AN INTERMINABLE CONVENIENCE FOR THOUGHT BY: RICHARD J.KOSCIEJEW

AN INTERMINABLE CONVENIENCE FOR THOUGHT
BY: RICHARD J.KOSCIEJEW
Freud was born in Freiberg (now Príbor, Czech Republic), on May 6, 1856, and educated at Vienna University. When he was three years old his family, fleeing from the anti-Semitic riots then raging in Freiberg, moved to Leipzig. Shortly thereafter, the family settled in Vienna, where Freud remained for most of his life.
 Although Freud’s ambition from childhood had been a career in law, he decided to become a medical student shortly before he entered Vienna University in 1873. Inspired by the scientific investigations of the German poet Goethe, Freud was driven by an intense desire to study natural science and to solve some of the challenging problems confronting contemporary scientists.
 In his third year at the university Freud began research work on the central nervous system in the physiological laboratory under the direction of the German physician Ernst Wilhelm von Brücke. Neurological research was so engrossing that Freud neglected the prescribed courses and as a result remained in medical school three years longer than was required normally to qualify as a physician. In 1881, after completing a year of compulsory military service, he received his medical degree. Unwilling to give up his experimental work, however, he remained at the university as a demonstrator in the physiological laboratory. In 1883, at Brücke’s urging, he reluctantly abandoned theoretical research to gain practical experience.
 Freud spent three years at the General Hospital of Vienna, devoting himself successively to psychiatry, dermatology, and nervous diseases. In 1885, following his appointment as a lecturer in neuropathology at Vienna University, he left his post at the hospital. Later the same year he was awarded a government grant enabling him to spend 19 weeks in Paris as a student of the French neurologist Jean Charcot. Charcot, who was the director of the clinic at the mental hospital, the Salpêtrière, was then treating nervous disorders by the use of hypnotic suggestion. Freud’s studies under Charcot, which centered largely on hysteria, influenced him greatly in channeling his interests to psychopathology.
 In 1886 Freud established a private practice in Vienna specializing in nervous disease. He met with violent opposition from the Viennese medical profession because of his strong support of Charcot’s unorthodox views on hysteria and hypnotherapy. The resentment he incurred was to delay any acceptance of his subsequent findings on the origin of neurosis.
 Freud’s first published work, On Aphasia, appeared in 1891; it was a study of the neurological disorder in which the ability to pronounce words or to name common objects is lost as a result of organic brain disease. His final work in neurology, an article, ‘Infantile Cerebral Paralysis,’ was written in 1897 for an encyclopedia only at the insistence of the editor, since by this time Freud was occupied largely with psychological rather than physiological explanations for mental illnesses. His subsequent writings were devoted entirely to that field, which he had named psychoanalysis in 1896.
 Freud’s new orientation was heralded by his collaborative work on hysteria with the Viennese physician Josef Breuer. The work was presented in 1893 in a preliminary paper and two years later in an expanded form under the title Studies on Hysteria. In this work the symptoms of hysteria were ascribed to manifestations of undischarged emotional energy associated with forgotten psychic traumas. The therapeutic procedure involved the use of a hypnotic state in which the patient was led to recall and reenact the traumatic experience, thus discharging by catharsis the emotions causing the symptoms. The publication of this work marked the beginning of psychoanalytic theory formulated on the basis of clinical observations.
 During the period from 1895 to 1900 Freud developed many of the concepts that were later incorporated into psychoanalytic practice and doctrine. Soon after publishing the studies on hysteria he abandoned the use of hypnosis as a cathartic procedure and substituted the investigation of the patient’s spontaneous flow of thoughts, called free association, to reveal the unconscious mental processes at the root of the neurotic disturbance.
 In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is defined as the unconscious defense against awareness of repressed experiences in order to avoid the resulting anxiety. He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech. Dream analysis led to his discoveries of infantile sexuality and of the so-called Oedipus complex, which constitutes the erotic attachment of the child for the parent of the opposite sex, together with hostile feelings toward the other parent. In these years he also developed the theory of transference, the process by which emotional attitudes, established originally toward parental figures in childhood, are transferred in later life to others. The end of this period was marked by the appearance of Freud’s most important work, The Interpretation of Dreams (1899). Here Freud analyzed many of his own dreams recorded in the 3-year period of his self-analysis, begun in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine.
 In 1902 Freud was appointed a full professor at Vienna University. This honor was granted not in recognition of his contributions but as a result of the efforts of a highly influential patient. The medical world still regarded his work with hostility, and his next writings, The Psychopathology of Everyday Life (1904) and Three Contributions to the Sexual Theory (1905), only increased this antagonism. As a result Freud continued to work virtually alone in what he termed ‘splendid isolation.’
 By 1906, however, a small number of pupils and followers had gathered around Freud, including the Austrian psychiatrists William Stekel and Alfred Adler, the Austrian psychologist Otto Rank, the American psychiatrist Abraham Brill, and the Swiss psychiatrists Eugen Bleuler and Carl Jung. Other notable associates, who joined the circle in 1908, were the Hungarian psychiatrist Sándor Ferenczi and the British psychiatrist Ernest Jones.
 Austrian doctor Sigmund Freud spent many hours refining his theories in this study of his home in Vienna, Austria. Freud pioneered the use of clinical observation to treat mental disease. The publication of The Interpretation of Dreams in 1899 detailed his technique of isolating the source of psychological problems by examining a patient’s spontaneous stream of thought.
 Increasing recognition of the psychoanalytic movement made possible the formation in 1910 of a worldwide organization called the International Psychoanalytic Association. As the movement spread, gaining new adherents through Europe and the U.S., Freud was troubled by the dissension that arose among members of his original circle. Most disturbing were the defections from the group of Adler and Jung, each of whom developed a different theoretical basis for disagreement with Freud’s emphasis on the sexual origin of neurosis. Freud met these setbacks by developing further his basic concepts and by elaborating his own views in many publications and lectures.
 After the onset of World War I Freud devoted little time to clinical observation and concentrated on the application of his theories to the interpretation of religion, mythology, art, and literature. In 1923 he was stricken with cancer of the jaw, which necessitated constant, painful treatment in addition to many surgical operations. Despite his physical suffering he continued his literary activity for the next 16 years, writing mostly on cultural and philosophical problems.
 When the Germans occupied Austria in 1938, Freud, a Jew, was persuaded by friends to escape with his family to England. He died in London on September 23, 1939.
 Freud created an entirely new approach to the understanding of human personality by his demonstration of the existence and force of the unconscious. In addition, he founded a new medical discipline and formulated basic therapeutic procedures that in modified form are applied widely in the present-day treatment of neuroses and psychoses. Although never accorded full recognition during his lifetime, Freud is generally acknowledged as one of the great creative minds of modern times.
 Among his other works are Totem and Taboo (1913), Ego and the Id (1923), New Introductory Lectures on Psychoanalysis (1933), and Moses and Monotheism (1939).
 Carl Jung (1875-1961), Swiss psychiatrist, who founded the analytical school of psychology. Jung broadened Sigmund Freud's psychoanalytical approach, interpreting mental and emotional disturbances as an attempt to find personal and spiritual wholeness.
 Born on July 26, 1875, in Kesswil, Switzerland, the son of a Protestant clergyman, Jung developed during his lonely childhood an inclination for dreaming and fantasy that greatly influenced his adult work. After graduating in medicine in 1902 from the universities of Basel and Zürich, with a wide background in biology, zoology, paleontology, and archaeology, he began his work on word association, in which a patient's responses to stimulus words revealed what Jung called ‘complexes’—a term that has since become universal. These studies brought him international renown and led him to a close collaboration with Freud. With the publication of Psychology of the Unconscious (1912; trans. 1916), however, Jung declared his independence from Freud's narrowly sexual interpretation of the libido by showing the close parallels between ancient myths and psychotic fantasies and by explaining human motivation in terms of a larger creative energy. He gave up the presidency of the International Psychoanalytic Society and cofounded a movement called analytical psychology.
 During his remaining 50 years Jung developed his theories, drawing on a wide knowledge of mythology and history; travels to diverse cultures in New Mexico, India, and Kenya; and especially the dreams and fantasies of his childhood. In 1921 he published a major work, Psychological Types (trans. 1923), in which he dealt with the relationship between the conscious and unconscious and proposed the now well-known personality types, extrovert and introvert. He later made a distinction between the personal unconscious, or the repressed feelings and thoughts developed during an individual's life, and the collective unconscious, or those inherited feelings, thoughts, and memories shared by all humanity. The collective unconscious, according to Jung, is made up of what he called ‘archetypes,’ or primordial images. These correspond to such experiences as confronting death or choosing a mate and manifest themselves symbolically in religions, myths, fairy tales, and fantasies.
 Jung's therapeutic approach aimed at reconciling the diverse states of personality, which he saw divided not only into the opposites of introvert and extrovert, but also into those of sensing and intuiting, and of feeling and thinking. By understanding how the personal unconscious integrates with the collective unconscious, Jung theorized, a patient can achieve a state of individuation, or wholeness of self.
 Jung wrote voluminously, especially on analytical methods and the relationships between psychotherapy and religious belief. He died on June 6, 1961, in Küsnacht.
 Alfred Adler (1870-1937), Austrian psychologist and psychiatrist, born in Vienna, and educated at Vienna University. After leaving the university he studied and was associated with Sigmund Freud, the founder of psychoanalysis. In 1911 Adler left the orthodox psychoanalytic school to found a neo-Freudian school of psychoanalysis. After 1926 he was a visiting professor at Columbia University, and in 1935 he and his family moved to the United States.
 In his analysis of individual development, Adler stressed the sense of inferiority, rather than sexual drives, as the motivating force in human life. According to Adler, conscious or subconscious feelings of inferiority (to which he gave the name inferiority complex), combined with compensatory defence mechanisms, are the basic causes of psychopathological behaviour. The function of the psychoanalyst, furthermore, is to discover and rationalize such feelings and break down the compensatory, neurotic will for power that they engender in the patient. Adler's works include The Theory and Practice of Individual Psychology (1918) and The Pattern of Life (1930).
 Jean Martin Charcot (1825-1893), French neurologist, considered the father of clinical neurology, born in Paris, and educated at the University of Paris. In 1856 he was appointed physician to the Central Bureau of Hospitals. In 1860 he became professor of pathological anatomy in the faculty of medicine at the University of Paris. Two years later he joined the staff of the Salpêtrière Hospital, and he opened the most highly regarded neurological clinic of his day. He specialized in the study of hysteria, locomotor ataxia, hypnosis, and aphasia. Cerebrospinal sclerosis was named Charcot's disease after him. Achieving international fame, Charcot became an honorary member of the American Neurological Association in 1881. He attracted pupils and scientists from all over the world. His most celebrated pupil was Sigmund Freud.
