It would hardly be accurate to say that we now live in a period of great enlightenment about or dependable treatment of mental disorders. In fact, surveys have found that 43 percent of respondents believe that people bring mental disorders on themselves, and 35 percent consider such disorders to be caused by sinful behavior (Stuber et al., 2014; NMHA, 1999). Nevertheless, there have been major changes over the past 50 years in the ways clinicians understand and treat abnormal functioning. There are more theories and types of treatment, more research studies, more information, and—perhaps because of those increases—more disagreements about abnormal functioning today than at any time in the past.

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In the 1950s, researchers discovered a number of new psychotropic medications—drugs that primarily affect the brain and reduce many symptoms of mental dysfunctioning. They included the first antipsychotic drugs, which correct extremely confused and distorted thinking; antidepressant drugs, which lift the mood of depressed people; and antianxiety drugs, which reduce tension and worry.

When given these drugs, many patients who had spent years in mental hospitals began to show signs of improvement. Hospital administrators, encouraged by these results and pressured by a growing public outcry over the terrible conditions in public mental hospitals, began to discharge patients almost immediately.

Since the discovery of these medications, mental health professionals in most of the developed nations of the world have followed a policy of deinstitutionalization, releasing hundreds of thousands of patients from public mental hospitals. On any given day in 1955, close to 600,000 people were confined in public mental institutions across the United States (see Figure 1.1). Today the daily patient population in the same kinds of hospitals is less than 40,000 (Althouse, 2010).

In short, outpatient care has now become the primary mode of treatment for people with severe psychological disturbances as well as for those with more moderate problems. When severely disturbed people do need institutionalization these days, they are usually hospitalized for a short period of time. Ideally, they are then provided with outpatient psychotherapy and medication in community programs and residences (Stein et al., 2015).

Chapters 2 and 12 will look more closely at this recent emphasis on community care for people with severe psychological disturbances—a philosophy called the community mental health approach. The approach has been helpful for many patients, but too few community programs are available to address current needs in the United States (Dixon & Schwarz, 2014). As a result, hundreds of thousands of persons with severe disturbances fail to make lasting recoveries, and they shuttle back and forth between the mental hospital and the community. After release from the hospital, they at best receive minimal care and often wind up living in decrepit rooming houses or on the streets. At least 100,000 people with such disturbances are homeless on any given day; another 135,000 or more are inmates of jails and prisons (Kooyman & Walsh, 2011; Althouse, 2010). Their abandonment is truly a national disgrace.

The treatment picture for people with moderate psychological disturbances has been more positive than that for people with severe disorders. Since the 1950s, outpatient care has continued to be the preferred mode of treatment for them, and the number and types of facilities that offer such care have expanded to meet the need.

Before the 1950s, outpatient care exclusively took the form of private psychotherapy, in which individuals seek out a self-employed therapist for counseling services. Since the 1950s, most health insurance plans have expanded coverage to include private psychotherapy, so that it is now widely available to people of all incomes. Today, outpatient therapy is also offered in a number of less expensive settings, such as community mental health centers, crisis intervention centers, family service centers, and other social service agencies. Surveys suggest that nearly one of every six adults in the United States receives outpatient treatment for psychological disorders in the course of a year (NIMH, 2010).

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Outpatient treatments are also becoming available for more and more kinds of problems. When Freud and his colleagues first began to practice, most of their patients suffered from anxiety or depression. Almost half of today’s clients suffer from those same problems, but people with other kinds of disorders are also receiving therapy. In addition, at least 20 percent of clients enter therapy because of milder problems in living—problems with marital, family, job, peer, school, or community relationships (Ten Have et al., 2013; Druss & Bornemann, 2010).

Yet another change in outpatient care since the 1950s has been the development of programs devoted exclusively to one kind of psychological problem. We now have, for example, suicide prevention centers, substance abuse programs, eating disorder programs, phobia clinics, and sexual dysfunction programs. Clinicians in these programs have the kind of expertise that can be acquired only by concentration in a single area.

