Philip Berman is also a social and cultural being. He is surrounded by people and by institutions, he is a member of a family and a cultural group, he participates in social relationships, and he holds cultural values. Such forces are always operating upon Philip, setting rules and expectations that guide or pressure him, helping to shape his behaviors, thoughts, and emotions.

According to the sociocultural model, abnormal behavior is best understood in light of the broad forces that influence an individual. What are the norms of the individual’s society and culture? What roles does the person play in the social environment? What kind of family structure or cultural background is the person a part of? And how do other people view and react to him or her? In fact, the sociocultural model is composed of two major perspectives—the family-social perspective and the multicultural perspective.

Proponents of the family-social perspective argue that clinical theorists should concentrate on those broad forces that operate directly on an individual as he or she moves through life—that is, family relationships, social interactions, and community events. They believe that such forces help account for both normal and abnormal behavior, and they pay particular attention to three kinds of factors: social labels and roles, social networks, and family structure and communication.

Social Labels and RolesAbnormal functioning can be influenced greatly by the labels and roles assigned to troubled people (Rüsch et al., 2014; Yap et al., 2013; Link et al., 2004, 2001). When people stray from the norms of their society, the society calls them deviant and, in many cases, “mentally ill.” Such labels tend to stick. Moreover, when people are viewed in particular ways, reacted to as “crazy,” and perhaps even encouraged to act sick, they gradually learn to accept and play the assigned social role. Ultimately the label seems appropriate.

A famous study called “On Being Sane in Insane Places” by clinical investigator David Rosenhan (1973) supports this position. Eight normal people, actually colleagues of Rosenhan, presented themselves at various mental hospitals, complaining that they had been hearing voices say the words “empty,” “hollow,” and “thud.” On the basis of this complaint alone, each was diagnosed as having schizophrenia and admitted.

Moreover, the pseudopatients had a hard time convincing others that they were well once they had been given the diagnostic label. Their hospitalizations ranged from 7 to 52 days, even though they behaved normally and stopped reporting symptoms as soon as they were admitted. In addition, the label “schizophrenia” kept influencing the way the staff viewed and dealt with them. For example, one pseudopatient who paced the corridor out of boredom was, in clinical notes, described as “nervous.” Overall, the pseudopatients came to feel powerless, invisible, and bored.

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Social Connections and SupportsFamily-social theorists are also concerned with the social environments in which people operate, including their social and professional relationships. How well do they communicate with others? What kind of signals do they send to or receive from others? Researchers have often found ties between deficiencies in social networks and a person’s functioning (Schwarzbach et al., 2013; Gask et al., 2011; Paykel, 2008, 2006, 2003). They have observed, for example, that people who are isolated and lack social support or intimacy in their lives are more likely to become depressed when under stress and to remain depressed longer than are people with supportive spouses or warm friendships.

Some clinical theorists believe that people who are unwilling or unable to communicate and develop relationships in their everyday lives will often find adequate social contacts online, using social networking sites like Facebook. Although this may be true for some such individuals, research suggests that people’s online relationships tend to parallel their offline relationships (Dolan, 2011). One survey of 172 college students, for example, found that those students with the most friends on Facebook also were particularly social offline, while those who were less willing to communicate with other people offline also tended to initiate far fewer relationships on Facebook (Sheldon, 2008).

Family Structure and CommunicationOf course, one of the important social networks for an individual is his or her family. According to family systems theory, the family is a system of interacting parts—the family members—who interact with one another in consistent ways and follow rules unique to each family (Goldenberg, Goldenberg, & Pelavin, 2014). Family systems theorists believe that the structure and communication patterns of some families actually force individual members to behave in a way that otherwise seems abnormal. If the members were to behave normally, they would severely strain the family’s usual manner of operation and would actually increase their own and their family’s turmoil.

Family systems theory holds that certain family systems are particularly likely to produce abnormal functioning in individual members. Some families, for example, have an enmeshed structure in which the members are grossly overinvolved in one another’s activities, thoughts, and feelings. Children from this kind of family may have great difficulty becoming independent in life (Santiseban et al., 2001). Some families display disengagement, which is marked by very rigid boundaries between the members. Children from these families may find it hard to function in a group or to give or request support (Corey, 2012, 2004).

