1 Introduction and Learning Objectives

Learning Objectives.

2 Psychopathology

Psychopathology is the scientific study of mental disorders, encompassing their theoretical foundations, causes (etiology), progression, symptoms, diagnosis, and treatment. This broad field draws on research from diverse areas, including psychology, biochemistry, pharmacology, psychiatry, neurology, and endocrinology. In this context, the term is sometimes used synonymously with abnormal psychology.

The phrase abnormal psychology has fallen out of favor in recent years, partly due to concerns that the word abnormal may be stigmatizing, but also as a reflection of evolving views on what it means to have a mental disorder.

One approach to defining and diagnosing psychological disorders has traditionally relied on statistical rarity. In this view, any aspect of behavior that is uncommon becomes associated with psychopathology. However, this practice can lead to over-pathologizing traits and behaviors that, while rare, have little or no impact on a person’s ability to function in real-world settings such as work, school, or home life.


A single red gummy bear stands out among many clear gummy bears, symbolizing individuality and difference.
Figure 1. A single red gummy bear stands out among a crowd of clear gummy bears. Uniqueness and statistical rarity has historically been used as a method to classify mental illness. Source: Pixabay.


Increasingly, diagnostic criteria for psychiatric disorders rely less on statistical rarity alone. For example, until recently, the diagnosis of Intellectual Disability (previously called Mental Retardation [a clinical descriptor that later became used as a pejorative and, in many contexts, as a slur]) was based largely on statistical rarity, with individuals scoring below 70 on IQ tests—roughly the 2nd percentile—qualifying for the diagnosis. Today, while low IQ remains part of the criteria, there is a much stronger emphasis on deficits in adaptive functioning.

Another traditional approach to diagnosing mental disorders is based on violation of social norms, which refers to behavior that breaks societal expectations. However, this approach reflects evoling cultural norms rather than meaningful aspects of individuals’ mental states. An important example is the historical classification of homosexuality as a mental disorder, which reflected prevailing cultural and religious attitudes rather than genuine indicators of mental illness. In 1973, the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), reflecting a significant shift in understanding and reducing stigma.

Other commonly used approaches to defining psychopathology include:

Each of these methods offers insights, but none fully defines psychopathology on its own, underscoring the complexity of understanding mental health and illness.

3 Classificaiton and Diagnosis

Ideally, the “rules” for classifying someone as, for example, depressed would be well agreed upon and based on objective criteria. Unfortunately, we do not have the same level of consensus in psychopathology as we do in physical medicine. One reason is that we rarely have clear, objective biological markers that definitively show whether someone has a mental disorder. For example, you cannot perform a blood test to diagnose Major Depressive Disorder.

In the absence of such diagnostic “truths,” we must rely on symptoms. Nearly all mental disorders for which we have labels describe clusters of symptoms rather than a single, definitive indicators of psychopathology. Pop psychology often promotes the pseudoscientific idea that a single act, thought, or behavior can define someone as mentally ill. But these suggestions are wrong and potential hurtful.

Researchers and clinicians often disagree on which symptoms should define specific mental illnesses. Instead, diagnostic criteria are typically established through debate and consensus among experts in the field. Some view this ambiguity as a sign that psychiatry is not a “hard science,” but rather a field shaped by evolving research, clinical judgment, and cultural context. However, while it’s true that psychiatry relies on reported symptoms and consensus criteria rather than gold-standard physical tests, its diagnostic methods and research practices are often both clinically useful and scientifically rigorous.

The primary tool for classifying mental disorders is the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is currently in its Fifth Edition. As noted above, to receive a diagnosis, patients must meet a specific combination of symptoms outlined in the diagnostic criteria.


Photograph of the DSM-5 and DSM-IV-TR manuals, used for diagnosing mental disorders.
Figure 2. The DSM-5 (top) and DSM-IV-TR (bottom), editions of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. The DSM provides standardized criteria for diagnosing mental health disorders and guides clinical practice and research worldwide. Source: Wikimedia Commons.


The DSM-5 follows a medical model approach, generally treating mental disorders as discrete categories rather than as points along a continuous spectrum. However, many mental health professionals recognize that some disorders are more continuous in nature rather than categorical—for example, depression may exist along a spectrum of severity—while others, such as schizophrenia, might be more categorical. Despite these nuances, under the DSM-5 system, disorders are defined as either present or absent based on meeting specific diagnostic criteria. That said, most disorders also allow for the severity of symptoms to be graded.

In recent years, the National Institute of Mental Health (NIMH) has proposed an alternative approach called the Research Domain Criteria (RDoC). Instead of focusing on traditional diagnostic categories, RDoC emphasizes studying mental health and illness along dimensions of observable behavior and neurobiological systems. The goal is to develop a framework that better connects genetics, brain function, and behavior, ultimately leading to more precise and personalized treatments. However, at the present time, the RDoC approach is purely a research tool and is not used in mental healthcare settings.

4 Prevalence


World map showing the estimated number of people with mental health and neurodevelopmental disorders in 2016, excluding alcohol and drug use disorders. Darker shades indicate higher numbers, with China and India showing over 100 million affected individuals each.
Figure 3. Estimated number of people with mental health and neurodevelopmental disorders worldwide in 2016 (excluding alcohol and drug use disorders). The data reflect modeled estimates of true prevalence rather than solely diagnosed cases. Source: Wikimedia Commons.


Some mental disorders have reasonably high lifetime prevalence—meaning experienced at some point in a person’s lifetime. For example:

Other disorders are relatively rare, such as:

Prevalence refers to the total number of people who have experienced a disorder during a specific period, such as over their lifetime or in a single year.

