred to as a “personal construct,” a personal myth about life, such as, “Your family members are the only people that you can really trust”). Psychological disorders are discussed as disorders of input (e.g., faulty perception), storage (e.g., amnesia from brain trauma), retrieval (e.g., selective recall as in paranoia), manipulation of information (e.g., via defense mechanisms), and output (e.g., the “flight of ideas” in mania). There is also a focus on how individuals encode information. For example, aggressive young males as well as those who watch a large amount of violent programming on television (and these groups do overlap somewhat) are more likely to encode neutral behaviors of others as threatening. Similarly, when males receive messages from their environment (e.g., “When women say ‘no’ and they don’t appear very angry, they really mean ‘yes’ ”), they may be more likely to misinterpret signals or statements from women they are interested in, a fertile situation for date rape. Sociocultural theorists such as Thomas Szasz, who pioneered the concept of the “myth of mental illness,” and R. D. Laing take this a step further to propose that the cause of abnormal behavior is to be found in society rather than in the individual who manifests a disorder. They look to the conflict and stress engendered by social problems (e.g., poverty, discrimination, social isolation) or the messages embedded in a society’s overall structure as the explanation for psychological disorder. For example, Laing often speaks of “unjust societies” as creating psychological disorder in the oppressed. The weakness of the sociocultural perspective has always been trying to explain why certain individuals in the same conditions are affected with manifest disorder, while others are not. THE HUMANISTIC-EXISTENTIAL PERSPECTIVE From a humanistic viewpoint, anxiety and depression are a result of cultural and social structures that impede the full expression of the personality (Everly & Lating, 2004; Farber, 2010; Maslow, 1954; May, 1981; Rogers, 1961). The psychodynamicist sees these emotions as determined early in development and maintained by defense mechanisms. The behavioral therapist argues that they are a function of experience with a variety of conditions that results in patterns being learned, unlearned, and relearned throughout life. However, the humanist sees anxiety and depression as inevitable as long as societies thwart a person’s goodness and inborn drive for self-actualization. Anxiety and depression are therefore functions of the society and will continue until the right kind of social atmosphere is made available (Schneider & Leitner, 2002). Two conditions often implicated by the humanists are a repressive society and/or poverty. Poverty obviously limits the options a person can take, not only in development of the self but also in remedying disorder and deficit. Within a repressive society, fear of self-expression forces the individual to adopt constricted or disordered response patterns, with anxiety or depression as a common concomitant response. Humanists emphasize that the person receiving treatment should not be considered a “patient,” but instead is a “client,” putting more emphasis on equality in the relationship. Curiously, the word client derives from the Latin word for an underling who leans on a patron in a fawning, subservient manner—so perhaps a better word is needed. Humanists would contend that because the individual is forced to sacrifice to social demands that are inconsistent and arbitrary, the defense strategies that he or she adopts reflect the irrational nature of the society. Anxiety and depression may therefore be a prerequisite for existence in a chaotic world (May, 1981). Because of the limitations and constraints of society, pure humanists may not focus very much on the concerns of an individual client. They often feel their energy is better directed at righting the original causes. Indeed, Carl Rogers, the founder of nondirective, or client-centered, therapy, virtually ceased doing any individual therapy in favor of working with whole subgroups from the perspective of a humanistic educator and social engineer. Directly attacking conditions generated by poverty would not be relevant with Danielle, although it might be with some other cases in this book (e.g., see the case of Abby in Chapter 13 on family violence and child abuse). It is true that some aspects of Danielle’s problem might be relevant to change by humanistic social engineering, but it is unlikely there would be enough benefits to directly help her in any immediate sense. Some parts of the community psychology movement are quite consistent with the humanistic approach. The idea here is that a change in social conditions, through educational efforts or a redirection of social variables, will change the level of disorder (or more likely, act to prevent emergence of that disorder in persons vulnerable to it in the future). Existential psychotherapists such as Viktor Frankl and Medard Boss are more concerned about the individual “choices” of the client. Like cognitive therapists, they would directly confront the distorted beliefs of the client, probably placing more emphasis on the absurdity or paradoxes inherent in the particular individual’s conditions in the world (Frankl, 1975). At the same time, they might as well change the focus of the problem from the original causal conditions—be they social forces, biological disorder, early environment, or whatever—toward the choices the individual has to make in the here and now (Boss, 1963). This focus on the present is also a constant theme in Gestalt therapy, which has strong existential and cognitive components (Bongar & Beutler, 1995). Although existential theories are most closely associated with European philosophy and psychology, they are not unknown in