Philip Berman’s angry and impulsive personal style might be seen as the product of a disturbed family structure. According to family systems theorists, the whole family—Philip’s mother, father, and brother, and Philip himself—relate in such a way as to maintain Philip’s behavior. Family theorists might be particularly interested in the conflict between Philip’s mother and father and the imbalance between their parental roles. They might see Philip’s behavior as both a reaction to and stimulus for his parents’ behaviors. With Philip acting out the role of the misbehaving child, or scapegoat, his parents may have little need or time to question their own relationship.

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Family systems theorists would also seek to clarify the precise nature of Philip’s relationship with each parent. Is he enmeshed with his mother and/or disengaged from his father? They would look too at the rules governing the sibling relationship in the family, the relationship between Philip’s parents and brother, and the nature of parent-child relationships in previous generations of the family.

The family-social perspective has helped spur the growth of several treatment approaches, including group, family, and couple therapy, and community treatment. Therapists of any orientation may work with clients in these various formats, applying the techniques and principles of their preferred models (see MindTech below). However, more and more of the clinicians who use these formats believe that psychological problems emerge in family and social settings and are best treated in such settings, and they include special sociocultural strategies in their work.

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Group TherapyThousands of therapists specialize in group therapy, a format in which a therapist meets with a group of clients who have similar problems. One survey of clinical psychologists showed that almost one-third of them devoted some portion of their practice to group therapy (Norcross & Goldfried, 2005). Typically, members of a therapy group meet together with a therapist and discuss the problems of one or more of the people in the group. Together they develop important insights, build social skills, strengthen feelings of self-worth, and share useful information or advice (Corey, Corey, & Corey, 2013; Burlingame & Baldwin, 2011). Many groups are created with particular client populations in mind; for example, there are groups for people with alcoholism, for those who are physically handicapped, and for people who are divorced, abused, or bereaved.

Research suggests that group therapy is of help to many clients, often as helpful as individual therapy (Burlingame & Baldwin, 2011). The group format also has been used for purposes that are educational rather than therapeutic, such as “consciousness raising” and spiritual inspiration.

A format similar to group therapy is the self-help group (or mutual help group). Here people who have similar problems (for example, bereavement, substance abuse, illness, unemployment, or divorce) come together to help and support one another without the direct leadership of a professional clinician (Lake, 2014; White & Madara, 2010; Mueller et al., 2007). According to estimates, there are now between 500,000 and 3 million such groups in the United States alone, attended each year by as many as 3 to 4 percent of the population. In addition, numerous self-help chat groups have emerged on the Internet in recent years.

Family TherapyFamily therapy was first introduced in the 1950s. A therapist meets with all members of a family, points out problem behaviors and interactions, and helps the whole family to change its ways (Goldenberg et al., 2014). Here, the entire family is viewed as the unit under treatment, even if only one of the members receives a clinical diagnosis. The following is a typical interaction between family members and a therapist:

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Family therapists may follow any of the major theoretical models, but many of them adopt the principles of family systems theory (Riina & McHale, 2014; Chabot, 2011). Although all kinds of mental health professionals practice family systems therapy, this approach is particularly common among social workers. Around 2 percent of all clinical psychologists, 5 percent of counseling psychologists, and 14 percent of social workers identify themselves mainly as family systems therapists (Prochaska & Norcross, 2013).

As you read earlier, family systems theory holds that each family has its own rules, structure, and communication patterns that shape the individual members’ behavior. In one family systems approach, structural family therapy, therapists try to change the family power structure, the roles each person plays, and the relationships between members (Goldenberg et al., 2014; Minuchin, 2007, 1997, 1987, 1974). In another, conjoint family therapy, therapists try to help members recognize and change harmful patterns of communication (Sharf, 2012; Satir, 1987, 1967, 1964).

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Family therapies of various kinds are often helpful to individuals, although research has not yet clarified how helpful (Goldenberg et al., 2014; Nichols, 2013; Kaslow, 2011). Some studies have found that as many as 65 percent of individuals treated with family approaches improve, while other studies suggest much lower success rates. Nor has any one type of family therapy emerged as consistently more helpful than the others (Bitter, 2013; Alexander et al., 2002).

Couple TherapyIn couple therapy, or marital therapy, the therapist works with two individuals who are in a long-term relationship. Often they are husband and wife, but the couple need not be married or even living together. Like family therapy, couple therapy often focuses on the structure and communication patterns in the relationship (Baucom & Boeding, 2013; Baucom et al., 2012, 2010, 2009; Gurman & Snyder, 2011). A couple approach may also be used when a child’s psychological problems are traced to problems in the parents’ relationship.