Incidence refers to the number of new cases of a disorder that emerge during a specific period (e.g., the number of people newly diagnosed in a given year).

Some mental disorders are found worldwide, while others appear only in certain cultural contexts. Generally speaking, the more biological or genetic the causes of a disorder, the more likely it is to appear across different cultures.

An example of a culturally specific disorder is Koro, observed primarily in Malaysia, Laos, the Philippines, and some other countries. Koro involves sudden, intense anxiety that the penis (in males) or the vulva and nipples (in females) will retract into the body, causing death.

Issues related to weight and body image are more prevalent in affluent societies. For instance, when considering the concepts of individualism vs. collectivism, we see cultural influence on disorders like Taijin Kyofusho. This disorder involves an intense fear that one’s body, appearance, or actions will offend, embarrass, or displease others—a concern more common in collectivist cultures.

Another example is Mal de Ojo (the “evil eye”), which is primarily found in the Mediterranean region and Latin America. In this belief, individuals think they have been cursed by someone’s envy or negative thoughts, resulting in physical or psychological distress.

Understanding cultural context is crucial in diagnosing and treating mental disorders, as cultural beliefs can shape how symptoms are experienced and expressed.

5 General Classifications

Now let’s talk about how mental disorders are classified in the DSM-5, and how this connects to the history of psychiatric diagnosis.


Photograph of Emil Kraepelin, a pioneering German psychiatrist known for his work on classifying mental disorders.
Figure 4. Emil Kraepelin, a German psychiatrist who developed one of the first systematic classifications of mental disorders and laid the foundation for modern psychiatric diagnosis. Source: Wikimedia Commons.


Much of our modern system comes from ideas originally developed by Emil Kraepelin (1856 – 1926), a German psychiatrist in the late 19th and early 20th centuries. Kraepelin believed that mental disorders were discrete diseases, each with its own symptoms, progression, and biological basis. This idea—that we can categorize mental illnesses in the same way we categorize physical illnesses—is often called the Neo-Kraepelinian approach. It strongly influenced how diagnostic manuals like the DSM were developed.

Historically, psychiatry relied heavily on broad terms like neurosis, psychosis, and character disorders:

These terms were useful for describing broad symptom clusters but proved too vague and overlapping for precise diagnosis. As psychiatry evolved, many of these broad categories were replaced by more specific diagnostic criteria.

For example, the term psychopathy historically described a severe personality disturbance involving a lack of empathy, impulsivity, and manipulative behavior. Today, while the concept persists, it is not a formal DSM diagnosis. Instead, some of its features overlap with Antisocial Personality Disorder (ASPD), though the two terms are not identical.

The DSM is updated periodically, which means diagnostic categories and terminology change over time. For instance:

One major structural change in the DSM-5 compared to the DSM-IV was the elimination of the multiaxial system. Under DSM-IV:

In DSM-5:

Also, did you notice that DSM-IV used Roman numerals while DSM-5 uses Arabic numerals? This change was intentional so that future revisions could be tracked more easily (e.g., DSM-5.1, DSM-5.2) without needing a completely new edition.

It would be impossible to cover all DSM mental disorders in class. Instead, we’ll cover a subset of the more common or more known types.

🎥 Watch this!
Follow this link to a YouTube video that explores the history of the DSM.

6 Mood Disorders

Both depression and bipolar disorder fall under the broader category of Mood Disorders. These disorders involve significant disturbances in a person’s emotional state, ranging from profound sadness to periods of excessive elation and energy.

Major Depressive Order is one of the most common psychiatric disorders, affecting about one in five people at some point in their lives. People experiencing depression often report a range of emotional symptoms such as deep sadness, a sense of hopelessness, and a loss of interest or pleasure in activities they once enjoyed. Cognitive symptoms can include negative thoughts about themselves, poor concentration, memory difficulties, and feelings of confusion. Motivation may also be affected, leading individuals to feel passive, struggle to initiate activities, and have difficulty following through with tasks. Physical symptoms frequently appear as changes in appetite and sleep patterns, persistent fatigue, increased aches and pains, and low energy. Depression is about twice as common in women as in men. If left untreated, depressive episodes can become recurring and more severe over time.


Graph showing mood fluctuations in Bipolar I, Bipolar II, and Cyclothymia.
Figure 5. Mood fluctuations in Bipolar I, Bipolar II, and Cyclothymia. Bipolar I involves full manic episodes, while Bipolar II involves hypomanic episodes and more significant depressive phases. Cyclothymia is characterized by less extreme mood swings that remain below the threshold of full mania or major depression. Source: Wikimedia Commons.


Bipolar Disorder, in contrast, is less common, affecting about 1–2% of the population. Previously referred to as manic-depressive illness, bipolar disorder is characterized by alternating episodes of depression and mania. During manic episodes, individuals may feel an extreme sense of energy, enthusiasm, and self-confidence. They may talk rapidly (pressured speech), display increased physical activity, sleep very little, and create grand plans that are often unrealistic. However, mania is not simply high energy; individuals in manic episodes can also become irritable, aggressive, or display an uncompromising attitude. In severe cases, mania may involve delusions or psychotic symptoms. People in manic states are prone to impulsive behaviors such as reckless spending, risky sexual encounters, or other dangerous activities. Bipolar disorder typically begins in young adulthood, often in the early twenties, and mood shifts tend to be more abrupt than those seen in major depression. Unlike depression, there are no significant differences in prevalence between men and women for bipolar disorder. The disorder is often recurrent, with episodes resurfacing every few years, but many individuals are able to manage symptoms successfully with treatments like lithium medication.