other cultural traditions. For example, the Akan people of Ghana believe that all people are endowed with the capacity for correct thought and correct action, and emphasize that each individual is ultimately responsible for his or her own life situation, a central tenet of existentialism. A technique termed Sunsum, or NTU, is a primary principle of the Bantu people and focuses on personal responsibility. A related saying (“Mmo’denbo’ Bu Musuo Abasa So,” translated as “If you try hard, you will always break the back of misfortune”) was the central theme of the 1997 International Convention of the Association of Black Psychologists. With Danielle, an existential therapist would likely point out that preoccupation with her anxiety and depression allows her to escape responsibility for making choices in her world. The “parallel life” that has been established in her marriage could go on indefinitely, as do many “conflict-habituated” marriages. Making authentic choices can change these and similar patterns. But those choices leave the person open to the burden of responsibility for their consequences. An existential therapist would try to get the individual to stop evading any important choices and their consequences (Frankl, 1975). Existentialists are also likely to have their clients squarely face the responsibility for past choices or, as is often the case, the results of avoiding a choice (Boss, 1963). This commonly entails “guilt,” and existentialists emphasize the difference between neurotic guilt and true guilt. Neurotic guilt is the experience of anxiety and depression from situations that the person had no part in bringing about, such as restrictive early parenting practices. True guilt entails the acceptance of responsibility for conscious choices or a lack of choosing and the willingness to live with a full acceptance and awareness of the consequences that cannot be changed, with efforts now being made to right any negative effects that can be changed. Here, anxiety and depression, especially the free-floating anxiety that Danielle occasionally experienced, are seen as possible symptoms of the avoidance of authentic choices and true guilt. THE BIOLOGICAL PERSPECTIVE Anxiety and depression from the biological perspective are seen as conditioned by a person’s physiology (Andreassi, 2000; Dattillo, Davis, & Goisman, 2008; DiLalla, 2004; McCullough, 2002). Also, some physiological conditions may be genetically determined. In Danielle’s case, there are indicators that she may have had some genetic disposition to developing anxiety responses; she was a “fussy” child, was easily startled, and had an anxious mother. The fact that Danielle’s mother had apparently been depressed would lead to the suggestion that Danielle’s occasional depression had a strong genetic component. However, this, of course, would have allowed Danielle to model the behavior as well, and she would have suffered the “contagion effect,” wherein depressives increase the depressive patterns in nearby normals. Findings that (1) children who experience a clinical depression in childhood or (2) adolescents who have frequent multiple unexplained physical symptoms are more at risk for clinical depression in adulthood may fit the biological model. The major biological theories of depression are typically a variation on the theme that depression reflects an alteration in the level of brain transmitters (chemicals that facilitate nerve transmission to the brain), such as norepinephrine or serotonin. This may be moderated by proteins such as P11 that regulate how brain cells respond to serotonin and dopamine. For example, the brain releases dopamine when a reward is attained, and this dopamine release generates positive feelings. The curious part is that more dopamine is released to the degree that the reward is unexpected, which may explain the pleasure obtained in such diverse activities as gambling and fishing. However, it should be remembered that a variety of external or psychological conditions (e.g., situationally generated stress or anxiety, prolonged inactivity, prolonged low sunlight conditions, and various substances such as caffeine and the “beta-blockers” used to treat high blood pressure and heart pain) can produce physiological changes that in turn generate depression (Johnson, 2008). Evidence does show that genetic variables play a part in significant endogenous (internally generated) depression. However, all indications are that major components of Danielle’s depression were exogenous, or reactive to the situational problems in her world. The traditional biological treatment for anxiety emphasizes chemotherapy with the drugs usually referred to as the “minor tranquilizers”—for example, meprobamate (Equanil) or the benzodiazepenes such as diazepam (Valium) (Bezchlibnyk-Butler & Jeffries, 1999). However, psychological techniques, such as relaxation training, can also be effective in reducing even the physiological components of anxiety. For depression, the biological theorist has traditionally used one of two major chemotherapies, the MAO inhibitors and the tricyclics, for any significant depression. Both have significant side effects (MAO inhibitors may produce toxic cardiovascular and liver reactions as well as problematic interactions with certain foods; tricyclics may produce dizziness as well as heart and gastrointestinal disorders). Both require trial-and-error adjustments (titration) on dosages, and both take from several days up to several weeks to show an effect. Some believe that these drugs deal with differentially generated depressions (i.e., the tricyclics for norepinephrine-based depression, MAO inhibitors when it’s serotonin based). Also, tricyclics seem to work better with depressives who show some delusional characteristics, and are helpful for chronic pain patients who are depressed. Other