Although the community mental health approach has often failed to address the needs of people with severe disorders, it has given rise to an important principle of mental health care—prevention (Grill & Monsell, 2014). Rather than wait for psychological disorders to occur, many of today’s community programs try to correct the social conditions that underlie psychological problems (poverty or violence in the community, for example) and to help individuals who are at risk for developing emotional problems (for example, teenage mothers or the children of people with severe psychological disorders). As you will see later, community prevention programs are not always successful, but they have grown in number, offering great promise as the ultimate form of intervention.

Prevention programs have been further energized in the past few years by the field of psychology’s ever-growing interest in positive psychology (Ramirez et al., 2014; Seligman & Fowler, 2011). Positive psychology is the study and promotion of positive feelings such as optimism and happiness, positive traits like hard work and wisdom, positive abilities, and group-directed virtues, including altruism and tolerance (see InfoCentral below).

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While researchers study and learn more about positive psychology in the laboratory, clinical practitioners with this orientation are teaching people coping skills that may help protect them from stress and encouraging them to pursue psychological wellness, meaningful activities, and enriching relationships—thus preventing mental disorders (Sergeant & Mongrain, 2014).

We are, without question, a society of multiple cultures, races, and languages. Members of racial and ethnic minority groups in the United States collectively make up 35 percent of the population, a percentage that is expected to grow to more than 50 percent in the coming decades (Santa-Cruz, 2010; U.S. Census Bureau, 2010). This change is partly because of shifts in immigration trends and partly because of higher birth rates among minority groups in the United States (NVSR, 2010).

In response to this growing diversity, a new area of study called multicultural psychology has emerged. 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 may differ psychologically (Alegría et al., 2013, 2010). As you will see throughout this book, the field of multicultural psychology has begun to have a powerful effect on our understanding and treatment of abnormal behavior.

So many people now seek therapy that insurance companies have changed their coverage for mental health patients. Today the dominant form of coverage is the managed care program—a program in which the insurance company determines such key issues as which therapists its clients may choose, the cost of sessions, and the number of sessions for which a client may be reimbursed (Domino, 2012; Glasser, 2010).

At least 75 percent of all privately insured persons in the United States are currently enrolled in managed care programs (Deb et al., 2006). The coverage for mental health treatment under such programs follows the same basic principles as coverage for medical treatment, including a limited pool of practitioners from which patients can choose, preapproval of treatment by the insurance company, strict standards for judging whether problems and treatments qualify for reimbursement, and ongoing reviews. In the mental health realm, both therapists and clients typically dislike managed care programs (Lustig et al., 2013). They fear that the programs inevitably shorten therapy (often for the worse), unfairly favor treatments whose results are not always lasting (for example, drug therapy), pose a special hardship for those with severe mental disorders, and result in treatments determined by insurance companies rather than by therapists (Turner, 2013).

A key problem with insurance coverage—both managed care and other kinds of insurance programs—is that reimbursements for mental disorders tend to be lower than those for medical disorders. This places persons with psychological difficulties at a distinct disadvantage (Sipe et al., 2015). Thus, in 2008 the U.S. Congress passed a federal parity law that directed insurance companies to provide equal coverage for mental and medical problems, and in 2014 the mental health provisions of the Affordable Care Act (the ACA)—referred to colloquially as “Obamacare”—went into effect and extended the reach of the earlier law. The ACA designates mental health care as 1 of 10 types of “essential health benefits” that must be provided by all insurers (SAMHSA, 2014; Pear, 2013). It also requires all health plans to provide preventive mental health services at no additional cost (for example, free screenings for depressive disorders) and to allow membership to individuals who have preexisting mental conditions. It is not yet clear whether such provisions will in fact result in better treatment for people with psychological problems.

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One of the most important developments in the clinical field has been the growth of numerous theoretical perspectives that now coexist in the field. Before the 1950s, the psychoanalytic perspective, with its emphasis on unconscious psychological problems as the cause of abnormal behavior, was dominant. Since then, additional influential perspectives have emerged, particularly the biological, behavioral, cognitive, humanistic-existential, and sociocultural schools of thought. At present, no single viewpoint dominates the clinical field as the psychoanalytic perspective once did. In fact, the perspectives often conflict and compete with one another.