Mood disorders seem to arise from a combination of genetic and biological vulnerabilities. People who have a first-degree relative with depression or bipolar disorder are about three times more likely to develop one of these disorders themselves, and twin studies strongly suggest a genetic component. Research indicates that individuals with mood disorders may also have abnormalities in their neurotransmitter systems, particularly involving serotonin and norepinephrine, potentially due to fewer receptor sites or imbalances in how these chemicals function in the brain.

From a psychoanalytic perspective, depression is believed to stem from unresolved conflicts or losses that trace back to childhood experiences. For example, psychoanalytic theory suggests that if a person experiences a significant loss—such as the death of a loved one, a breakup, or the loss of a job—and lacks an inner sense of self-worth or security, they may turn their anger inward and blame themselves for the event. This self-directed anger and guilt is thought to reflect patterns established in childhood, particularly if the individual did not receive sufficient love, care, or validation during their early years.

In contrast, cognitive theories focus heavily on depression, less so on bipolar disorder, because bipolar disorder appears to have a stronger biological component. One influential cognitive theorist, Aaron Beck, proposed that people with depression tend to interpret events in their lives in negative, pessimistic, and hopeless ways. Beck described the cognitive triad, which includes negative thoughts about the self, such as feeling inadequate or worthless; negative views about the world or present experiences, like believing that others dislike or reject them; and negative expectations for the future, such as thinking that nothing will ever improve.

When discussing mood disorders, it’s crucial to address suicide, which, while not a mental disorder itself, often reflects emotional, cognitive, and behavioral symptoms associated with conditions like depression and bipolar disorder. Many misconceptions surround suicide, such as the belief that threats of self-harm are merely a cry for help or that most people are unable to carry out suicidal actions. In reality, all suicide attempts must be taken seriously. In the United States, about 1.7% of all deaths result from suicide. Although females are more likely to attempt suicide, males are more likely to die by suicide, primarily due to their choice of more lethal methods such as firearms. Suicide rates are highest among adults aged 75 and older, but it remains the second leading cause of death among young people aged 10 to 24. Firearms are by far the most common method used in completed suicides, while poisoning is the most common means of attempted suicide among women. When assessing suicide risk, mental health professionals consider factors like suicidal ideation, whether the person has a specific plan, and whether they have access to means. If someone you know is feeling suicidal, it’s crucial to encourage them to seek help, such as by calling a suicide hotline or ensuring they have supportive people around them.

7 Anxiety Disorders


Artistic depiction of a person experiencing anxiety, with abstract lines representing emotional distress.
Figure 6. Artistic depiction of anxiety. Anxiety disorders are among the most common mental health conditions, involving excessive fear, worry, and related behavioral and physiological responses. Source: Wikimedia Commons.


Anxiety disorders are among the most common mental health conditions, affecting millions of people worldwide. They involve excessive fear or anxiety that is difficult to control and significantly interferes with daily functioning. While fear is a normal response to real or perceived danger, anxiety disorders involve fears that are often disproportionate, persistent, and sometimes triggered without any obvious threat.

In the DSM-5, anxiety disorders include a range of specific diagnoses, such as Generalized Anxiety Disorder (GAD), Panic Disorder, Social Anxiety Disorder, Specific Phobias, Agoraphobia, and Separation Anxiety Disorder. Though each disorder has unique features, they share a common core of excessive worry or fear.

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a variety of topics—such as health, work, finances, or minor daily concerns—that the individual finds difficult to control. People with GAD often experience restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances.

Panic Disorder involves sudden and repeated episodes of intense fear known as panic attacks. These attacks can include physical symptoms such as a racing heart, shortness of breath, chest pain, dizziness, or feelings of impending doom. Many individuals with panic disorder develop a fear of having future attacks, leading them to avoid certain places or situations.

Social Anxiety Disorder, also known as social phobia, involves a strong fear of being judged, embarrassed, or humiliated in social or performance situations. People with social anxiety often avoid social interactions, which can interfere with relationships, work, or school.

Specific Phobias are intense, irrational fears of particular objects or situations, such as animals, heights, flying, or receiving injections. Even though the person may realize the fear is excessive, they often go to great lengths to avoid the phobic stimulus.

Agoraphobia involves fear and avoidance of places or situations where escape might be difficult or help unavailable in the event of panic-like symptoms or other distressing events. This can lead to significant restriction of daily activities, with some individuals becoming essentially homebound.

8 Schizophrenia and Other Psychotic Disorders

Schizophrenia belongs to a broader category in the DSM-5 called Schizophrenia Spectrum and Other Psychotic Disorders. This group includes conditions characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. While schizophrenia is the most well-known of these disorders, the spectrum also includes conditions such as schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and delusional disorder.

Schizophrenia itself is a severe and often debilitating psychological disorder marked by significant disruptions in personality organization, a distorted sense of reality, and substantial impairment in daily functioning. Importantly, schizophrenia appears across all cultures and populations. Individuals with this disorder often require medical treatment and may experience periods of hospitalization alongside ongoing outpatient care.

Schizophrenia is characterized by a wide range of symptoms, which clinicians typically categorize into positive symptoms and negative symptoms. Positive symptoms involve the addition of abnormal experiences or behaviors not usually present in healthy individuals, while negative symptoms involve the absence or reduction of normal functions.


Chart summarizing positive and negative symptoms of schizophrenia.
Figure 7. Positive and negative symptoms of schizophrenia include hallucinations, delusions, disorganized thinking, flat affect, avolition, social withdrawal, and more. Source: Wikimedia Commons.