 Wilhelm Reich (1897-1957), Austrian psychoanalyst and biophysicist. Once associated with Sigmund Freud's Viennese clinic, he broke with Freud's movement and later immigrated to the United States, where he taught at the New School for Social Research in New York City from 1939 to 1941. By this time Reich had developed his theory of an orgone energy, postulating that this energy permeates the universe and that humans must release it through sexual activity if they are not to develop neuroses. In 1942 he founded the Orgone Institute and invented an ‘orgone box’ to aid in energy release; however, he was found guilty of fraudulent claims for his methods and sentenced to two years in a federal penitentiary, where he died. Reich's actual contributions to psychology are still the subject of a great deal of controversy.
 Like Jung, Austrian physician Alfred Adler believed that Freud overemphasized the importance of sexual and aggressive drives. Adler was particularly interested in sibling relationships, birth order, and relationships with parents. He would ask patients about their early memories and use this information to analyze their attitudes, beliefs, and behaviours. He helped his patients by encouraging them to meet important life goals: love, work, and friendship.
 For Adler and modern therapists who draw from his work, interest in others and participation in society are important goals of therapy. Adlerian therapists see therapy in part as educational, and they use a number of innovative action techniques to help patients change mistaken beliefs and interact more fully with family members and others.
 Humanistic therapies focus on the client's present rather than past experiences, and on conscious feelings rather than unconscious thoughts. Therapists try to create a caring, supportive atmosphere and to guide clients toward personal realizations and insights. Clients are encouraged to take responsibility for their lives, to accept themselves, and to recognize their own potential for growth and change.
 The length of therapy depends on the severity of the problem and on a client's ability to change and try new behaviours. Because humanistic therapies emphasize the relationship between client and therapist and a gradual development of increased responsibility by the client, these therapies typically take a year or two of weekly sessions.
 Three of the most influential forms of humanistic therapy are existential therapy, person-centred therapy, and Gestalt therapy.
 Based on a philosophical approach to people and their existence, existential therapy deals with important life themes. These themes include living and dying, freedom, responsibility to self and others, finding meaning in life, and dealing with a sense of meaninglessness. More than other kinds of therapists, existential therapists examine individuals' awareness of themselves and their ability to look beyond their immediate problems and daily events to problems of human existence.
 The first existential therapists were European psychiatrists trained in psychoanalysis who were dissatisfied with Freud's emphasis on biological drives and unconscious processes. Existential therapists help their clients confront and explore anxiety, loneliness, despair, fear of death, and the feeling that life is meaningless. There are few techniques specific to existential therapy. Therapists normally draw on techniques from a variety of therapies. One well-known existential therapy is logotherapy, developed by Austrian psychiatrist Viktor E. Frankl in the 1940s (logos is Greek for meaning).
 Viktor Frankl (1905-1997), Austrian psychiatrist who developed a form of existential psychotherapy known as logotherapy. Logotherapy is based on Frankl’s theory that the underlying need of human existence is to find meaning in life (logos is a Greek word for ‘meaning’).
 Born in Vienna, Austria, Frankl was educated at the University of Vienna, where he earned a medical degree in 1930. In 1942 Frankl and his family, who were Jewish, were arrested by the Nazis and imprisoned in concentration camps. Frankl’s mother, father, brother, and pregnant wife were all killed in the camps. Frankl spent the next three years at Auschwitz, Dachau, and other concentration camps. During his imprisonment, Frankl helped despairing prisoners maintain their psychological health. He also recorded, on stolen bits of paper, his theories and experiences, which he later made use of in his books. After his release, Frankl returned to Vienna and became professor of neurology and psychiatry at the University of Vienna Medical School, a position he retained for the rest of his career.
 In his best-known book, Man's Search for Meaning: An Introduction to Logotherapy (1962; translated into English, 1970), Frankl described how he and other prisoners in the concentration camps found meaning in their lives and summoned the will to survive. The remainder of the book outlines the theory and practice of logotherapy. In addition to its influence on the field of psychotherapy, Man’s Search for Meaning found an enormous readership among the general public. By the time of Frankl’s death, it had sold more than 10 million copies in 24 languages. Frankl published 31 other books on his psychological theories.
 In the 1940's and 1950's American psychologist Carl Rogers developed a form of psychotherapy known as person-centred therapy. This approach emphasizes that each person has the capacity for self-understanding and self-healing. The therapist tries to demonstrate empathy and true caring for clients, allowing them to reveal their true feelings without fear of being judged.
 Person-centred therapy, originally called client-centered therapy, is perhaps the best-known form of humanistic therapy. American psychologist Carl Rogers developed this type of therapy in the 1940's and 1950's. Rogers believed that people, like other living organisms, are driven by an innate tendency to maintain and enhance themselves, which in turn moves them toward growth, maturity, and life enrichment. Within each person, Rogers believed, is the capacity for self-understanding and constructive change.
 Person-centred therapy emphasizes understanding and caring rather than diagnosis, advice, and persuasion. Rogers strongly believed that the quality of the therapist-client relationship influences the success of therapy. He felt that effective therapists must be genuine, accepting, and empathic. A genuine therapist expresses true interest in the client and is open and honest. An accepting therapist cares for the client unconditionally, even if the therapist does not always agree with him or her. An empathic therapist demonstrates a deep understanding of the client's thoughts, ideas, experiences, and feelings and communicates this empathic understanding to the client. Rogers believed that when clients feel unconditional positive regard from a genuine therapist and feel empathically understood, they will be less anxious and more willing to reveal themselves and their weaknesses. By doing so, clients gain a better understanding of their own lives, move toward self-acceptance, and can make progress in resolving a wide variety of personal problems.
 Person-centred therapists use an approach called active listening to demonstrate empathy—letting clients know that they are being fully listened to and understood. First, therapists must show through their body position and facial expression that they are paying attention—for example, by directly facing the client and making good eye contact. During the therapy session, the therapist tries to restate what the client has said and seeks clarification of the client’s feelings. The therapist may use such phrases as ‘What I hear you saying is…’ and ‘You’re feeling like…’ The therapist seeks mainly to reflect the client’s statements back to the client accurately, and does not try to analyze, judge, or lead the direction of discussion. For example:
 Client: I always felt my husband loved me. I just don’t understand why this happened.
 Therapist: You feel surprised by the fact that he left you, because you thought he loved you. It comes as a real surprise.
 Client: M-hm. I guess I haven’t really accepted that he could do this to me. A big part of me still loves him.
 Therapist: You seem to still be hurting from what he did. The love you have for him is so strong.
Many therapists, not just those of humanistic orientation, have adopted elements of Rogers’s approach.
 Gestalt is a German word referring to wholeness and the concept that a whole unit is more than the sum of its parts. Gestalt therapy was developed in the 1940s and 1950s by Frederick (Fritz) Perls, a German-born psychiatrist who immigrated to the United States. Like person-centred therapy, Gestalt therapy tries to make individuals take responsibility for their own lives and personal growth and to recognize their capacity for healing themselves. However, Gestalt therapists are willing to use confrontational questions and techniques to help clients express their true feelings. In the following example, the therapist helps the client become more aware of her own behaviour and her responsibility for it:
 Client: You know, you just can't do anything right in today's world.
 Therapist: Please repeat that phrase using the word I instead of you.
 Client: I can't do anything right, it seems.
 Therapist: Would you change the word can't to won't?
 Client: I won't do anything right.
 Therapist: What won't you do that you want to do?
The general goal of Gestalt therapy is awareness of self, others, and the environment that brings about growth, wholeness, and integration of one’s thoughts, feelings, and actions. Gestalt therapists use a wide variety of techniques to make clients more aware of themselves, and they often invent or experiment with techniques that might help to accomplish this goal. One of the best-known Gestalt techniques is the empty-chair technique, in which an empty chair represents another person or another part of the client’s self. For example, if a client is angry at herself for not being kinder to her mother, the client may pretend her mother is sitting in an empty chair. The client may then express her feelings by speaking in the direction of the chair. Alternatively, the client might play the role of the understanding daughter while sitting in one chair and the angry daughter while sitting in another. As she talks to different parts of herself, differences may be resolved. The empty-chair technique reflects Gestalt therapy’s strong emphasis on dealing with problems in the present.
 Behavioural therapies differ dramatically from psychodynamic and humanistic therapies. Behavioural therapists do not explore an individual’s thoughts, feelings, dreams, or past experiences. Rather, they focus on the behaviour that is causing distress for their clients. They believe that behaviour of all kinds, both normal and abnormal, is the product of learning. By applying the principles of learning, they help individuals replace distressing behaviours with more appropriate ones.
 Typical problems treated with behavioural therapy include alcohol or drug addiction, phobias (such as a fear of heights), and anxiety. Modern behavioural therapists work with other problems, such as depression, by having clients develop specific behavioural goals—such as returning to work, talking with others, or cooking a meal. Because behavioural therapy can work through nonverbal means, it can also help people who would not respond to other forms of therapy. For example, behavioural therapists can teach social and self-care skills to children with severe learning disabilities and to individuals with schizophrenia who are out of touch with reality.
 Behavioural therapists begin treatment by finding out as much as they can about the client's problem and the circumstances surrounding it. They do not infer causes or look for hidden meanings, but rather focus on observable and measurable behaviours. Therapists may use a number of specific techniques to alter behaviour. These techniques include relaxation training, systematic desensitization, exposure and response prevention, aversive conditioning, and social skills training.
 Relaxation training is a method of helping people with high levels of anxiety and stress. It also serves as an important component of some other behavioural treatments.
 In one type of relaxation exercise, people learn to tighten and then relax one muscle group at a time. This method, called progressive relaxation, was developed in the 1930s by American physiologist and psychologist Edmund Jacobson. At first, the therapist gives spoken instructions to the client. Later the client can practice the relaxation exercise at home using a tape recording of the therapist’s voice. The following example, adapted from Jacobson’s work, illustrates a brief relaxation procedure:
 Just settle back as comfortably as you can, close your eyes, and let yourself relax to the best of your ability … Now clench up both fists tighter and tighter and study the tension as you do so. Keep them clenched and feel the tension in your fists, hands, forearms … Now relax. Let the fingers of your hands become loose and observe the contrast in your feelings … Now let yourself go and try to become more relaxed all over. Take a deep breath … Just let your whole body become more and more relaxed.
