1.3 The Transition to Scientific Accounts of Psychological Disorders

Each of the prescientific explanations of psychological disorders proved inadequate. There is, however, one positive legacy from the prescientific era: The mentally ill came to be regarded as ill, and so were treated humanely, at least in some places and some eras. If the Beales had lived in the 18th century or earlier, they might have ended up in Bedlam on display. If the Beales were diagnosed today, they would almost certainly receive treatments that would enable them to function more effectively in the world. Let’s now consider the crucial transition from prescientific times to today.

Freud and the Importance of Unconscious Forces

Sigmund Freud (1856–1939), a Viennese neurologist, played a major role in making the study of psychological disorders a science. He not only developed new methods for both diagnosis and treatment (many of which are still in use today) but also proposed a rich and intricate theory, which continues to have massive influence on many clinicians.

Initially Freud, influenced by the French neurologist Jean-Martin Charcot, used hypnosis with his patients in Vienna. Although he had some success, he found that not everyone was equally hypnotizable and that patients’ symptoms often returned. This led Freud to develop another method to help patients with hysteria: free association, a technique in which patients are encouraged to say whatever thoughts occur to them. Free association was part of Freud’s treatment that involved talking—often referred to as the “talking cure”—which rested on his idea that mental disorders in general arise in part because of unconscious conflicts. His idea was that talking freely would help a person to reduce his or her unconscious conflicts and so provide some relief from the psychological disorder.

Freud developed a far-reaching theory of the origins, nature, and treatment of psychopathology based on both his work with patients (who were mostly middle-class and upper-middle-class women) and his observations about himself. His psychoanalytic theory (the Greek word psyche means “mind”) proposes that thoughts, feelings, and behaviors are a result of conscious and unconscious forces continually interacting in the mind. Psychoanalytic theory also suggests that the mind is organized to function across three levels of consciousness:

• The conscious consists of thoughts and feelings that are in awareness; this is normal awareness.
• The preconscious consists of thoughts and feelings that a person does not perceive, but that can be brought voluntarily into conscious awareness in the future.
• The unconscious includes thoughts and feelings that cannot be perceived or called into awareness on command, but which have power to influence a person.

According to Freud, people have sexual and aggressive urges from birth onward. Freud argued that when we find such urges unacceptable, they are banished to our unconscious, where they inevitably gain strength and eventually demand release. Unconscious urges can be released as conscious feelings or thoughts, or as behaviors. Freud believed that abnormal experiences and behaviors arise from this process. For example, according to psychoanalytic theory, one woman’s extreme fear of eating dust arose from unconscious sexual impulses related to “taking in” semen (the dust symbolically represented semen; Frink, 1921).

Freud (1923/1961) also distinguished three psychological structures of the mind—the id, the ego, and the superego:

• The id is the seat of sexual and aggressive drives, as well as of the desire for immediate gratification of physical and psychological needs. These physical needs (such as for food and water) and psychological drives (-sexual and aggressive) constantly require satisfaction. The id is governed by the pleasure principle, seeking gratification of needs without regard for the consequences.
• The superego, the seat of a person’s conscience, works to impose morality. According to Freud, the superego is responsible for feelings of guilt, which motivate the person to constrain his or her sexual and aggressive urges that demand immediate gratification. People with an inflexible morality—an overly rigid sense of right and wrong—are thought to have too strong a superego.
• Meanwhile, the ego tries to mediate the id’s demands for immediate gratification and the superego’s high standards of morality, as well as the constraints of external reality. Normally, the ego handles the competing demands well. However, when the ego is relatively weak, it is less able to manage the conflicts among the id, superego, and reality, which then cause anxiety and other symptoms.

Figure 1.2 shows how the three mental structures are related to the three levels of consciousness.

One of Freud’s lasting contributions to the field of psychopathology—and all of psychology, in fact—is his notion of the unconscious, the thoughts and feelings that cannot be perceived or called into awareness on command, but which have power to influence a person.

Freud also identified five distinct stages of development (the oral, anal, phallic, latency, and genital stages) through which children proceed from infancy into adulthood. Four of these stages involve particular erogenous zones, which are areas of the body (the mouth, genitals, and anus) that can satisfy the id’s urges and drives. Freud called these five stages psychosexual stages because he believed that each erogenous zone demands some form of gratification and that each stage requires that a person successfully complete a key task for healthy psychological development. All of these stages arise during infancy or childhood, although they may not be resolved until adulthood, if ever. An unresolved conflict or issue from an earlier stage, which leaves the person focused on issues related to that stage, is referred to as a fixation. For example, according to Freud (1905/1955), people with a fixation at the oral stage use food or alcohol to alleviate anxiety.

Freud proposed two general categories of mental illness: neuroses and psychoses. A neurosis is a pattern of thoughts, feelings, or behaviors that expresses an unresolved conflict between the ego and the id or between the ego and the superego.