One hallmark of schizophrenia is disturbances in thought. People may experience disorganized thinking, sometimes producing speech patterns known as word salad, where thoughts are expressed in a jumbled, incoherent manner, such as, “I went to the store. Coffee is too strong for me. That’s okay because the car doesn’t cost as much as she thought.” Another example is clang associations, in which speech is driven by rhyming or sound similarity rather than meaning—for example, responding, “mill, bill,” when asked, “Have you taken your pill?” Individuals may also struggle to maintain attention and experience delusions, which are firmly held false beliefs that persist despite evidence to the contrary. These delusions often include delusions of grandeur, where someone believes they possess great power or significance, or delusions of persecution, where they feel targeted or plotted against by others.

Schizophrenia also involves disturbances in perception, such as heightened sensitivity to sounds, intensified colors, or distortions in how bodies or objects appear. One of the most well-known symptoms is hallucinations, which are sensory experiences occurring in the absence of external stimuli. The most common are auditory hallucinations, such as hearing voices, while visual hallucinations are less frequent. Some hallucinations may arise from misinterpreting ordinary stimuli—for instance, interpreting the hum of an air conditioner as voices speaking, or perceiving one’s own thoughts as externally spoken words.

In terms of emotional expression, individuals may show a lack of emotional responsiveness, display sudden emotional outbursts, or exhibit emotions that are inappropriate to the situation—for example, laughing during a funeral.

There can also be significant motor symptoms and withdrawal from reality. Some individuals exhibit bizarre physical movements, such as grimacing or repetitive gestures. Others may become highly agitated and excited, or conversely, display catatonic immobility, where they remain motionless for hours, standing or sitting like a statue.

Ultimately, schizophrenia severely affects a person’s ability to function, making it difficult for many individuals to manage social interactions, hold jobs, or perform everyday tasks.

The Other Psychotic Disorders referenced in the DSM typically relate to differences in the duration of symptoms (e.g., Brief Psychotic Disorder) or cases where symptoms of psychosis overlap with mood disorders (e.g., Schizoaffective Disorder).

9 Personality Disorders

Personality disorders are enduring patterns of inner experience and behavior that deviate markedly from cultural expectations. These patterns are inflexible, pervasive across many situations, and lead to significant distress or impairment in social, occupational, or other areas of functioning. In the DSM-5, personality disorders are categorized into three clusters based on descriptive similarities.

9.1 Cluster A: Odd or Eccentric Disorders

Cluster A includes disorders characterized by odd, eccentric thinking or behavior.

  • Paranoid Personality Disorder involves a chronic and pervasive mistrust and suspicion of others, leading individuals to interpret others’ motives as malevolent—even when there’s no objective evidence.
  • Schizoid Personality Disorder is marked by a persistent lack of interest in social relationships, emotional coldness, detachment, and a preference for solitary activities. These individuals often appear indifferent to praise or criticism.
  • Schizotypal Personality Disorder includes chronic social and interpersonal deficits, along with cognitive or perceptual distortions. People may display odd beliefs, magical thinking, unusual perceptual experiences, eccentric behavior, and disorganized or peculiar speech. Though not psychotic, their symptoms sometimes resemble a milder form of schizophrenia spectrum disorders.

9.2 Cluster B: Dramatic, Emotional, or Erratic Disorders

Cluster B disorders are characterized by dramatic, overly emotional, or unpredictable thinking and behavior.

  • Antisocial Personality Disorder is characterized by a pervasive disregard for, and violation of, the rights of others. Individuals often display impulsivity, deceitfulness, irresponsibility, lack of remorse, and repeated engagement in criminal or exploitative behavior. A diagnosis requires evidence of conduct disorder symptoms before age 15 and that the individual is at least 18 years old.
  • Borderline Personality Disorder involves chronic instability in moods, self-image, and interpersonal relationships. Individuals often experience intense episodes of anger, depression, or anxiety, as well as impulsive behaviors such as self-harm or substance abuse. The term “borderline” historically referred to individuals who seemed to straddle the line between neurosis and psychosis, though this terminology is less emphasized today.
  • Histrionic Personality Disorder is marked by excessive emotionality and attention-seeking behavior. Individuals often feel uncomfortable when not the center of attention, may use physical appearance or dramatic behavior to draw notice, and can be highly suggestible or easily influenced by others.
  • Narcissistic Personality Disorder involves a pervasive pattern of grandiosity, a constant need for admiration, and a lack of empathy for others. Individuals may exploit others to achieve their own goals and often appear arrogant or entitled.

9.3 Cluster C: Anxious or Fearful Disorders

Cluster C disorders are characterized by anxious or fearful thinking and behavior.

  • Avoidant Personality Disorder involves social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Individuals may avoid social interactions due to fears of rejection, criticism, or embarrassment.
  • Dependent Personality Disorder is marked by pervasive and excessive needs to be cared for, leading to submissive and clinging behaviors, fears of separation, and difficulty making decisions without reassurance from others.
  • Obsessive-Compulsive Personality Disorder (OCPD) is characterized by a preoccupation with orderliness, perfectionism, mental and interpersonal control, and a need for control over one’s environment. Unlike Obsessive-Compulsive Disorder (OCD), OCPD does not typically involve true obsessions or compulsions but rather a rigid adherence to rules and perfectionistic standards that can interfere with relationships and productivity.

🌐 Explore this!
Follow this link to the MentalSpace website—a modern, interactive guide to mental health concepts for counselors, practitioners, and learners. Spend some time exploring the site. Click on Browse Categories and review at least one disorder you’ve already been introduced to and at least one disorder we have not discussed in class.

10 Meet Your Providers

Treatment of psychological disorders often involves a team of professionals, each with different skill sets. The table below summarizes some of the major categories.