 Another relaxation technique is meditation. In meditation, people try to relax both the mind and the body. In many forms of meditation, people begin by sitting comfortably on a cushion or chair. Then they gradually relax their body, begin to breathe slowly, and concentrate on a sensation—such as the inhaling and exhaling of breath—or on an image or object. In Transcendental Meditation, a person does not try to concentrate on anything, but merely sits in a quiet atmosphere and repeats a mantra (a specially chosen word) to try to achieve a state of restful alertness.
 Systematic desensitization, a procedure developed by South African psychiatrist Joseph Wolpe in the 1950s, gradually teaches people to be relaxed in a situation that would otherwise frighten them. It is often used to treat phobias and other anxiety disorders. The word desensitization refers to making people less sensitive to or frightened of certain situations.
 In the first step of desensitization, the therapist and client establish an anxiety hierarchy - a list of fear-provoking situations arranged in order of how much fear they provoke in the client. For a man afraid of spiders, for example, holding a spider may rank at the top of his anxiety hierarchy, whereas seeing a small picture of a spider may rank at the bottom. In the second step, the therapist has the client relax using one of the relaxation techniques described above. Then the therapist asks the client to imagine each situation on the anxiety hierarchy, beginning with the least-feared situation and moving upward. For example, the man may first imagine seeing a picture of a spider, then imagine seeing a real spider from far away, then from a short distance, and so forth. If the client feels anxiety at any stage, he or she is instructed to stop thinking about the situation and to return to a state of deep relaxation. The relaxation and the imagined scene are paired until the client feels no further anxiety. Eventually the client can remain free of anxiety while imagining the most-feared situation.
 Asking a client to encounter the feared situation is a technique called in vivo exposure. For the man who is afraid of spiders, a therapist might arrange to go to a park or zoo where visitors can touch large spiders. The therapist would model for the client how to approach a spider and how to handle it. The therapist may also encourage the man to walk gradually closer to the spider, reinforcing his progress with praise and reassurance as he does so. The goal for the therapist and patient would be for the man to pick up the spider.
 Problems are rarely as clear and simple as fear of spiders. Therapists may spend considerable time deciding on appropriate goals, which ones to pursue first, and then reevaluating or changing goals as therapy progresses. Systematic desensitization typically takes from 10 to 30 sessions, depending on the severity of the problem. In vivo therapies are more direct and may take less time.
 Exposure and response prevention is a behavioural technique often used to treat people with obsessive-compulsive disorder. In this technique, the therapist exposes the client to the situation that causes obsessive thoughts, but then prevents the client from acting on these thoughts. For example, to treat people who compulsively wash their hands because they fear contamination from germs, a therapist might have them handle something dirty and then prevent them from washing their hands. Therapists have also experimented with exposure and response prevention to treat people with bulimia nervosa, an eating disorder in which people engage in binge eating and afterward force themselves to vomit or, more occasionally, take laxatives. The therapist feeds the bulimic patients small amounts of food but prevents them from binging, taking laxatives, or vomiting.
 Behavioural therapists occasionally use a technique called aversive conditioning or aversion therapy. In this method, clients receive an unpleasant stimulus, such as an electric shock, whenever they perform an undesirable behaviour. For example, therapists treating patients with alcoholism may have them ingest the drug disulfiram (Antabuse). The drug makes the patients violently sick if they drink alcohol. Many therapists have found that aversive conditioning is not as effective as other behavioural techniques, and as a result, they use this technique very infrequently. For some problems, however, aversive conditioning can work when all other techniques have failed. For example, therapists have found that immediate application of an unpleasant stimulus can eliminate self-mutilation and other self-destructive behaviours in children with autism.
 Social skills training is a method of helping people who have problems interacting with others. Clients learn basic social skills such as initiating conversations, making eye contact, standing at the appropriate distance, controlling voice volume and pitch, and responding to questions. The therapist first describes and models the behaviour. Then the patient or client practices the behaviour in skits or role-playing exercises. The therapist watches the exercises and provides constructive criticism and further modelling. Therapists often conduct this kind of training with groups of people with similar problems. Social skills training often can help people with schizophrenia function more easily in public situations and reduce their risk of relapse or re-hospitalization.
 One popular form of social skills training is assertiveness training, another technique pioneered by Joseph Wolpe. This technique teaches people, often those who are shy, to make appropriate responses when someone does something to them that seems inappropriate or offensive or violates their rights. For example, if a woman has trouble saying no to a coworker who inappropriately asks her to handle some of his job responsibilities, she may benefit from learning how to become more assertive. In this example, the therapist would model assertive behaviour for the client, who would then role-play and rehearse appropriate responses to her coworker.
 Cognitive therapies are similar to behavioural therapies in that they focus on specific problems. However, they emphasize changing beliefs and thoughts, rather than observable behaviours. Cognitive therapists believe that irrational beliefs or distorted thinking patterns can cause a variety of serious problems, including depression and chronic anxiety. They try to teach people to think in more rational, constructive ways.
 In the mid-1950's American psychologist Albert Ellis developed one of the first cognitive approaches to therapy, rational-emotive therapy, now commonly called rational-emotive behaviour therapy. Trained in psychoanalysis in the 1940's, Ellis quickly became disillusioned with psychoanalytic methods, viewing them as slow and inefficient. Influenced by Alfred Adler’s work, Ellis came to regard irrational beliefs and illogical thinking as the major cause of most emotional disturbances. In his view, negative events such as losing a job or breaking up with a lover do not by themselves cause depression or anxiety. Rather, emotional disorders result when a person perceives the events in an irrational way, such as by thinking, ‘I’m a worthless human being.’
 Although rational-emotive behaviour therapists use many techniques, the most common technique is that of disputing irrational thoughts. First the therapist identifies irrational beliefs by talking with the client about his or her problems. Examples of irrational beliefs, according to Ellis, include the idea that unhappiness is caused by external events, the idea that one must be accepted and loved by everyone, and the idea that one must always be competent and successful to be a worthwhile person.
 To dispute the client’s irrational beliefs and longstanding assumptions, rational-emotive behaviour therapists often use confrontational techniques. For example, if a student tells the therapist, ‘I must get an A on this test or I will be a failure in life,’ the therapist might say, ‘Why must you? Do you think your entire career as a student will be through if you get a B?’ The therapist helps the client replace irrational thoughts with more reasonable ones, such as ‘I would like to get an A on the test, but if I don't, I have strategies I can use to do better next time.’
 Like Ellis before him, American psychiatrist Aaron T. Beck became disenchanted with psychoanalysis, finding that it often did not help relieve depression for his patients. In the 1960s Beck developed his own form of cognitive therapy for treating depression, and later applied it to other disorders. In Beck’s view, depressed people tend to have negative views of themselves, interpret their experiences negatively, and feel hopeless about their future. He sees these tendencies as a problem of faulty thinking. Like rational-emotive behaviour therapists, practitioners of Beck’s technique challenge the client's absolute, extreme statements. They try to help the client identify distorted thinking, such as thinking about negative events in catastrophic terms, and then suggest ways to change this thinking. The following example illustrates how a cognitive therapist might challenge a client’s absolute statement.
 Client: Everyone at work is smarter than me.
 Therapist: Everyone? Every single person at work is smarter than you?
 Client: Well, maybe not. There are a lot of people at work I don't know well at all. But my boss seems smarter; she seems to really know what's going on.
 Therapist: Notice how we went from everyone at work being smarter than you to just your boss.
Cognitive therapists often give their clients homework assignments designed to help them identify their own irrational patterns of thinking and to reinforce what they learn in therapy. For example, clients often keep a daily log in which they write down distressing emotions, the situation that caused the emotions, their thoughts at the time, whether the thoughts were distorted or not, and alternative ways of thinking about the situation.
 Helping individuals change problematic behaviours, thoughts, or feelings is not an easy task. Therapists have tried many creative approaches to help patients, some of which do not fall neatly into the major categories of psychodynamic, humanistic, behavioural, or cognitive. Two such therapies still in use today are transactional analysis and reality therapy.
 In the 1950's and 1960's Canadian-American psychiatrist Eric Berne developed a form of therapy he called transactional analysis. Although trained in psychoanalysis, Berne felt that the complexity of psychoanalytic terminology excluded patients from full participation in their own treatment. He developed a theory of personality based on the view that when people interact with each other, they function either as a parent, adult, or child. For example, he would characterize social interactions between two people as parent-adult, parent-child, adult-child, adult-adult, and so forth depending on the situation. He referred to social interactions as transactions and to analysis of these interactions as transactional analysis.
 In therapy, which is often conducted in groups, patients learn to recognize when they are assuming one of these roles and to understand when being an authoritarian parent or an impulsive child is appropriate or inappropriate. In addition to identifying these roles, clients learn how to change roles in order to behave in more desirable ways.
 American psychiatrist William Glasser developed reality therapy in the 1960's, after working with teenage girls in a correctional institution and observing work with severely disturbed schizophrenic patients in a mental hospital. He observed that psychoanalysis did not help many of his patients change their behaviour, even when they understood the sources of it. Glasser felt it was important to help individuals take responsibility for their own lives and to blame others less. Largely because of this emphasis on personal responsibility, his approach has found widespread acceptance among drug- and alcohol-abuse counselors, corrections workers, school counselors, and those working with clients who may be disruptive to others.
 Reality therapy is based on the premise that all human behaviour is motivated by fundamental needs and specific wants. The reality therapist first seeks to establish a friendly, trusting relationship with clients in which they can express their needs and wants. Then the therapist helps clients explore the behaviours that created problems for them. Clients are encouraged to examine the consequences of their behaviour and to evaluate how well their behaviour helped them fulfill their wants. The therapist does not accept excuses from clients. Finally, the therapist helps the client formulate a concrete plan of action to change certain behaviours, based on the client’s own goals and ability to make choices.
 Currently, many therapists describe their approach as eclectic or integrative, meaning that they use ideas and techniques from a variety of therapies. Many therapists like the opportunity to draw from many theories and not limit themselves to one or two. Most therapists who adopt an eclectic approach have a rationale for which techniques they use with specific clients, rather than just choosing an approach randomly or because it suits them at the time.
 One of the most influential eclectic approaches is cognitive-behavioural therapy. Other eclectic approaches use other combinations of therapies.