newer drugs (e.g., the selective serotonin reuptake inhibitors [SSRIs] such as Lexapro) offer fewer side effects and different modes of action (see Table 7.1 in Chapter 7). When depression accompanies physical pain, which is not uncommon, duloxetine is a drug of choice. In any case, research does indicate that all of these drugs, when they are effective, act at least in substantial part by increasing the frequency of activity-related behaviors, and they only indirectly and unpredictably change interpersonal and cognitive components (Nathan, Musselman, Schatzberg, & Nemeroff, 1995). Because not all severe depressions react positively to chemotherapy, and because it is a delayed reaction even when they do, electroconvulsive therapy (ECT) and, less commonly, psychosurgery are sometimes used for depression. These interventions seem to be useful with severe, acute depressions, especially where there is a suicidal component, since the delay in the developing effects of the antidepressants then is even more problematical. Even in the relatively small proportion of cases where ECT and psychosurgery are effective, one needs to balance any gain with the irrevocable nature of this type of intervention and the several potentially severe side effects. A newer biological approach that offers promise is “vagus nerve stimulation.” In this treatment, a pacemaker-like device the size of a pocket watch is implanted in the body. It sends small electric shocks into the vagus nerve in the neck. This approach has improved mood in a number of severely depressed patients who have not responded well to other treatments. THE MULTICULTURAL PERSPECTIVE Some disorders show a remarkable consistency across cultures (e.g., schizophrenia); in others, the content of the pattern is affected by one’s culture (e.g., the named characters [Jesus Christ, Allah] in a delusional system; see Chapter 6). It is also true that in some instances, both the pattern and content of a disorder are set by the culture, as in the examples shown in Table 2.1. In addition, some mental health care (often not enough) is provided in virtually all cultures. For example, in Bregbo, a fishing village near Abidjan, Ivory Coast, in Africa, there is a monument to Albert Atcho, a legendary healer known as the Prophet. With his large starfish-shaped rings, Atcho, who died in 1990 at the age of 84, is said to have cured thousands of people, sons and daughters of the rich and poor alike, who streamed to his home from far and wide. Although Atcho’s powers were considered by his constituents to be a gift of God, his techniques clearly blended a warm and supportive acceptance, much like Carl Rogers’s “unconditional positive regard,” hypnotic-like suggestion techniques, and the facilitation of catharsis and commitment by way of a lengthy confessional process. Mental health practitioners have an ethical responsibility to provide effective interventions to all clients by tailoring treatment to accommodate the cultural contexts, beliefs, and values relevant to a clients’ well-being (Trimble & Fisher, 2006). With the current focus on empirically supported treatments it is essential to rigorously evaluate the effectiveness of cultural modifications to existing treatment approaches. Overall, meta-analysis studies have shown that interventions targeted to a specific cultural group have been found to be four times more effective than interventions provided to groups of clients from a diverse set of cultural backgrounds (Griner & Smith, 2006). Some suggestions for improving mental health services aimed at serving diverse cultural populations include the following: 1. Directly incorporating relevant cultural values into therapy (Rowe & Grills, 1993; Wampold, 2001) 2. If possible clients should be matched with therapists of the same race/ethnicity and who speak the same native language (Coleman et al., 1995; Lam & Sue, 2001) 3. Whenever possible mental health resources should be made available in the community where the target client population lives (Zane, Hatanaka, Park, & Akutsu, 1994) 4. Mental health practitioners should utilize resources available within the clients’ community (i.e., spiritual leaders), (Jackson-Gilfort, Liddle, Tejeda, & Dakof, 2001) THE VARIOUS MENTAL HEALTH PROFESSIONALS Just as there are various theories and techniques, there is a variety of mental health professionals. This can be confusing to laypersons and even professionals, such as judges. For example, in Jaffee v. Redmond (116 S.Ct.; 64 L.W. 4490, June 13, 1996), the Supreme Court created a new “evidentiary privilege” that supported confidentiality in federal cases for psychotherapy clients of clinical psychologists, psychiatrists, and clinical social workers. The Court did not support it for other types of social workers, or any type of counselor, citing lack of definition of the speciality and/or weak credentialing-training requirements. In any case, the following is a list of the various titles. Clinical Psychologist: Has a master’s degree and a Ph.D. or Psy.D. in psychology, with specialized training in assessment techniques (including psycho-diagnostic tests) and research skills, along with skills in intervention, is increasingly (depending on the state) allowed to prescribe psychotropic medications Counseling Psychologist: Has a Ph.D. or Psy.D. in psychology; traditionally, though not necessarily, works with adjustment problems (e.g., in student health or counseling centers) not involving severe emotional disorders Experimental Psychologist: Has a Ph.D.; provides much of the basic and applied research data that allow one to progress in the study of human behavior Clinical Social Worker: Has a master’s degree in social work, sometimes a B.A., and very occasionally a Ph.D., with a specialized interest in mental health settings Psychiatrist: Has an M.D., with a specialization