Although some degree of conflict exists in any long-term relationship, many couples in our society have serious marital discord. The divorce rate in Canada, the United States, and Europe is now close to 50 percent of the marriage rate. Many couples who live together without marrying apparently have similar levels of difficulty (Martins et al., 2014; Harway, 2005).

Couple therapy, like family and group therapy, may follow the principles of any of the major therapy orientations. Cognitive-behavioral couple therapy, for example, uses many techniques from the cognitive and behavioral perspectives (Baucom & Boeding, 2013; Becvar & Becvar, 2012). Therapists help spouses recognize and change problem behaviors largely by teaching specific problem-solving and communication skills. A broader, more sociocultural version, called integrative couple therapy, further helps partners accept behaviors that they cannot change and embrace the whole relationship nevertheless (Christensen et al., 2014, 2010, 2006). Partners are asked to see such behaviors as an understandable result of basic differences between them.

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Couples treated by couple therapy seem to show greater improvement in their relationships than couples with similar problems who do not receive treatment, but no one form of couple therapy stands out as superior to others (Christensen et al., 2014, 2010; Gurman & Snyder, 2011). Although marital functioning improved in two-thirds of treated couples by the end of therapy, fewer than half of those who are treated achieve “distress free” or “happy” relationships. One-fourth of all treated couples eventually separate or divorce.

Community TreatmentCommunity mental health treatment programs allow clients, particularly those with severe psychological difficulties, to receive treatment in familiar social surroundings as they try to recover. In 1963 President John F. Kennedy called for such a “bold new approach” to the treatment of mental disorders—a community approach that would enable most people with psychological problems to receive services from nearby agencies rather than distant facilities or institutions. Congress passed the Community Mental Health Act soon after, launching the community mental health movement across the United States. Community-based treatments, including community day programs and residential services, continue to be a major part of today’s efforts to help people with severe mental disorders (Cuddeback et al., 2013; Daly, 2010). A number of other countries have launched similar community movements over the past several decades.

As you read in Chapter 1, a key principle of community treatment is prevention. This involves clinicians actively reaching out to clients rather than waiting for them to seek treatment. Research suggests that such efforts are often very successful (Beardslee et al, 2013; Drukker et al., 2013) Community workers recognize three types of prevention, which they call primary, secondary, and tertiary. Primary prevention consists of efforts to improve community attitudes and policies. Its goal is to prevent psychological disorders altogether. Community workers may, for example, consult with a local school board, offer public workshops on stress reduction, or construct Web sites on how to cope effectively.

Secondary prevention consists of identifying and treating psychological disorders in the early stages, before they become serious. Community workers may work with teachers, ministers, or police to help them recognize the early signs of psychological dysfunction and teach them how to help people find treatment. Similarly, hundreds of mental health Web sites provide this same kind of information to family members, teachers, and the like.

The goal of tertiary prevention is to provide effective treatment as soon as it is needed so that moderate or severe disorders do not become long-term problems. Community agencies across the United States successfully offer tertiary care for millions of people with moderate psychological problems but, as you read in Chapter 1, they often fail to provide the services needed by hundreds of thousands with severe disturbances (Althouse, 2010). One of the reasons for this failure is lack of funding, an issue that you will read about in later chapters.

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Culture refers to the set of values, attitudes, beliefs, history, and behaviors shared by a group of people and communicated from one generation to the next (Matsumoto & Hwang, 2012, 2011; Matsumoto, 2007, 2001). We are, without question, a society of multiple cultures. Indeed, by the year 2050, members of racial and ethnic minority groups in the United States will collectively outnumber white Americans (Kaiser Family Foundation, 2010; U.S. Census Bureau, 2010).

Partly in response to this growing diversity, the multicultural, or culturally diverse, perspective has emerged (Leong, 2014, 2013). Multicultural psychologists seek to understand how culture, race, ethnicity, gender, and similar factors affect behavior and thought and how people of different cultures, races, and genders differ psychologically (Alegría et al., 2014, 2012, 2007, 2004). Today’s multicultural view is different from past—less enlightened—cultural perspectives: it does not imply that members of racial, ethnic, and other minority groups are in some way inferior or culturally deprived in comparison with a majority population. Rather, the model holds that an individual’s behavior, whether normal or abnormal, is best understood when examined in the light of that individual’s unique cultural context, from the values of that culture to the special external pressures faced by members of the culture.