 There are almost no pure cognitive or behavioural therapists. Usually therapists combine cognitive and behavioural techniques in an approach known as cognitive-behavioural therapy. For example, to treat a woman with depression, a therapist may help her identify irrational thinking patterns that cause the distressing feelings and to replace these irrational thoughts with new ways of thinking. The therapist may also train her in relaxation techniques and have her try new behaviours that help her become more active and less depressed. The client then reports the results back to the therapist.
 Cognitive-behavioural therapy has rapidly become one of the most popular and influential forms of psychotherapy, in part because it takes a relatively short period of time compared to humanistic and psychoanalytic therapies, and also because of its ability to treat a wide range of problems. Sometimes cognitive-behavioural therapy takes only a few sessions, but more often it extends for 20 or 30 sessions over four to six months. The length of therapy usually depends on the severity and number of the client’s problems.
 Some therapists have one particular way of understanding clients - that is, they adhere to one theory of personality—but use many techniques from a variety of theories. Other therapists may understand clients using two or three theories of personality and only use techniques to bring about change that are consistent with those theories. Some therapists have combined psychodynamic and behavioural therapies in ways to help their clients deal with fears and anxieties but also understand their causes.
 Therapists may use different approaches to treat different problems. For example, a therapist might find that clients who are grieving over the loss of a spouse may respond best to a humanistic approach, in which they can share their grieving and their hurts with the therapist. However, the same therapist may use a cognitive-behavioural approach with a person who reports being anxious most of the time.
 All of the individual therapies can also be used with groups. People may choose group therapy for several reasons. First, group therapy is usually less expensive than individual therapy, because group members share the cost. Group therapy also allows a therapist to provide treatment to more people than would be possible otherwise. Aside from cost and efficiency advantages, group therapy allows people to hear and see how others deal with their problems. In addition, group members receive vital support and encouragement from others in the group. They can try out new ways of behaving in a safe, supportive environment and learn how others perceive them.
 Groups also have disadvantages. Individuals spend less time talking about their own problems than they would in one-on-one therapy. Also, certain group members may interact with other group members in hurtful ways, such as by yelling at them or criticizing them harshly. Generally, therapists try to intercede when group members act in destructive ways. Another disadvantage of group therapy involves confidentiality. Although group members usually promise to treat all therapy discussions as confidential, some group members may worry that other members will share their secrets outside of the group. Group members who believe this may be less willing to disclose all of their problems, lessening the effectiveness of therapy for them.
 Groups vary widely in how they work. The typical group size is from six to ten people with one or two therapists. Often two therapists prefer to work together in a group so that they can respond not only to one person’s issues, but also to discussions between group members that may be occurring quickly. Some groups are open or drop-in groups—new clients may join at any time and members may attend or skip whatever sessions they desire. Other groups are closed and admit new members only when all members agree. Regular attendance is usually required in these groups. In closed groups, both the therapist and group members will ask a member to provide an explanation for missing a meeting.
 When forming a group, therapists try to make clear to potential participants the goals of the group and for whom it is appropriate. Therapists will often screen potential participants to learn about their problems and decide whether the group is right for them. Sometimes therapists prefer diversity among group members in terms of age, gender, and problem. In other cases, therapists may limit membership in a group to individuals with similar problems and backgrounds. For example, some groups may form specifically for individuals who are grieving the loss of a loved one, individuals who abuse drugs or alcohol, people with eating disorders, people suffering from depression, or troubled elderly individuals.
 The techniques used in group therapy depend largely on the theoretical orientation of the therapist. Humanistic therapists tend to respond to the feelings and experiences of other members. They may also interpret or comment on social interactions between group members. In cognitive-behavioural groups, group members try to change their own thoughts and behaviours and support and encourage other members to do the same. Psychoanalytic groups focus on childhood experiences and their impact on participants’ current behaviours, thoughts, and feelings.
 Psychodrama, the first form of group therapy, was developed in the 1920s by Jacob L. Moreno, an Austrian psychiatrist. Moreno brought his method to the United States in 1925, and its use spread to other parts of the world. Participants in psychodrama act out their problems—often on a real stage and with props—as a means of heightening their awareness of them. The therapist serves as the director, suggesting how participants might act out problems and assigning roles to other group members. For example, a woman might reenact a scene from her childhood with other group members playing her father, mother, brother, or sister. Groups who use psychodrama may do so weekly or simply as a one-time demonstration.
 A self-help group or support group involves people with a common problem who meet regularly to share their experiences, support each other emotionally, and encourage change or recovery. They are usually free of charge to interested participants. Self-help groups are not strictly considered psychotherapy because they are not led by a licensed mental health professional. However, they can serve as an important source of help for people in emotional distress.
 There are thousands of self-help and support groups in the United States and Canada. The oldest and best known is Alcoholics Anonymous, which uses a 12-step program to treat alcoholism. Other groups have formed for cancer patients, parents whose children have been murdered, compulsive gamblers, battered women, obese people, and many other types of people.
 Family therapy involves the participation of one or more members of the same family who seek help for troubled family relationships or the problems of individual family members. Typical problems that bring families into family therapy are delinquent behaviour by a child or adolescent, a child’s poor performance in school, hostilities between a parent and child or between siblings, and severe psychological disturbance or mental illness in a parent or child.
 One of the most influential forms of family therapy, family systems therapy, views the family as a single, complex system or unit. Individual members are interdependent parts of the system. Rather than treating one person’s symptoms in isolation, therapists try to understand the symptoms in the larger context of the family. For example, a boy who begins picking fights with classmates might do so to get more attention from his busy parents. Therapists work from the rationale that current family relationships profoundly affect, and are affected by, an individual family member’s psychological problems. For this reason, most family therapists prefer to work with the entire family during a session, rather than meeting with family members individually.
 In most family therapy sessions, the therapist encourages family members to air their feelings, frustrations, and hostilities. By observing how they interact, the therapist can help them recognize their roles and relationships with each other. The therapist tries to avoid assigning blame to any particular family member. Instead, the therapist makes suggestions about how family members might adjust their roles and prevent future conflict.
 Couples therapy, also called marital therapy or marriage counseling, is designed to help intimate partners improve their relationship. Therapists treat married couples as well as unmarried couples of the opposite or same sex. Therapists normally hold sessions with both partners present. At certain times during therapy, however, the therapist may choose to see the partners individually.
 Couples may seek therapy for a variety of problems, many of which concern a breakdown of communication or trust between the partners. For example, an extramarital affair by one partner may cause the other partner to feel emotional pain, anger, and distrust. Some partners may feel distant from one another or experience sexual problems. In other cases, one or both partners may have psychological problems or alcohol or drug problems that negatively affect their relationship.
 The techniques used in therapy vary depending on the theoretical orientation of the therapist and the nature of the couple’s problem. Most often, therapists focus on improving communication between partners and on helping them learn to manage conflict. By observing the partners as they talk to each other, the therapist can learn about their communication patterns and the roles they assume in their relationship. The therapist may then teach the partners new ways of expressing their feelings verbally, how to listen to each other, and how to work together to solve problems. The therapist may also suggest that they try out new roles. For example, if one partner makes all of the decisions in the relationship, the therapist may encourage the couple to try sharing decision-making power.
 Because most couples therapists also have training in family therapy, they often examine the influence of the couple’s relationships with parents, children, and siblings. Psychoanalytically oriented therapists may focus on how the partners’ childhood experiences affect their current relationship with each other. For couples who cannot work through their differences or reestablish trust and intimacy, separation or divorce may be the best choice. Therapists can help such partners separate in constructive ways.
 Some psychotherapists specialize in working with children. Therapists deal with children who are anxious, depressed, or have difficulty getting along with others at home or school. Some children have psychological problems resulting from family issues such as divorce, new stepparents, single-parent homes, death of a parent or sibling, being homeless, or being raised in an alcoholic family. Other children have emotional problems related to physical disabilities, learning disabilities, or attention-deficit hyperactivity disorder.
 Play therapy is a special technique that therapists often use with children aged 2 to 12. For children, play is a natural way of learning and relating to others. Play therapy can help therapists both to understand children's problems and to help children deal with their feelings, behaviours, and thoughts. Therapists may use playhouses, puppets, a toy telephone, dolls, sandboxes, food, finger paints, and other toys or objects to help children express their thoughts and feelings. In addition to projecting a caring and gentle manner, therapists who work with children are trained to understand and interpret children’s nonverbal and verbal expressions.
 Can memories of early childhood abuse be forgotten and then recovered later in life? Criminal accusations based on recovered memories pose complex questions for the legal system and stir heated debate among psychologists. In this essay written for Encarta Encyclopedia, psychologist Henry L. Roediger, III, of Washington University in St. Louis, Missouri, examines the evidence on both sides of the issue.
 For most people, psychotherapy involves a common sequence of events: finding a therapist, assessing the problem, exploring the problem, resolving the problem, and terminating therapy. Sometimes therapy will end prematurely, before the problem is resolved. For example, the therapist or client may move to a new city.
 When someone has a personal problem and seeks help from a therapist, the individual may turn to a variety of people to get a referral—a friend, a pastor or rabbi, or a family physician. Phone books list associations of psychologists, psychiatrists, and social workers that can also provide referrals to therapists. As noted earlier, however, some health insurance plans may restrict a person’s choice of therapist.
 When prospective clients call a therapist for an appointment, they may discuss several aspects of therapy. One concern is availability—is the therapist taking on new patients? Are there hours when both patient and therapist can meet? Another issue is fees. Both therapists in private practice and those in community mental health agencies have to negotiate fees depending in part on the client’s health insurance plan. Some agencies do not require health insurance and have very low fees or a sliding scale that sets fees depending on the ability of the client to pay.
 During the first meeting, clients try to explain their problems to the therapist. The therapist usually asks about the nature of the problems, what may make the problems better or worse, and how long the problems have existed. For many therapists, hearing details, even small ones, helps them to assess the problems and to decide the best form of treatment. Some therapists collaborate with clients in deciding the goals of therapy and what treatment methods will be used. Assessment does not stop with the first session, but continues through therapy. Occasionally, goals of therapy change upon assessment of new issues or problems.
 During therapy, the client sits across from the therapist—except in classical psychoanalysis, in which the client lies on a couch. The specific nature of the discussions between therapist and client differs greatly depending on the therapist’s theoretical orientation. Some therapists are interested in unconscious forces and the early childhood years of the client (psychodynamic therapy), others in actions of the client (behavioural therapy), others in the client’s thinking patterns (cognitive therapy), and yet others in all or some of these aspects. Therapists often take notes during a session or make notes after the session has ended. Sessions typically last from 45 to 50 minutes, although therapists may hold longer sessions during the initial stages of treatment. Clients typically meet weekly with the therapist, although some may meet twice a week or more.