Freud (1938) defined psychosis as a break from reality characterized by conflict between the ego’s view of reality and reality itself. (Note that this is not the current conventional definition of psychosis—an impaired ability to perceive reality, such as arises with hallucinations—used by most mental health clinicians and researchers, and which we use in the rest of this textbook.) According to the psychoanalytic view, then, schizophrenia involves a psychosis because it is an escape from reality into one’s own internal world (Dorcus & Shaffer, 1945).

Freud was also revolutionary in proposing that parents’ interactions with their child are central in the formation of personality. For instance, parents who are too strict about toilet training their toddler may inadvertently cause their child to tend to become fixated at the anal stage.

In addition to proposing an explanation for how internal psychological conflict arises, Freud, along with his daughter, the noted psychoanalyst Anna Freud (1895–1982), suggested how such conflicts are resolved: The ego frequently employs unconscious defense mechanisms, which work to transform the conflicts in a way that prevents unacceptable thoughts and feelings from reaching consciousness. If successful, defense mechanisms can decrease anxiety (see TABLE 1.2).

Psychoanalytic theory has been modified by Freud’s followers; these variations fall under the term psychodynamic theory and have attracted many adherents. Psychodynamic theorists have focused on areas that Freud did not develop fully:

• normal versus abnormal development of the self (Kohut, 1971);
• the contribution of additional sources of motivation, such as feelings of inferiority (Ansbacher & Ansbacher, 1956);
• the development and work of the ego (Hartmann, 1939);
• the possibility that our species has certain inborn and unconscious archetypes (an archetype is an abstract, ideal characterization of a person, object, or concept) that underlie some aspects of motivation (Jung, 1983).

In addition, Karen Horney (1885–1952) and other psychologists conducted research on the ways that moment-to-moment interactions between child and parent can contribute to psychological disorders (Horney, 1937; Kernberg, 1986; Sullivan, 1953). This emphasis on the contribution that an infant’s social world can make to psychopathology is one of the lasting contributions of psychodynamic theory. Treatment based on psychodynamic theory is generally referred to as psychodynamic therapy. Various modifications of psychodynamic therapy have been developed based on specific alterations of Freud’s theory.

One challenge to psychodynamic theory is that its guiding principles, and those of its corresponding treatments, rest primarily on subjective interpretations of what patients say and do. Another challenge is that the theory is not generally testable using scientific methodologies. For instance, according to psychodynamic theory, a fear of eating dust could be due to a sublimation of sexual impulses or a reaction formation to an unconscious desire to play with fecal matter (see TABLE 1.2). The problem is not that there can be more than one hypothesis based on psychodynamic theory, but rather that there is no evidence and no clear means for obtaining evidence that either hypothesis (or both) is correct.

Nevertheless, psychodynamic theory rested on a fundamental insight that was crucial for the development of later theories and treatments: Mental processes are the internal operations that underlie cognitive and emotional functions (such as perception, memory, and guilt feelings) and most human behavior. In addition, psychodynamic theory’s focus on mental contents—the specific memories, knowledge, goals, and other material that are stored and processed in the mind—has led to much fruitful research. Furthermore, the notion that some mental processes and mental contents are hidden away from consciousness has proven invaluable to understanding psychopathology.

The Humanist Response

Some psychologists, such as Abraham Maslow (1908–1970), reacted adversely to Freud’s ideas, especially two notions: (1) that mental processes are mechanistic (with the same sort of cause-and-effect relations that govern all machines), driven by sexual and aggressive impulses, and (2) that humans don’t really have free will because our behavior is in response to unconscious processes. These psychologists proposed a different view of human nature and mental illness that came to be called humanistic psychology, which focuses on free will, innate goodness, creativity, and the self (Maslow, 1968).

Carl Rogers (1902–1987) proposed that symptoms of distress and mental illness arise when a potential route to personal growth is blocked, as can occur when a person lacks a coherent and unified sense of self or when there is a mismatch—an incongruence—between the ideal self (the qualities a person wants to have) and the real self (the qualities the person actually has) (Rogers, 1942). For example, suppose a woman believes she should always be energetic (ideal self), but her real self is someone who is often energetic, but not always. The incongruence between the two selves can lead her to feel bad about herself, which in turn creates feelings of apathy and guilt.

Rogers developed client-centered therapy to help people reduce such incongruence and to help them create solutions to their problems by releasing their “real selves.” In accordance with this approach of self-empowerment, Rogers (1942) stressed that his clients were not patients who are seen to be “sick” and lacking in power. Referring to people as “clients” indicated that they had control over their own lives and were interested in self-improvement through engagement with mental health services (Kahn, 1998).

Although the emphasis on self-empowerment has proven useful, the humanist approach, like all approaches, falls short on its own as a general method for conceptualizing and treating mental illness. As we shall see, other factors (e.g., biological and social) must be considered.