Type of Mental Health Professional Description
Clinical psychologist Holds an academic doctorate (PhD or PsyD) and is required to be licensed to practice. Has expertise in psychological testing, diagnosis, psychotherapy, research, and prevention of mental and emotional disorders. May work in private practice, hospitals, or community mental health centers.
Counseling psychologist Holds an academic doctorate (PhD or PsyD) and is licensed to practice. Specializes in helping individuals cope with life transitions, stress, and less severe mental health issues. Often focuses on adjustment problems, career counseling, relationship concerns, and personal growth. May work in private practice, schools, colleges, or community agencies.
Psychiatrist Holds a medical degree (MD or DO) and is required to be licensed to practice. Has expertise in the diagnosis, treatment, and prevention of mental and emotional disorders. Often has training in psychotherapy. May prescribe medications, electroconvulsive therapy, or other medical procedures.
Social worker Holds a master’s degree in social work (MSW) with supervised training in social services or mental health settings. Most states require certification or licensing. May also provide psychotherapy, depending on training and licensure.
Marriage and family therapist Usually holds a master’s degree (MFT), with extensive supervised experience in couple or family therapy. May also have training in individual therapy. Many states require licensing.
Psychiatric nurse Holds an RN degree and has selected psychiatry or mental health nursing as a specialty area. Typically works on a hospital psychiatric unit or in a community mental health center. May or may not have training in psychotherapy.


There is considerable overlap among many of these professions. For example, clinical psychologists and counseling psychologists often work in similar or even interchangeable settings. Moreover, depending on the laws in specific states or the rules of governing agencies, some of these fields share professional privileges. For instance, in certain states, psychologists can earn prescribing privileges (with restrictions). Nonetheless, these subfields collaborate closely and complement one another’s skill sets. In hospitals and many other treatment settings, patients are typically seen by a variety of providers, each bringing their own unique expertise to the care team.

Even within these categories, there are many sub-specialties. For example, clinical psychologists often specialize in fields such as child clinical psychology, clinical neuropsychology, and clinical health psychology.

🧠 Clinical Note: Earlier in this course, we discussed emotional intelligence (EI)—the ability to perceive, understand, and regulate emotions. These skills are especially relevant for therapists. Research shows that clinicians with stronger EI tend to form more effective therapeutic relationships, respond more accurately to clients’ emotional cues, and manage challenging sessions with greater composure. Higher EI is also associated with lower burnout among mental-health professionals. Because the therapeutic relationship is a key predictor of treatment outcome, emotional intelligence is an important asset in a therapist’s toolkit.

11 Historical Context

An colloquial expression often used to describe different forms of treatment for mental health disorders is “hugs and drugs.” Hugs refers to psychotherapy and broader aspects of human connection, including talk therapy, support groups, counseling, empathy, and social support. Drugs refers to biomedical interventions, particularly medications such as antidepressants, antipsychotics, and mood stabilizers.

Psychotherapy involves the use of psychological techniques to help individuals cope with emotional, behavioral, and interpersonal challenges. In contrast, biomedical treatments rely on medications and other medical procedures to alleviate the symptoms associated with psychological disorders. Today, these treatment approaches seem obvious and widely accepted. However, throughout history, the ways people treated mental illness were far less humane and certainly less effective.

In ancient times, people believed that psychological illnesses were caused by possession by evil spirits. Exorcisms were performed in attempts to free a person’s soul from these demons. Treatments could be brutal, including flogging, starving, burning, or causing individuals to bleed profusely. The witch hunts of the 15th, 16th, and 17th centuries were driven by the notion that individuals thought to be mentally ill were possessed by Satan and deserved punishment. Tragically, thousands of people who were likely suffering from mental illnesses were tortured or murdered during this period.


Photograph of a human skull with two trephination holes, labeled as made by flint scraper and obsidian.
Figure 8. Human skull showing evidence of ancient trepanation — surgical openings in the skull made with tools such as flint scrapers and obsidian. Historically, this procedure was performed to address physical or mental ailments. Source: Wikimedia Commons.


While it’s easy to look back and wonder how people could be so cruel and ignorant, we have to remember the power of the placebo effect. The placebo effect refers to the fact that many people report and even experience real improvements in psychological and physical health simply because they believe they’re receiving treatment. The effectiveness of a placebo often increases when the treatment appears legitimate or dramatic. As a result, some early treatments for psychological disorders may have “worked,” at least to the extent that people felt better, and this placebo effect continues to play a role in modern treatment outcomes.

As time progressed, early asylums often viewed individuals with mental illnesses as more beast-like than human. Patients were frequently chained and confined, driven by fear that they might be dangerous. Over time, however, society’s understanding began to shift. People started to recognize that mental illness had biological and environmental causes, rather than being spiritual or moral failings. Major figures in this change were Philippe Pinel (1745–1826) and Dorothea Dix (1802–1887), whose work promoted more humane treatment of individuals with mental illness. Despite this progress, a lingering fear and stigma toward asylums and mental illness still persist in society today.

In the U.S., a significant change began in the mid-1950s with a movement called deinstitutionalization, which continued through the 1970s and 1980s. This effort aimed to transfer the care of people with mental illnesses from hospitals to community-based settings. In theory, this made sense; mental hospitals can be highly restrictive and often hinder a person’s reintegration into everyday life. Furthermore, during this time, the first effective antipsychotic medications (such as chlorpromazine) became available, offering new hope for treatment.

However, deinstitutionalization came with unforeseen consequences. Policymakers underestimated the resources that local communities would need to support people with mental illnesses. Many communities failed to pick up the slack, leaving individuals without adequate services. As a result, as many as one-third of former mental hospital patients found themselves unhoused.