 When does therapy end? Clients and therapists discuss this issue together and determine when it is best to stop. Ideally their decision depends on their judgments about the client’s degree of progress and improvement. Some clients may find that therapy does not seem to be making progress, and may decide to change therapists. However, the cost of therapy may also factor in the decision to end therapy. Managed-care companies generally limit the number of sessions they will subsidize to between 15 and 20. Some therapists, especially those in private practice, may arrange to go beyond these limits by negotiating a fee that the client will pay for services. In other cases, the therapist may refer the client to other mental health agencies that have lower fees and do not require insurance. At the end of therapy, the therapist may schedule a follow-up session several months later to check the client’s progress. Also, the therapist and client agree on what to do if the client’s problems recur.
 Almost since the inception of psychotherapy, therapists and their clients have asked, ‘Does it work? Does psychotherapy help people resolve their problems, feel better, and change the way they deal with other people?’ Therapists and clients are not the only ones asking these questions. In recent years, the agencies that fund mental health services—health insurance companies, health maintenance organizations, and government organizations—have increased their scrutiny of the effectiveness of various psychotherapies in an effort to contain costs.
 Measuring the effectiveness of psychotherapy is an extremely complex task. Asking psychotherapists or their clients, ‘How helpful has therapy been?’ is only a start. The answer does provide some information about how therapists and their clients perceive therapy. However, it does not answer the question of whether psychotherapy is effective because both therapists and clients have vested interests in believing that therapy succeeded. Therapists want to uphold their professional reputation and sense of competence, and clients want to feel that their investment of time and money has been worthwhile. Because of these biases, most studies of effectiveness rely on other evaluations of a client’s improvement: psychological tests given before and after treatment, reports from the client’s friends and family, and reports from impartial interviewers who do not know the client or whether the client received any therapy.
 In 1952 British psychologist Hans Eysenck reviewed the results of 24 studies of psychotherapy and came to a controversial conclusion: Although two-thirds of patients who received psychotherapy showed improvement, a roughly equal proportion of patients who had been on a waiting list for therapy improved with no treatment. According to Eysenck, the patients on the waiting list showed spontaneous remission—recovery without treatment. Although researchers soon exposed flaws in his analysis and problems with the original studies, Eysenck’s findings touched off hundreds of new studies on the effectiveness of psychotherapy.
 In 1980 American researchers statistically combined the results of 475 studies on psychotherapy outcomes using a technique known as meta-analysis. Their study found that the average psychotherapy recipient showed more improvement than 80 percent of untreated individuals. Later studies have confirmed that overall, psychotherapy is better than no therapy at all. Furthermore, it appears at least as effective as drug treatment for most psychological problems. However, psychotherapy is not effective for everyone. About 10 percent of people who receive psychotherapy show no improvement or actually get worse.
 Researchers have also studied how quickly people improve with psychotherapy. One analysis, which reviewed data from more than 2400 psychotherapy patients, found that 50 percent of people receiving once-a-week psychotherapy showed significant improvement after eight sessions, or two months. After six months, or 26 sessions, about 75 percent of people show improvement. However, most people required about a year of psychotherapy for relief from severe symptoms, such as feelings of worthlessness.
 Are some types of psychotherapy more effective than others? This question has been hotly debated for decades, and research on this issue presents many difficulties. In conducting studies that compare different therapies, researchers seek to make sure that each treatment group is as similar as possible. For example, researchers may limit the groups to people with the same severity of depression. In addition, within each treatment group, researchers try to make sure that therapists are using the same techniques and are trained similarly. However, patients do not come to therapy with simple problems that fit easily into studies. Furthermore, therapists of the same theoretical orientation may vary in their techniques and in the skillfulness with which they apply them.
 Because of these problems, there is no conclusive answer about which type of therapy is best. Most studies have failed to demonstrate that any one approach is superior to another. The meta-analysis of 475 studies mentioned earlier, for example, found that psychodynamic, humanistic, behavioural, and cognitive approaches were all about equally effective. In the 1990s a major study by the National Institute of Mental Health compared the effectiveness of cognitive-behavioural therapy, interpersonal psychotherapy (a form of short-term psychodynamic therapy that focuses on social relations), and drug therapy for people with depression. The study found that all three types of treatment helped individuals become less depressed. Furthermore, no one method was significantly more effective than the others.
 Some researchers suggest that all therapies share certain qualities, and that these qualities account for the similar effectiveness of therapies despite quite different techniques. For instance, all therapies offer people hope for recovery. People who begin therapy often expect that therapy will help them, and this expectation alone may lead to some improvement (a phenomenon known as the placebo effect). Also, people in psychotherapy may find that simply being able to talk freely and openly about their problems helps them to feel better. Finally, the support, encouragement, and warmth that clients feel from their therapist lets them know they are cared about and respected, which may positively affect their mental health.
 Although different therapeutic approaches may be equally effective on average, mental health researchers agree that some types of therapy are best for particular problems. For panic disorder and phobias, behavioural and cognitive-behavioural therapies seem most effective. Behavioural techniques, often in combination with medication, are also an effective treatment for obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and sexual dysfunction. Cognitive-behavioural, psychodynamic, and humanistic approaches all provide moderate relief from depression.
 Mental health professionals agree that the effectiveness of therapy depends to a large extent on the quality of the relationship between the client and therapist. In general, the better the rapport is between therapist and client, the better the outcome of therapy. If a person does not trust a therapist enough to describe deeply personal problems, the therapist will have trouble helping the person change and improve. For clients, trusting that the therapist can provide help for their problems is essential for making progress.
 The founder of person-centered therapy, Carl Rogers, believed that the most important qualities in a therapist are being genuine, accepting, and empathic. Almost all therapists today would agree that these qualities are important. Being genuine means that therapists care for the client and behave toward the client as they really feel. Being accepting means that therapists should appreciate clients for who they are, despite the things that they may have done. Therapists do not have to agree with clients, but they must accept them. Being empathic means that therapists understand the client’s feelings and experiences and convey this understanding back to the client.
 In helping their clients, all therapists follow a code of ethics. First, all therapy is confidential. Therapists notify others of a client’s disclosures only in exceptional cases, such as when children disclose abuse by parents, parents disclose abuse of children, or clients disclose an intention to harm themselves or others. Also, therapists avoid dual relationships with clients—that is, being friends outside of therapy or maintaining a business relationship. Such relationships may reduce the therapist’s objectivity and ability to work with the client. Ethical therapists also do not engage in sexual relationships with clients, and do not accept as clients people with whom they have been sexually intimate.
 As more immigrants to the United States and Canada have entered therapy, psychotherapists and counselors have learned the importance of taking a client’s cultural background into account when assessing the problem and determining treatment. Scholars recognize that most psychotherapies are based on Western systems of psychology, which stress the desirability of individualism and independence. However, cultures of Asia and other regions commonly emphasize different values, such as conformity, dependency on others, and obeying one’s parents. Thus, techniques that might be effective for someone from North America, Europe, or Australia might be inappropriate for a recent immigrant from Vietnam, Japan, or India. In order to provide effective treatment, therapists must be aware of their own cultural biases and become familiar with their client’s ethnic and cultural background.
 Behaviour Modification, psychological methods for treating maladjustment and for changing observable behaviour patterns. In the behaviour modification process, the procedures used are monitored so that changes can be made when necessary. Physical and mental coercion, brain surgery, brainwashing, drug use, and psychotherapy are often considered methods of behaviour modification because they try to, and frequently do, change behaviour. None of them, however, is behaviour modification as the term is used in present-day psychology.
 Russian physiologist Ivan Pavlov won the 1904 Nobel Prize in physiology or medicine. Pavlov is best known for his work on reflex
The foundation for  modification was laid at the beginning of the 20th century in the experimental laboratory of the Russian physiologist Ivan P. Pavlov. A dog was being trained to salivate when a circle was projected on a screen and not to salivate when an ellipse was shown. The shape of the ellipse was gradually modified to resemble the circle. When only a slight difference between the circle and the ellipse could be perceived, the dog became agitated and no longer displayed the conditioned response it had acquired. This type of disturbance was called an ‘experimentally induced neurosis.’
 A second landmark event for  modification took place when Pavlov's conditioning principles were extended to humans. In 1920 the American psychologists John B. Watson and Rosalie Rayner reported an experimental study in which an 11-month-old baby who had previously played with a white laboratory rat was conditioned to be fearful of the rat by associating a loud noise with the animal, a process known as pairing. The psychologist Mary Cover Jones later performed experiments designed to reduce already established fears in children. She found two methods particularly effective: (1) associating a feared object with a different stimulus capable of arousing a positive reaction, and (2) placing the child who feared a certain object with other children who did not.
 Modification techniques were used in the 1940s and '50s by psychologists in South Africa, England, and the United States. Joseph P. Wolpe, a South African physician, questioned the effectiveness of psychotherapy for treating disturbed young adults, especially those with disabling fear reactions. To deal with anxiety disturbances, Wolpe devised treatment procedures based on Pavlov's classical-conditioning model. At about the same time, a group of psychologists in London, headed by Hans J. Eysenck and M. B. Shapiro, launched a new program of research on the development of treatment techniques, basing their investigations on the learning theory of the American psychologists Clark L. Hull and Kenneth W. Spence.
 In the US two kinds of investigations helped to establish the field of modification. One was a further extension of the classical-conditioning principles to clinical problems such as bed-wetting and alcoholism. The other was the application of the operant-conditioning principles developed by B. F. Skinner to the education and training of handicapped children in schools and institutions and to the treatment of adults in psychiatric hospitals.
 By the early 1960's, modification had become a clearly identifiable applied psychology movement with two components:  therapy and applied  analysis.
 Some of the treatment techniques used in  therapy became prominent enough to acquire specific names. Among them are systematic desensitization, aversion therapy, and biofeedback.
 Systematic desensitization, the most widely used technique, attempts to treat disturbances having identifiable sources, such as a paralyzing fear of closed spaces. This method usually involves training the individual to relax in the presence of fear-producing stimuli. The therapist assumes that the anxiety reaction will be replaced gradually with the new relaxation response; this is called reciprocal inhibition.
 Aversion therapy is used to break disabling bad habits. An aversive stimulus, such as an electric shock, is given together with the ‘bad habit,’ such as an alcoholic drink. Repeated pairings result in changing the values of such stimuli from positive attraction to repulsion.