in emotional disorders, just as other physicians might specialize in pediatrics or family medicine Psychoanalyst: Usually has either an M.D. or Ph.D., with a training emphasis in some form of psychoanalytic therapy Psychiatric Nurse: Has an R.N., sometimes with an M.A., with specialized training for work with psychiatric patients Pastoral Counselor: Has a ministerial degree with some additional training in counseling techniques, to help clients whose emotional difficulties center on a religious or spiritual conflict Specialty Counselor: A technician of the mental health field; often has no higher than a bachelor’s degree, and sometimes less than that, but with specific training to assist in the treatment of a specific focus problem (e.g., alcohol and drug abuse problems, or sexual problems) “That’s nice,” she said. But seeing him struggle she wanted to laugh. What a misshapen and ridiculous thing the penis was! Half of them didn’t even work properly and all of them looked pathetic and detachable, like some wrinkled sea creature-like something you’d find goggling at you and swaying in an aquarium. —Paul Theroux, Doctor Slaughter (1984, p. 140) AN OVERALL PERSPECTIVE ON TREATMENT CHANGE Early studies of psychotherapy include work by such pioneers as Carl Rogers (the first person to audiotape a therapy session for research purposes) and Tim Leary (yes, the Timothy Leary of LSD 1960s notoriety, and the godfather of Winona Ryder [see Chapter 12]) and the first meta-analytic studies of psychotherapy (Smith, Glass, & Miller, 1980). Seligman (1995) and others have reviewed these studies, including a massive study by Consumer Reports and another meta-analysis by Bickman (2005), to generally conclude the following: 1. Psychotherapy is effective; the average person who is treated is about 75 percent better off than untreated control subjects. 2. Long-term treatment is better than short-term treatment. 3. No specific treatment modality is clearly better for some disorders. 4. Medication plus psychotherapy is not consistently better than psychotherapy alone. 5. The curative effects of psychotherapy are often more long term than those of medication. 6. The effective use of psychotherapy can reduce the costs of physical disorders. 7. There is no clear evidence that psychologists, psychiatrists, and social workers differ in treatment effectiveness. 8. All three of these groups are more effective than counselors or long-term family doctoring. 9. Clients whose length of therapy or choice of therapy was limited by insurance or managed care did worse than those without such limits. 10. Approximately 5 percent of persons who seek treatment do get worse, usually not markedly so (Nolan, Strassle, Roback, & Binder, 2004). Prochaska, DiClemente, and Norcross (1992) have provided a useful model for change behaviors. Although designed originally to respond to substance-abuse behaviors, it is helpful for responding to virtually all disorders. They conceptualize change as occurring in five stages: 1. Precontemplation: The person avoids any confrontation of true issues and generally denies realistic consequences. 2. Contemplation: There is at least some acknowledgment of responsibility and problematic consequences and at least a minimal openness to the possibility of change, although effective change has not yet been instituted. 3. Preparation: This is the decision point. There is enough acknowledgment of problematic behaviors and consequences that the person can make the required cognitive shift to initiate change. 4. Action: There is a higher sense of self-liberation or willpower, generating sets of behaviors toward positive coping and away from situations that condition the undesired behavior. 5. Maintenance: Efforts are directed toward remotivation and developing skills and patterns that avoid relapse and promote a positive lifestyle. The following, adapted from Prochaska et al. (1992), lists the major change processes that are embedded in the various treatments and theories. They are listed in the order in which they occur in the overall change process: Consciousness raising is more likely to occur in the precontemplation and contemplation stages, and self-disclosure and trust are more likely to be central to the action and maintenance processes. Consciousness Raising: Increasing information about self and problem: observations, confrontations, interpretations, bibliotherapy Dramatic Relief: Experiencing and expressing feelings about one’s problems and solutions: psychodrama, grieving losses, role playing Environmental Reevaluation: Assessing how one’s problem affects physical environment: empathy training, documentation of effects Self-Reevaluation: Assessing how one feels and thinks about oneself with respect to a problem: value clarification, imagery, corrective emotional experience Choice and Commitment: Choosing and committing to act or believing in the ability to change: decision-making therapy, New Year’s resolutions, logotherapy techniques, commitment-enhancing techniques Reinforcement Management: Rewarding one’s self or being rewarded by others for making changes: contingency con tracts, overt and covert reinforcement, self-reward Self-Disclosure and Trust: Being open and trusting about problems with someone who cares: therapeutic alliance, social support, self-help groups Counterconditioning: Substituting alternatives for problem behaviors: relaxation, desensitization, assertion, positive self-statements Stimulus Control: Avoiding or countering stimuli that elicit problem behaviors: restructuring one’s environment (e.g., removing alcohol or fattening foods), avoiding high-risk cues, fading techniques Sociopolitical: Increasing alternatives for nonproblem behaviors available in society: advocating for rights of repressed, empowering, policy interventions. Table 2.1 Culture-Bound Syndromes