Today, the mental healthcare system in the United States is widely considered to be broken—a point on which most patients, psychologists, and policymakers agree. However, there is far less consensus about the best path forward to address these challenges.

🎥 Watch this OPTIONAL!
Follow this link to a YouTube video for a FRONTLINE and ProPublica investigation into New York’s effort to let people with mental illnesses live independently

12 Psychotherapy


A modern psychotherapy office with two chairs, a small table, and calming decor.
Figure 9. A modern psychotherapy office designed to create a safe and calming environment for clients. Such spaces are intended to support open communication and emotional well-being. Source: Pixabay.


As noted above, psychotherapy refers to the treatment of psychological disorders by psychological (rather than physical or biological) means. The term embraces a number of different techniques. Each has its own idiosyncrasies in terms of goals, language, and explanations for illness and change, but they often share common elements. Indeed, surveys of practitioners consistently show that most therapists identify as either integrative, blending techniques into a unified framework, or eclectic, selecting methods pragmatically from different approaches.

It should be noted that although we would like to know the truth regarding the causes and solutions to psychological illnesses, research conducted on psychotherapy is much more focused on efficacy—the practical, real-world benefits of these techniques over and above no treatment or the placebo effect. In other words, fully understanding the cause of a mental illness may not be entirely necessary to provide effective treatment.

12.1 Psychoanalytic Therapy

Psychoanalytic therapy, created by Freud, involves exploring early relationships in childhood, particularly with parents, which have led to conflicts in the unconscious. It is hoped that by bringing these conflicts into awareness—that is, moving that which is unconscious into the conscious—a person can deal with problems in a more rational and realistic way.

Psychoanalytic therapists use techniques including free association (spontaneously saying whatever comes to mind), dream analysis (interpreting the symbolic meaning of dreams), hypnosis (a focused, suggestible state of awareness), and projective testing (using ambiguous stimuli to reveal unconscious thoughts and feelings) for exploring the unconscious.

The therapist also encourages and explores transference, which is the tendency for the client to make the therapist the object of emotional responses (e.g., seeing the therapist as a father figure). By pointing out how the client reacts to them, the therapist can help the client understand how they interact with others.

The therapist also searches for resistance, which refers to the person’s conscious or unconscious attempts to block access to repressed memories and conflicts. It is thought that only by confronting this resistance can the client gain insight into, and eventually deal with, psychological conflicts.

The therapist focuses on changing the personality. Freud believed that an unhealthy ego (the rational, reality-oriented part of personality) needs to be strengthened and given more control over the id (the instinctual, pleasure-seeking drives) and superego (the moral conscience), allowing itself to be governed by the reality principle (the ability to delay gratification and make decisions based on real-world constraints).

Traditional psychoanalysis is a very lengthy procedure, often lasting 50 or more sessions and potentially continuing indefinitely. Becuase of this length treatment process, psychoanalysts are often not reimbursed by managed care organizations (HMOs), meaning people frequently must pay for services out of pocket. This has created a situation where only a very select group of individuals has the time and financial resources to undergo psychoanalysis.

In response to this, many time-limited psychotherapies have emerged. These techniques tend to be more problem-focused and deemphasize exploring the entire childhood. This approach is often called psychodynamic therapy.

12.2 Behavioral Therapy

Behavioral therapy includes a variety of strategies and techniques based on the principles of classical and operant conditioning. Behavioral therapists believe that maladaptive behaviors are learned, and they care less about understanding the underlying causes and more about changing the problematic behaviors.

Behavioral therapy often begins with carefully defining the problematic behavior and then developing new behaviors, using classical and operant learning principles, to replace previously learned maladaptive behaviors.

Systematic desensitization involves asking the client to relax and either imagine or physically confront each situation in a hierarchy of anxiety-, depression-, or fear-provoking scenarios. The client must first learn relaxation techniques to help overcome the learned anxiety response.

In vivo exposure encourages the client to actually experience the anxiety-provoking situation in real life, using techniques developed in therapy. Like systematic desensitization, this process is often conducted in a gradual hierarchy.


A pyramid diagram showing graded steps for practicing public speaking, starting from identifying a topic and building up to giving the final presentation in class.
Figure 10. An example of an exposure hierarchy used in therapy for public speaking anxiety, where individuals gradually build confidence through increasingly challenging steps. Source: Wikimedia Commons.


The goal of both techniques is to counter-condition the client, replacing a maladaptive response (e.g., anxiety) with a more adaptive response (e.g., relaxation).

Modeling—having clients watch someone else perform an activity or face a psychologically disturbing situation—is another technique sometimes used in behavioral therapy.

Behavioral rehearsal is a type of role-playing or “dress rehearsal,” where the therapist encourages the client to practice more adaptive behaviors in a safe setting.

Clients are also taught self-regulation, which involves monitoring or observing their own behavior and using various techniques—such as self-reinforcement or self-punishment—to change maladaptive behaviors. As the saying goes, “Teach a man to fish…”

12.3 Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a general term for treatment methods that use behavior modification techniques while also incorporating strategies to change maladaptive beliefs (like those we discussed in relation to depression). CBT helps individuals recognize their cognitive distortions and challenge negative thinking patterns. Often, the psychologist encourages the client to test their negative views of themselves, the world, and the future (e.g., “I’m a complete idiot, everyone hates me, I’ll never do any better”) through behavioral experiments.

Below is an example illustrating how CBT might work in practice:

  • Antecedent
    Sally walks down the street and sees Jim, but Jim doesn’t wave.

  • Cognitive Distortion
    “Jim hates me. I’m worthless. He’s always going to hate me.”

  • Consequence
    Sally avoids Jim. Jim thinks Sally is unfriendly.