 Biofeedback is most often used in treating disturbed  that has a physical basis. It provides an individual with information about an ongoing physiological process such as blood pressure or heartbeat rate. By the use of a mechanical device, indications of moment-to-moment variations in bodily functioning can be observed and monitored by the individual. The therapist may provide some reward for desirable changes, such as a decrease in blood pressure.
 Applied  analysis is used to develop educational and treatment techniques that can be tailored to each individual's requirements while still following a constant format, whether the patients are retarded or disturbed children in a school or residential setting, or adults in a psychiatric hospital or rehabilitation center. Five essential steps characterize this approach: (1) deciding what the individual can do to ameliorate the problem; (2) devising a program to weaken undesirable  and strengthen desirable substitute ; (3) carrying out the treatment program according to al principles; (4) keeping careful and objective records; and (5) altering the program if progress can thereby be improved.
 Ego, in psychoanalysis, term denoting the central part of the personality structure that deals with reality and is influenced by social forces. According to the psychoanalytic theories developed by Sigmund Freud, the ego constitutes one of the three basic provinces of the mind, the other two being the id and the superego. Formation of the ego begins at birth in the first encounters with the external world of people and things. The ego learns to modify behaviour by controlling those impulses that are socially unacceptable. Its role is that of mediator between unconscious impulses and acquired social and personal standards.
 In philosophy, ego means the conscious self or ‘I.’ It was viewed by some philosophers, notably the 17th-century Frenchman René Descartes and the 18th-century German Johann Gottlieb Fichte, as the sole basis of reality; they saw the universe as existing only in the individual's knowledge and experience of it. Other philosophers, such as the 18th-century German Immanuel Kant, proposed two forms of ego, one perceiving and the other thinking.
 States of Consciousness. No simple, agreed-upon definition of consciousness exists. Attempted definitions tend to be tautological (for example, consciousness defined as awareness) or merely descriptive (for example, consciousness described as sensations, thoughts, or feelings). Despite this problem of definition, the subject of consciousness has had a remarkable history. At one time the primary subject matter of psychology, consciousness as an area of study suffered an almost total demise, later reemerging to become a topic of current interest.
 French thinker René Descartes applied rigorous scientific methods of deduction to his exploration of philosophical questions. Descartes is probably best known for his pioneering work in philosophical skepticism. Author Tom Sorell examines the concepts behind Descartes’s work Meditationes de Prima Philosophia (1641; Meditations on First Philosophy), focusing on its unconventional use of logic and the reactions it aroused.
 Most of the philosophical discussions of consciousness arose from the mind-body issues posed by the French philosopher and mathematician René Descartes in the 17th century. Descartes asked: Is the mind, or consciousness, independent of matter? Is consciousness extended (physical) or unextended (nonphysical)? Is consciousness determinative, or is it determined? English philosophers such as John Locke equated consciousness with physical sensations and the information they provide, whereas European philosophers such as Gottfried Wilhelm Leibniz and Immanuel Kant gave a more central and active role to consciousness.
 The philosopher who most directly influenced subsequent exploration of the subject of consciousness was the 19th-century German educator Johann Friedrich Herbart, who wrote that ideas had quality and intensity and that they may inhibit or facilitate one another. Thus, ideas may pass from ‘states of reality’ (consciousness) to ‘states of tendency’ (unconsciousness), with the dividing line between the two states being described as the threshold of consciousness. This formulation of Herbart clearly presages the development, by the German psychologist and physiologist Gustav Theodor Fechner, of the psychophysical measurement of sensation thresholds, and the later development by Sigmund Freud of the concept of the unconscious.
 The experimental analysis of consciousness dates from 1879, when the German psychologist Wilhelm Max Wundt started his research laboratory. For Wundt, the task of psychology was the study of the structure of consciousness, which extended well beyond sensations and included feelings, images, memory, attention, duration, and movement. Because early interest focused on the content and dynamics of consciousness, it is not surprising that the central methodology of such studies was introspection; that is, subjects reported on the mental contents of their own consciousness. This introspective approach was developed most fully by the American psychologist Edward Bradford Titchener at Cornell University. Setting his task as that of describing the structure of the mind, Titchener attempted to detail, from introspective self-reports, the dimensions of the elements of consciousness. For example, taste was ‘dimensionalized’ into four basic categories: sweet, sour, salt, and bitter. This approach was known as structuralism.
 By the 1920s, however, a remarkable revolution had occurred in psychology that was to essentially remove considerations of consciousness from psychological research for some 50 years: ism captured the field of psychology. The main initiator of this movement was the American psychologist John Broadus Watson. In a 1913 article, Watson stated, ‘I believe that we can write a psychology and never use the terms consciousness, mental states, mind . . . imagery and the like.’ Psychologists then turned almost exclusively to , as described in terms of stimulus and response, and consciousness was totally bypassed as a subject. A survey of eight leading introductory psychology texts published between 1930 and the 1950s found no mention of the topic of consciousness in five texts, and in two it was treated as a historical curiosity.
 Beginning in the late 1950's, however, interest in the subject of consciousness returned, specifically in those subjects and techniques relating to altered states of consciousness: sleep and dreams, meditation, biofeedback, hypnosis, and drug-induced states. Much of the surge in sleep and dream research was directly fueled by a discovery relevant to the nature of consciousness. A physiological indicator of the dream state was found: At roughly 90-minute intervals, the eyes of sleepers were observed to move rapidly, and at the same time the sleepers' brain waves would show a pattern resembling the waking state. When people were awakened during these periods of rapid eye movement, they almost always reported dreams, whereas if awakened at other times they did not. This and other research clearly indicated that sleep, once considered a passive state, was instead an active state of consciousness.
 During the 1960s, an increased search for ‘higher levels’ of consciousness through meditation resulted in a growing interest in the practices of Zen Buddhism and Yoga from Eastern cultures. A full flowering of this movement in the United States was seen in the development of training programs, such as Transcendental Meditation, that were self-directed procedures of physical relaxation and focused attention. Biofeedback techniques also were developed to bring body systems involving factors such as blood pressure or temperature under voluntary control by providing feedback from the body, so that subjects could learn to control their responses. For example, researchers found that persons could control their brain-wave patterns to some extent, particularly the so-called alpha rhythms generally associated with a relaxed, meditative state. This finding was especially relevant to those interested in consciousness and meditation, and a number of ‘alpha training’ programs emerged.
 Another subject that led to increased interest in altered states of consciousness was hypnosis, which involves a transfer of conscious control from the subject to another person. Hypnotism has had a long and intricate history in medicine and folklore and has been intensively studied by psychologists. Much has become known about the hypnotic state, relative to individual suggestibility and personality traits; the subject has now largely been demythologized, and the limitations of the hypnotic state are fairly well known. Despite the increasing use of hypnosis, however, much remains to be learned about this unusual state of focussed attention.
 Finally, many people in the 1960s experimented with the psychoactive drugs known as hallucinogens, which produce disorders of consciousness. The most prominent of these drugs are lysergic acid diethylamide, or LSD; mescaline; and psilocybin; the latter two have long been associated with religious ceremonies in various cultures. LSD, because of its radical thought-modifying properties, was initially explored for its so-called mind-expanding potential and for its psychotomimetic effects (imitating psychoses). Little positive use, however, has been found for these drugs, and their use is highly restricted.
 Scientists have long considered the nature of consciousness without producing a fully satisfactory definition. In the early 20th century American philosopher and psychologist William James suggested that consciousness is a mental process involving both attention to external stimuli and short-term memory. Later scientific explorations of consciousness mostly expanded upon James’s work. In this article from a 1997 special issue of Scientific American, Nobel laureate Francis Crick, who helped determine the structure of DNA, and fellow biophysicist Christof Koch explain how experiments on vision might deepen our understanding of consciousness.
 As the concept of a direct, simple linkage between environment and behaviour became unsatisfactory in recent decades, the interest in altered states of consciousness may be taken as a visible sign of renewed interest in the topic of consciousness. That persons are active and intervening participants in their behaviour has become increasingly clear. Environments, rewards, and ppunishments are not simply defined by their physical character. Memories are organized, not simply stored. An entirely new area called cognitive psychology has emerged that centres on these concerns. In the study of children, increased attention is being paid to how they understand, or perceive, the world at different ages. In the field of animal behaviour, researchers increasingly emphasize the inherent characteristics resulting from the way a species has been shaped to respond adaptively to the environment. Humanistic psychologists, with a concern for self-actualization and growth, have emerged after a long period of silence. Throughout the development of clinical and industrial psychology, the conscious states of persons in terms of their current feelings and thoughts were of obvious importance. The role of consciousness, however, was often de-emphasized in favour of unconscious needs and motivations. Trends can be seen, however, toward a new emphasis on the nature of states of consciousness.
 Mental Illness, disorder characterized by disturbances in a person’s thoughts, emotions, or behaviour. The term mental illness can refer to a wide variety of disorders, ranging from those that cause mild distress to those that severely impair a person’s ability to function. Mental health professionals sometimes use the terms psychiatric disorder or psychopathology to refer to mental illness.
 Severe mental illness almost always alters a person’s life dramatically. People with severe mental illnesses experience disturbing symptoms that can make it difficult to hold a job, go to school, relate to others, or cope with ordinary life demands. Some individuals require hospitalization because they become unable to care for themselves or because they are at risk of committing suicide.
 The symptoms of mental illness can be very distressing. People who develop schizophrenia may hear voices inside their head that say nasty things about them or command them to act in strange or unpredictable ways. Or they may be paralyzed by paranoia—the deep conviction that everyone, including their closest family members, wants to injure or destroy them. People with major depression may feel that nothing brings pleasure and that life is so dreary and unhappy that it is better to be dead. People with panic disorder may experience heart palpitations, rapid breathing, and anxiety so extreme that they may not be able to leave home. People who experience episodes of mania may engage in reckless sexual behaviour or may spend money indiscriminately, acts that later cause them to feel guilt, shame, and desperation.
 Other mental illnesses, while not always debilitating, create certain problems in living. People with personality disorders may experience loneliness and isolation because their personality style interferes with social relations. People with an eating disorder may become so preoccupied with their weight and appearance that they force themselves to vomit or refuse to eat. Individuals who develop post-traumatic stress disorder may become angry easily, experience disturbing memories, and have trouble concentrating.