In addition, a variety of professionals now offer help to people with psychological problems. Before the 1950s, psychotherapy was offered only by psychiatrists, physicians who complete three to four additional years of training after medical school (a residency) in the treatment of abnormal mental functioning. After World War II, however, with millions of soldiers returning home to countries throughout North America and Europe, the demand for mental health services expanded so rapidly that other professional groups had to step in to fill the need.

Among those other groups are clinical psychologists—professionals who earn a doctorate in clinical psychology by completing four to five years of graduate training in abnormal functioning and its treatment and also complete a one-year internship in a mental health setting. Psychotherapy is also provided by counseling psychologists, educational and school psychologists, psychiatric nurses, marriage therapists, family therapists, and—the largest group—psychiatric social workers (see Table 1.2). Each of these specialties has its own graduate training program. Theoretically, each conducts therapy in a distinctive way, but in reality clinicians from the various specialties often use similar techniques.

A related development in the study and treatment of mental disorders since World War II has been a growing appreciation of the need for effective research. Clinical researchers have tried to determine which concepts best explain and predict abnormal behavior, which treatments are most effective, and what kinds of changes may be required. Well-trained clinical researchers conduct studies in universities, medical schools, laboratories, mental hospitals, mental health centers, and other clinical settings throughout the world. Their work has produced important discoveries and has changed many of our ideas about abnormal psychological functioning.

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The breathtaking rate of technological change that characterizes today’s world has begun to have significant effects—both positive and negative—on the mental health field, and it will undoubtedly affect the field even more in the coming years. Let’s consider just a small sample of these effects.

Our digital world provides new triggers for abnormal behavior. As you’ll see in Chapter 10, for example, many individuals who grapple with gambling disorder have found the ready availability of Internet gambling to be all too inviting. Similarly, the Internet, text messaging, and social media have become convenient tools for those who wish to stalk or bully others, express sexual exhibitionism, or pursue pedophilic desires (Aboujaoude et al., 2015). Likewise, some clinicians believe that violent video games may contribute to the development of antisocial behavior (Zhuo, 2010). And, in the opinion of many clinicians, constant text messaging, tweeting, and Internet browsing may contribute to shorter attention spans and establish a foundation for attention problems (Richtel, 2010).

A number of clinicians also worry that social networking can contribute to psychological dysfunctioning in certain cases. On the positive side, research indicates that, on average, social media users are particularly likely to maintain close relationships, receive social support, be trusting, and lead active lives (Hampton et al., 2011; Rainie et al., 2011). On the negative side, however, is research suggesting that social networking sites may increase peer pressure and social anxiety in some adolescents (Charles, 2011; Hampton et al., 2011). The sites may, for example, cause some people to develop fears that others in their network will exclude them socially. Similarly, there is clinical concern that sites such as Facebook may facilitate shy people’s withdrawal from valuable face-to-face relationships.

In addition, the face of clinical treatment is constantly changing in our fast-moving digital world. The use of cybertherapy, for example, is growing by leaps and bounds as a treatment option (Blanken et al., 2015; Pope & Vasquez, 2011). As you’ll see in Chapter 2, cybertherapy takes such forms as long-distance therapy between clients and therapists using Skype, therapy offered by computer programs, treatment enhanced by the use of video game–like avatars and other virtual reality experiences, and Internet-based support groups. Similarly, countless Web sites offer a wealth of mental health information. And literally thousands of apps are devoted to relaxing people, cheering them up, or otherwise improving their psychological states (see MindTech below).

Unfortunately, as you’ll also see throughout the book, the cybertherapy movement is not without its problems. Along with the body of mental health information now available online comes an enormous amount of misinformation about psychological problems and their treatments, offered by persons and sites that are far from knowledgeable. Similarly, the issue of quality control is a major problem for Internet-based therapy, support groups, and the like. Moreover, there are now numerous anti-treatment Web sites that try to guide people away from seeking help for their psychological problems (Davey, 2010). In Chapters 3, 7, and 9, for example, you will read about the growing phenomenon of pro-anorexia and pro-suicide Web sites and their dangerous effects on vulnerable people. Clearly, the impact of technological change presents formidable challenges for clinicians and researchers alike.

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