  • Better Cognition
    “Maybe Jim didn’t see me. Maybe Jim is shy.”

  • Better Consequence
    Sally says hello to Jim. Jim thinks Sally is friendly.

12.4 Humanistic Therapy

The goal of humanistic therapy is to help the client become the person they are capable of being by breaking down the barriers that prevent their natural inclination to be good and productive. The humanistic therapist encourages the client to explore their underlying emotions and motives—similar to psychoanalysts—but with an emphasis on the here and now, rather than the past.

Unlike other approaches, humanistic therapists do not interpret or attempt to modify the client’s thoughts directly. Instead, they aim to facilitate the client’s own understanding and explanation of their thoughts and behavior by remaining client-centered.

Carl Rogers believed that a therapist—or facilitator, as he preferred to call them—should demonstrate unconditional positive regard, meaning the therapist does not judge the client, no matter what the client says. Instead, the therapist remains:

  • Empathetic: Strives to understand the client’s point of view and feelings.
  • Warm: Deals with problems constructively and compassionately.
  • Genuine: Is open, honest, and authentic, rather than playing a distant “therapist role.”

12.5 Gestalt Therapy

Gestalt therapy focuses on helping individuals become intensely aware of how they are feeling and being in the present moment. The therapist works to explore unconscious processes by discovering and resolving underlying conflicts.

Gestalt therapy is often considered one of the most intense forms of therapy. Sessions can be highly confrontational and emotionally charged because the goal is to push individuals out of their emotional shells and help them become more aware of their entire personality.

12.6 Group, Family, and Marital Therapy


A group therapy session with several people sitting in a circle, engaged in discussion.
Figure 11. Group therapy sessions can provide support, shared experiences, and new perspectives, helping participants feel less alone in their struggles. Source: Wikimedia Commons.


Often, people need to work out their problems in the presence of others. Group therapy allows individuals to test their behaviors and thoughts in a social context. It also provides a sympathetic ear from others who are experiencing similar problems.

Family therapy is useful when the dynamics within a family appear to be a primary root of the problem. Family therapists understand that psychological issues are often systemic, meaning there’s a need to address multiple sources of difficulties within the family unit.

Marital or couples therapy can be valuable in helping one partner cope with a psychological illness with the support of the other. It can also help partners improve communication, develop greater understanding and sensitivity to each other’s needs, and learn more effective ways of managing conflict.

12.7 Psychotherapy with Children

All of the therapeutic models described can be used to help treat children with psychological illnesses. However, each approach has its limitations depending on factors such as the child’s age, the motivation of the parents, and the specific nature of the presenting illness.

Generally speaking, children often do not receive the psychological help they need, either because their parents fear having a “crazy child” or because their parents are not sufficiently concerned about the child’s well-being. Ironically, this lack of parental support or awareness is often the very reason why the child could benefit from therapy in the first place.

12.8 Is One Brand of Psychotherapy the Best?

So which brand of psychotherapy is the best? Although research consistently shows that psychotherapy produces moderate effect sizes in treating psychological illness, differences between the various types of therapy are usually non-existent. However, certain therapies are better suited for specific types of disorders. For example, behavioral therapy is particularly effective for treating phobias.

In addition, research shows that there are common factors underlying the effectiveness of most forms of psychotherapy. These include:

  • A warm, trusting relationship between therapist and client
  • Reassurance and emotional support, helping clients feel safe and understood
  • Desensitization, gradually reducing emotional distress related to fears or triggers
  • Reinforcement of adaptive responses, encouraging healthier behaviors and coping strategies
  • Understanding or insight into one’s thoughts, feelings, and behaviors

While techniques can be taught in school, many of these keys to therapy are likely more related to ingrained personality traits than purely academic knowledge. This probably explains why research shows that paraprofessionals can often perform quite well as therapists, and that there’s sometimes little difference in efficacy between individuals with master’s degrees and those with PhDs.

However, the more severe the disorder (e.g., schizophrenia, bipolar disorder) and the more serious the behavior involved (e.g., suicide, aggression), the more essential it becomes to have a trained professional involved. This is because there are numerous rules, procedures, and ethical considerations that must be followed in such cases.

One significant benefit of seeking help from a professional rather than a non-professional is that professionals are legally accountable for their work and are required to keep all information disclosed in therapy confidential. There is no such guarantee that a friend will do the same.

Finally, it’s important to note that many professional mental health providers—especially those with a PhD—are trained to conduct and evaluate clinical research. These clinicians are often well equipped to review the scientific literature on emerging interventions and help patients assess whether a new technique is a valid option for their treatment.

13 Biomedical Therapies

Psychotherapeutic drugs are probably the most popular form of biological therapy. They can be useful 1) because many psychological disorders seem to have biological etiologies and 2) because thought is biological in nature.


Venn diagram showing the overlap of various drug classes, including stimulants, depressants, hallucinogens, and antipsychotics, with examples of drugs listed in each category.
Figure 12. Venn diagram illustrating the relationships and overlaps among classes of psychoactive substances, including stimulants, depressants, hallucinogens, and antipsychotics. Source: Wikipedia Commons.


13.1 Psychoactive Drugs

Psychoactive drugs are substances that alter thoughts, emotions, or behaviors by affecting the brain’s chemistry. They are commonly used to treat mental health conditions. Different classes of these drugs target specific neurotransmitter systems, leading to varying therapeutic effects and side effects.

13.1.1 Antianxiety Drugs

Most drugs used to treat anxiety belong to the benzodiazepine family. They are commonly referred to by their trade names: Valium (diazepam), Librium (chlordiazepoxide), and Xanax (alprazolam). Antianxiety drugs reduce tension and cause drowsiness, as they depress the central nervous system. These tranquilizers are not as addictive as barbiturates but can still lead to dependence, particularly if a person is not also working to overcome the root causes of their anxiety or phobia.