 Experiences of mental illness often differ depending on one’s culture or social group, sometimes greatly so. For example, in most of the non-Western world, people with depression complain principally of physical ailments, such as lack of energy, poor sleep, loss of appetite, and various kinds of physical pain. Indeed, even in North America these complaints are commonplace. But in the United States and other Western societies, depressed people and mental health professionals who treat them tend to emphasize psychological problems, such as feelings of sadness, worthlessness, and despair. The experience of schizophrenia also differs by culture. In India, one-third of new cases of schizophrenia involve catatonia, a behavioural condition in which a person maintains a bizarre statuelike pose for hours or days. This condition is rare in Europe and North America.
 With appropriate treatment, most people can recover from mental illness and return to normal life. Even those with persistent, long-term mental illnesses can usually learn to manage their symptoms and live productive lives.
 In most societies mental illness carries a substantial stigma, or mark of shame. The mentally ill are often blamed for bringing on their own illnesses, and others may see them as victims of bad fate, religious and moral transgression, or witchcraft. Such stigma may keep families from acknowledging that a family member is ill. Some families may hide or overprotect a member with mental illness - keeping the person from receiving potentially effective care - or they may reject the person from the family. When magnified from individuals to a whole society, such attitudes lead to underfunding of mental health services and terribly inadequate care. In much of the world, even today, the mentally ill are chained, caged, or hospitalized in filthy, brutal institutions. Yet attitudes toward mental illness have improved in many areas, especially owing to health education and advocacy for the mentally ill.
 Mental illness creates enormous social and economic costs. Depression, for example, affects some 500 million people in the world and results in more time lost to disability than such chronic diseases as diabetes mellitus and arthritis. Estimating the economic cost of mental illness is complex because there are direct costs (actual medical expenditures), indirect costs (the cost to individuals and society due to reduced or lost productivity, for example), and support costs (time lost to care of family members with mental illnesses). One study estimated that in 1985 the economic costs of mental illness in the United States totalled $103.7 billion. Of this, treatment and support costs totalled $42.5 billion, which represented 11.5 percent of the total cost of care for all illnesses.
 Another method of estimating the cost of mental illness to society measures the impact of premature deaths and disablements. Research by the World Health Organization and the World Bank estimated that in 1990, among the world’s population aged 15 to 44 years, depression accounted for more than 10 percent of the total burden attributable to all diseases. Two other illnesses, bipolar disorder and schizophrenia, accounted for another 6 percent of the burden. This research has helped governments recognize that mental illnesses constitute a far greater challenge to public health systems than previously realized.
 No universally accepted definition of mental illness exists. In general, the definition of mental illness depends on a society’s norms, or rules of behaviour. Behaviours that violate these norms are considered signs of deviance or, in some cases, of mental illness.
 Because norms vary between cultures, behaviours considered signs of mental illness in one culture may be considered normal in other cultures. For example, in the United States, a person who experiences trance and possession states (altered states of consciousness) is usually diagnosed as suffering from a mental illness. Yet, in many non-Western countries, people consider such states an essential part of human experience. In Native American culture, it is common for people to hear the voices of recently deceased loved ones. In contrast, most mental health professionals in Western cultures would consider such behaviour a possible symptom of schizophrenia or psychosis.
 The variation in behavioural norms does not mean, however, that definitions of mental illness are necessarily incompatible across cultures. Many behaviours are recognized throughout the world as being indicative of mental illness. These include extreme social withdrawal, violence to oneself, hallucinations (false sensory perceptions), and delusions (fixed, false ideas).
 Another way of defining mental illness is based on whether a person’s behaviours are maladaptive—that is, whether they cause a person to experience problems in coping with common life demands. For example, people with social phobia may avoid interacting with other people and experience problems at work as a result. Critics note that under this definition, political dissidents could be considered mentally ill for refusing to accept the dictates of their government.
 Mental illness affects people of all ages, races, cultures, and socioeconomic classes. The prevalence of mental illness refers to how many people experience a mental illness during a specified time period.
 In the United States, researchers estimate that about 24 percent of people 18 or older, or about 44 million adults, experience a mental illness or substance-related disorder during the course of any given year. The most common of these disorders are depression, alcohol dependence, and various phobias (irrational fears of things or situations). An estimated 2.6 percent of adults in the United States, or about 4.8 million people, suffer from a severe and persistent mental illness - such as schizophrenia, bipolar disorder, or a severe form of depression or panic disorder - in any given year. An additional 2.8 percent of adults, or about 5.2 million people, experience a mental illness that seriously interferes with one or more aspects of their daily life, such as their ability to work or relate to other people. All of these figures exclude people who are homeless and those living in prisons, nursing homes, or other institutions—populations that have high rates of mental illness.
 International surveys have demonstrated that from 30 to 40 percent of people in a given population experience a mental illness during their lives. These surveys also reveal that anxiety disorders are usually even more common than depression.
 Anorexia nervosa is a serious eating disorder that compels its victims to starve themselves—in some cases, to death. An increasingly common illness among adolescent and young adult women, anorexia nervosa has complex causes, which make treating it successfully a difficult matter. This 1998 article from Scientific American Presents explores the factors that contribute to the prevalence of anorexia nervosa and some promising new options for treatment.
 Young people can suffer from mental illnesses and psychological problems just as adults can. Prevalence estimates in industrialized countries indicate that from 14 to 20 percent of individuals under age 18 suffer from a diagnosable mental disorder. In the United States, an estimated 9 to 13 percent of children between the ages of 9 and 17 suffer from a serious emotional disturbance—that is, a disorder that severely disrupts a child's daily functioning in the family, school, or community.
 Anxiety disorders are the most common childhood mental disorders, affecting an estimated 8 to 10 percent of children and adolescents in the United States. Children with these disorders experience persistent, unrealistic worry or uneasiness that interferes with their ability to function normally. About 4 percent of children and young adolescents experience severe separation anxiety and worry excessively about becoming separated from their parents. Depression is another common childhood mental disorder, affecting up to 2.5 percent of children (under age 13) and up to 8.3 percent of adolescents in the United States. Depression in children can lead to failure in school, poor self-image, troubled social relations, and even suicide.
 A number of mental disorders are usually first diagnosed in infancy, childhood, or adolescence. Autism is a relatively rare disorder that appears before the age of three and severely impairs a child's ability to interact socially and to communicate with others. Attention-deficit hyperactivity disorder begins before the age of seven. Its symptoms include an inability to sit still, focus attention, or control impulses. Eating disorders, such as anorexia nervosa and bulimia nervosa, most often affect adolescent girls.
 With a greater percentage of people living beyond the age of 65—both in the industrialized nations of the West and the developing countries of Asia, Africa, and Latin America—the problem of mental illness among the elderly has grown significantly. Researchers estimate that from 15 to 25 percent of elderly people in the United States suffer from significant symptoms of mental illness. Dementia, characterized by confusion, memory loss, and disorientation, occurs mostly among the elderly. A study of residents of Boston, Massachusetts, revealed that about 10 percent of people over the age of 65 suffer from Alzheimer’s disease, the most common form of dementia, and research on residents of Shanghai, China found that 4.6 percent of people over 65 suffer from this condition.
 Major depression, the most severe form of depression, affects from 1 to 2 percent of people aged 65 or older who are living in the community (rather than in nursing homes or other institutions). The prevalence of depression and other mental illnesses is much higher among elderly residents of nursing homes. Although most older people with depression respond to treatment, many cases of depression among the elderly go undetected or untreated. Research indicates that depression is a major risk factor for suicide among the elderly in the United States. People over age 65 in the United States have the highest suicide rate of any age group.
 Like physical diseases, the highest rates of mental illness occur among people in the lower socioeconomic classes, especially those living in severe poverty. Rates of almost all mental illnesses decline as levels of income and education increase. A national survey published in 1994 indicated that people who earned $19,000 or less annually in the United States were twice as likely to have experienced an anxiety disorder as people who earned $70,000 or more. The hardships associated with poverty seem to contribute to the development of some mental illnesses, particularly anxiety disorders and depression. In addition, debilitating mental illnesses, such as schizophrenia, may cause individuals to drift to lower socioeconomic classes.
 Generally, the overall prevalence rates of mental illnesses among men and women are similar. However, men have much higher rates of antisocial personality disorder and substance abuse. In the United States, women suffer from depression and anxiety disorders at about twice the rate of men. The gender gap is even wider in some countries. For example, in China, women suffer from depression at nine times the rate of men.
 Mental illness is becoming an increasing problem for two reasons. First, increases in life expectancy have brought increased numbers of certain chronic mental illnesses. For example, because more people are living into old age, more people are suffering from dementia. Second, a number of studies provide evidence that rates of depression are rising throughout the world. The reasons may be related to such factors as economic change, political and social violence, and cultural disruptions. While some have questioned these findings, dramatic increases in the numbers of refugees and people dislocated from their homes by economic forces or civil strife are associated with great increases in a variety of mental illnesses for those populations. According to the United Nations High Commissioner for Refugees, the number of refugees worldwide increased from 2.5 million in 1971 to 13.2 million in 1996, peaking at 17 million in 1991.
 A number of mental illnesses—such as depression, anxiety disorders, schizophrenia, and bipolar disorder—occur worldwide. Others seem to occur only in particular cultures. For example, eating disorders, such as anorexia nervosa (compulsive dieting associated with unrealistic fears of fatness), occur mostly among girls and women in Europe, North America, and Westernized areas of Asia, whose cultures view thinness as an essential component of female beauty. In Latin America, people who experience overwhelming fright after a dangerous or traumatic event are said to have susto (fright), an illness in which their soul has been frightened away. In some societies of West Africa and elsewhere, brain fag describes individuals (usually students) who experience difficulties in concentrating and thinking, as well as physical symptoms of pain and fatigue.
 Most mental health professionals in the United States use the Diagnostic and Statistical Manual of Mental Disorders(DSM), a reference book published by the American Psychiatric Association, as a guide to the different kinds of mental illnesses. The fourth edition, known as DSM-IV, describes more than 300 mental disorders, behavioural disorders, addictive disorders, and other psychological problems and groups them into broad categories. This article describes some of the major categories, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders, personality disorders, cognitive disorders, dissociative disorders, somatoform disorders, factitious disorders, substance-related disorders, eating disorders, and impulse-control disorders. Mental health professionals in many other parts of the world use a different classification system, the International Classification of Diseases (ICD), published by the World Health Organization.
 The DSM and ICD are both categorical systems of classification, in which each mental illness is defined by its own unique set of symptoms and characteristics. In theory, each disorder should possess diagnostic criteria that are independent of one another, just as tuberculosis and lung cancer are discrete diseases. Yet symptoms of many mental disorders overlap, and many people - such as those who experience both depression and severe anxiety - show symptoms of more than one disorder at the same time. For these reasons, some mental health professionals advocate a dimensional system of classification. In contrast to the categorical approach, which sees mental disorders as qualitatively distinct from normal behaviour, a dimensional system views behaviour as falling along a continuum of normality, with some behaviours considered more abnormal than others. In a dimensional system, diagnoses do not describe discrete diseases but rather portray the relative importance of an array of symptoms.