The groups in the United States that have received the most attention from multicultural researchers are ethnic and racial minority groups (African American, Hispanic American, American Indian, and Asian American groups) and groups such as economically disadvantaged persons, gays and lesbians, and women (although women are not technically a minority group). Each of these groups is subjected to special pressures in American society that may contribute to feelings of stress and, in some cases, to abnormal functioning. Researchers have learned, for example, that psychological abnormality, especially severe psychological abnormality, is indeed more common among poorer people than among wealthier people (Wittayanukorn, 2013; Sareen et al., 2011) (see Figure 3-5). Perhaps the pressures of poverty explain this relationship.

Of course, membership in these various groups overlaps. Many members of minority groups, for example, also live in poverty. The higher rates of crime, unemployment, overcrowding, and homelessness; the inferior medical care; and the limited educational opportunities typically available to poor people may place great stress on many members of such minority groups (Alegria et al., 2014; Miller et al., 2011).

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Multicultural researchers have also noted that the prejudice and discrimination faced by many minority groups may contribute to various forms of abnormal functioning (McDonald et al., 2014;Guimón, 2010; Carter, 2007). Women in Western society receive diagnoses of anxiety disorders and of depression at least twice as often as men (Jeglic & Murphy-Eberenz, 2012). Similarly, African Americans, Hispanic Americans, and American Indians are more likely than white Americans to experience serious psychological distress or extreme sadness (see Table 3-3). American Indians also have exceptionally high alcoholism and suicide rates (CDCP, 2011; Beals et al., 2005). Although many factors may combine to produce these differences, prejudice based on race and sexual orientation, and the problems such prejudice poses, may contribute to abnormal patterns of tension, unhappiness, low self-esteem, and escape (Guimón, 2010).

Studies conducted throughout the world have found that members of ethnic and racial minority groups tend to show less improvement in clinical treatment, make less use of mental health services, and stop therapy sooner than members of majority groups (Cook et al., 2014; Comas-Diaz, 2012, 2011; Ward, 2007).

A number of studies suggest that two features of treatment can increase a therapist’s effectiveness with minority clients: (1) greater sensitivity to cultural issues and (2) inclusion of cultural morals and models in treatment, especially in therapies for children and adolescents (Comas-Diaz, 2014; Inman & DeBoer, 2013; Castro, Holm-Denoma, & Buckner, 2007). Given such findings, some clinicians have developed culture-sensitive therapies, approaches that are designed to help address the unique issues faced by members of cultural minority groups. Therapies geared to the pressures of being female, called gender-sensitive, or feminist, therapies, follow similar principles (Calogero, Tantleff-Dunn, & Thompson, 2011).

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Culture-sensitive approaches typically include the following elements (Prochaska & Norcross, 2013; Wyatt & Parham, 2007):

The family-social and multicultural perspectives have added greatly to the understanding and treatment of abnormal functioning. Today most clinicians take family, cultural, social, and societal issues into account, factors that were overlooked just 35 years ago. In addition, clinicians have become more aware of the impact of clinical and social roles. Finally, the treatment formats offered by the sociocultural model sometimes succeed where traditional approaches have failed.

At the same time, the sociocultural model has certain problems. To begin with, sociocultural research findings are often difficult to interpret. Indeed, research may reveal a relationship between certain family or cultural factors and a particular disorder yet fail to establish that they are its cause. Studies show a link between family conflict and schizophrenia, for example, but that finding does not necessarily mean that family dysfunction causes schizophrenia. It is equally possible that family functioning is disrupted by the tension and conflict created by the psychotic behavior of a family member.

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Another limitation of the sociocultural model is its inability to predict abnormality in specific individuals. If, for example, social conditions such as prejudice and discrimination are key causes of anxiety and depression, why do only some of the people subjected to such forces experience psychological disorders? Are still other factors necessary for the development of the disorders?

Given these limitations, most clinicians view the family-social and multicultural explanations as operating in conjunction with the biological or psychological explanations. They agree that family, social, and cultural factors may create a climate favorable to the development of certain disorders. They believe, however, that biological or psychological conditions—or both—must also be present for the disorders to evolve.