13.1.2 Antidepressant Drugs

Drugs used to treat depression elevate the mood of depressed individuals. These medications often work by increasing the availability of norepinephrine and serotonin.

  • MAO inhibitors block the activity of an enzyme used to break down norepinephrine and serotonin, thus raising levels of these neurotransmitters in the brain.
  • Tricyclic antidepressants prevent the reuptake of norepinephrine and serotonin, also increasing their availability.

While effective, these drugs have undesirable side effects, such as dry mouth, blurred vision, constipation, and potential dangerous interactions (e.g., MAOs can be fatal when combined with certain foods).

Many newer drugs, called Selective Serotonin Reuptake Inhibitors (SSRIs) — like Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine) — produce fewer side effects but can still cause issues like sexual dysfunction, diarrhea, nausea, and nervousness.

Other medications like Effexor (venlafaxine) and Cymbalta (duloxetine) are dual-reuptake inhibitors, reducing reuptake of both serotonin and norepinephrine.

13.1.3 Antipsychotic Drugs

The first drugs used to treat schizophrenia belonged to a family called typical (first-generation) antipsychotics, many of which were phenothiazines, including Thorazine (chlorpromazine), Prolixin (fluphenazine), Stelazine (trifluoperazine), and Mellaril (thioridazine). Other first-generation drugs, such as Navane (thiothixene) and Haldol (haloperidol), are from related chemical classes but work in a similar way. Because excess dopamine activity is believed to contribute to schizophrenia, these drugs work by blocking D2 dopamine receptors, preventing the neurotransmitter’s usual effects.

Antipsychotics have been crucial in alleviating hallucinations and confusion and have helped many individuals avoid permanent institutionalization. However, they also produce significant side effects, such as dry mouth, blurred vision, and difficulties concentrating. A serious side effect is Tardive Dyskinesia (TD), involving involuntary movements of the tongue, face, mouth, or jaw — e.g., lip-smacking, sucking noises, or repeated facial grimacing. The “Thorazine shuffle,” a stereotypical shuffling gait, is due to sedation and motor side effects.

Newer atypical antipsychotics — e.g., Clozaril (clozapine), Risperdal (risperidone), Zyprexa (olanzapine), Serlect (sertindole), Seroquel (quetiapine) — target both dopamine and serotonin, producing fewer movement-related side effects (though they may cause metabolic issues like weight gain and diabetes). Third-generation antipsychotics like Abilify (aripiprazole) aim to stabilize dopamine levels more precisely by acting as partial dopamine agonists.

13.1.4 ADHD Drugs

Stimulants have been prescribed to treat ADHD for decades, including Ritalin and Concerta (methylphenidate) and Adderall (amphetamine salts). A newer non-stimulant medication is Strattera (atomoxetine).

Although public debate continues about the morality and appropriateness of medicating children, there is broad scientific consensus that these medications are effective. While overdiagnosis remains a concern for some, untreated ADHD increases risks for academic failure, social difficulties, injury, substance abuse, and even death. These medications have proven effective in reducing symptoms and improving daily functioning.

13.1.5 Psychoactive Drugs: Benefits and Controversies

Psychoactive drugs have been tremendously helpful in treating psychological illnesses, granting many individuals freedom from debilitating symptoms. Yet because these drugs alter conscious experience, cause side effects, and remain complex in their mechanisms, controversy — both justified and not — will likely persist.

13.2 Frontal Lobotomy

A frontal lobotomy is a surgical procedure in which regions of the prefrontal cortex are destroyed using a tool similar to an ice pick. Though widely criticized today, it was once considered a groundbreaking medical treatment for severe mental illnesses like schizophrenia. Many early practitioners lacked proper surgical training, and the procedure fell out of favor in the 1950s as professionals realized it quieted patients more than cured them. The introduction of antipsychotic medications provided a more humane and effective alternative. Today, the frontal lobotomy is widely recognized as both ineffective and deeply unethical, representing a serious violation of medical ethics.

13.3 Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT), also known as electroshock therapy, involves applying a mild electric current to the brain to induce a seizure similar to an epileptic convulsion. While ECT fell out of popularity with the advent of psychoactive drugs, it remains an effective modern treatment for severe depression. Today’s ECT is much safer and more humane than earlier versions, using targeted electrical currents and muscle relaxants. However, the primary side effect remains retrograde amnesia (memory loss of events prior to treatment).

13.4 Transcranial Magnetic Stimulation (TMS)

Transcranial Magnetic Stimulation (TMS) is a newer, non-invasive treatment for depression and other mental health disorders. TMS uses magnetic fields to stimulate nerve cells in specific brain regions associated with mood regulation. Unlike ECT, TMS does not require anesthesia and is not intended to cause seizures. Side effects are generally mild, such as scalp discomfort or headaches. TMS is especially useful for patients who haven’t responded well to medications or other treatments.

🎥 Videos to Watch

Please watch the following short video clips related to psychotherapy approaches:

  • 🔗 Aaron Beck on Cognitive Therapy — Watch Video
  • 🔗 Carl Rogers on Person-Centered Therapy — Watch Video
  • 🔗 Gestalt Therapy with Erving Polster — Watch Video
  • 🔗 Otto Kernberg: Psychoanalytic Psychotherapy for Personality Disorders — Watch Video
  • 🔗 The Core Components of DBT | Marsha Linehan — Watch Video
  • 🔗 What is Mindfulness? — Watch Video

14 Summary

🎥 Watch this before ending!

Summary.