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