 Definitions and classifications of mental illnesses change as research improves understanding of them. For example, DSM-IV allows a diagnosis of schizophrenia only when characteristic symptoms have lasted at least one month, whereas the previous edition of DSM required a duration of only one week.
 Anxiety disorders involve excessive apprehension, worry, and fear. People with generalized anxiety disorder experience constant anxiety about routine events in their lives. Phobias are fears of specific objects, situations, or activities. Panic disorder is an anxiety disorder in which people experience sudden, intense terror and such physical symptoms as rapid heartbeat and shortness of breath. People with obsessive-compulsive disorder experience intrusive thoughts or images (obsessions) or feel compelled to perform certain behaviours (compulsions). People with post-traumatic stress disorder relive traumatic events from their past and feel extreme anxiety and distress about the event.
 These positron emission tomography scans of the brain of a person with bipolar disorder show the individual shifting from depression, top row, to mania, middle row, and back to depression, bottom row, over the course of 10 days. Blue and green indicate low levels of brain activity, while red, orange, and yellow indicate high levels of brain activity.
 American psychiatrist Kay Redfield Jamison is regarded as one of the world’s leading authorities on bipolar disorder, also known as manic-depressive illness. In her book An Unquiet Mind: A Memoir of Moods and Madness (1995), Jamison reveals her own struggle against the illness, which caused her to experience violent mood swings. In this excerpt, she describes her initial resistance to taking medication that, while necessary to prevent debilitating depression, extinguished the exhilarating highs of mania.’An Unquiet Mind’ written and read by Kay Redfield Jamisonaffective disorders, create disturbances in a person’s emotional life. Depression, mania, and bipolar disorder are examples of mood disorders. Symptoms of depression may include feelings of sadness, hopelessness, and worthlessness, as well as complaints of physical pain and changes in appetite, sleep patterns, and energy level. In mania, on the other hand, an individual experiences an abnormally elevated mood, often marked by exaggerated self-importance, irritability, agitation, and a decreased need for sleep. In bipolar disorder, also called manic-depressive illness, a person’s mood alternates between extremes of mania and depression.
 People with schizophrenia and other psychotic disorders lose contact with reality. Symptoms may include delusions and hallucinations, disorganized thinking and speech, bizarre behaviour, a diminished range of emotional responsiveness, and social withdrawal. In addition, people who suffer from these illnesses experience an inability to function in one or more important areas of life, such as social relations, work, or school.
 Personality disorders are mental illnesses in which one’s personality results in personal distress or a significant impairment in social or work functioning. In general, people with personality disorders have poor perceptions of themselves or others. They may have low self-esteem or overwhelming narcissism, poor impulse control, troubled social relationships, and inappropriate emotional responses. Considerable controversy exists over where to draw the distinction between a normal personality and a personality disorder.
 In contrast to people with somatoform disorders, people with factitious disorders intentionally produce or fake physical or psychological symptoms in order to receive medical attention and care. For example, an individual might falsely report shortness of breath to gain admittance to a hospital, report thoughts of suicide to solicit attention, or fabricate blood in the urine or the symptoms of rash so as to appear ill. Munchausen syndrome represents the most extreme and chronic variant of the factitious disorders.
 Substance-related disorders result from the abuse of drugs, side effects of medications, or exposure to toxic substances. Many mental health professionals regard these disorders as behavioural or addictive disorders rather than as mental illnesses, although substance-related disorders commonly occur in people with mental illnesses. Common substance-related disorders include alcoholism and other forms of drug dependence. In addition, drug use can contribute to symptoms of other mental disorders, such as depression, anxiety, and psychosis. Drugs associated with substance-related disorders include alcohol, caffeine, nicotine, cocaine, heroin, amphetamines, hallucinogens, and sedatives.
 Osteoporosis, breast cancer, and eating disorders are sometimes considered women's diseases, but doctors have found that men may also suffer from these same medical problems. Because men have these conditions so rarely, detection and treatment are often quite slow. To help with early diagnosis, this article from FDA Consumer describes some of the symptoms and possible causes of these serious diseases.
 Eating disorders are conditions in which an individual experiences severe disturbances in eating behaviours. People with anorexia nervosa have an intense fear about gaining weight and refuse to eat adequately or maintain a normal body weight. People with bulimia nervosa repeatedly engage in episodes of binge eating, usually followed by self-induced vomiting or the use of laxatives, diuretics, or other medications to prevent weight gain. Eating disorders occur mostly among young women in Western societies and certain parts of Asia.
 People with impulse-control disorders cannot control an impulse to engage in harmful behaviours, such as explosive anger, stealing (kleptomania), setting fires (pyromania), gambling, or pulling out their own hair (trichotillomania). Some mental illnesses—such as mania, schizophrenia, and antisocial personality disorder—may include symptoms of impulsive behaviour.
 People have tried to understand the causes of mental illness for thousands of years. The modern era of psychiatry, which began in the late 19th and early 20th centuries, has witnessed a sharp debate between biological and psychological perspectives of mental illness. The biological perspective views mental illness in terms of bodily processes, whereas psychological perspectives emphasize the roles of a person’s upbringing and environment.
 These two perspectives are exemplified in the work of German psychiatrist Emil Kraepelin and Austrian psychoanalyst Sigmund Freud. Kraepelin, influenced by the work in the mid-1800s of German psychiatrist Wilhelm Griesinger, believed that psychiatric disorders were disease entities that could be classified like physical illnesses. That is, Kraepelin believed that the fundamental causes of mental illness lay in the physiology and biochemistry of the human brain. His classification system of mental disorders, first published in 1883, formed the basis for later diagnostic systems. Freud, on the other hand, argued that the source of mental illness lay in unconscious conflicts originating in early childhood experiences. Freud found evidence for this idea through the analysis of dreams, free association, and slips of speech.
 This debate has continued into the late 20th century. Beginning in the 1960s, the biological perspective became dominant, supported by numerous breakthroughs in psychopharmacology, genetics, neurophysiology, and brain research. For example, scientists discovered many medications that helped to relieve symptoms of certain mental illnesses and demonstrated that people can inherit a vulnerability to some mental illnesses. Psychological perspectives also remain influential, including the psychodynamic perspective, the humanistic and existential perspectives, the behavioural perspective, the cognitive perspective, and the sociocultural perspective.
 Many mental health professionals today favour a combination of perspectives, acknowledging that both biology and a person’s environment play important roles in mental illness. This approach recognizes that people are not only products of the genes inherited from their parents, but products of the families and social worlds into which they are born. In this view, environments shape how biological factors will be manifested. For example, an infant may inherit genes that could enable her to become a tall adult, but if she is malnourished as a child, she will never achieve that potential. Likewise, an individual who does not possess a biological vulnerability for depression may nevertheless become severely depressed following the death of a loved one or after experiencing an act of torture.
 Advances in brain imaging techniques, such as magnetic resonance imaging (MRI) and positron emission tomography (PET), have enabled scientists to study the role of brain structure in mental illness. Some studies have revealed structural brain abnormalities in certain mental illnesses. For example, some people with schizophrenia have enlarged brain ventricles (cavities in the brain that contain cerebrospinal fluid). However, this may be a result of schizophrenia rather than a cause, and not all people with schizophrenia show this abnormality.
 A variety of medical conditions can cause mental illness. Brain damage and strokes can cause loss of memory, impaired concentration and speech, and unusual changes in behaviour. In addition, brain tumours, if left to grow, can cause psychosis and personality changes. Other possible biological factors in mental illness include an imbalance of hormones, deficiencies in diet, and infections from viruses.
 In the late 19th century Viennese neurologist Sigmund Freud developed a theory of personality and a system of psychotherapy known as psychoanalysis. According to this theory, people are strongly influenced by unconscious forces, including innate sexual and aggressive drives. In this 1938 British Broadcasting Corporation interview, Freud recounts the early resistance to his ideas and later acceptance of his work. Freud’s speech is slurred because he was suffering from cancer of the jaw. He died the following year.
 The psychodynamic perspective views mental illness as caused by unconscious and unresolved conflicts in the mind. As stated by Freud, these conflicts arise in early childhood and may cause mental illness by impeding the balanced development of the three systems that constitute the human psyche: the id, which comprises innate sexual and aggressive drives; the ego, the conscious portion of the mind that mediates between the unconscious and reality; and the superego, which controls the primitive impulses of the id and represents moral ideals. In this view, generalized anxiety disorder stems from a signal of unconscious danger whose source can only be identified through a thorough analysis of the person’s personality and life experiences. Modern psychodynamic theorists tend to emphasize sexuality less than Freud did and focus more on problems in the individual’s relationships with others.
 Both the humanistic and existential perspectives view abnormal behaviour as resulting from a person’s failure to find meaning in life and fulfill his or her potential. The humanistic school of psychology, as represented in the work of American psychologist Carl Rogers, views mental health and personal growth as the natural conditions of human life. In Rogers’s view, every person possesses a drive toward self-actualization, the fulfilment of one’s greatest potential. Mental illness develops when circumstances in a person’s environment block this drive. The existential perspective sees emotional disturbances as the result of a person’s failure to act authentically—that is, to behave in accordance with one’s own goals and values, rather than the goals and values of others.
 The pioneers of behaviourism, American psychologists John B. Watson and B. F. Skinner, maintained that psychology should confine itself to the study of observable behaviour, rather than explore a person’s unconscious feelings. The behavioural perspective explains mental illness, as well as all of human behaviour, as a learned response to stimuli. In this view, rewards and punishments in a person’s environment shape that person’s behaviour. For example, a person involved in a serious car accident may develop a phobia of cars or generalize the fear to all forms of transportation.
 The cognitive perspective holds that mental illness results from problems in cognition—-that is, problems in how a person reasons, perceives events, and solves problems. American psychiatrist Aaron Beck proposed that some mental illnesses—such as depression, anxiety disorders, and personality disorders—result from a way of thinking learned in childhood that is not consistent with reality. For example, people with depression tend to see themselves in a negative light, exaggerate the importance of minor flaws or failures, and misinterpret the behaviour of others in negative ways. It remains unclear, however, whether these kinds of cognitive problems actually cause mental illness or merely represent symptoms of the illnesses themselves.
 The sociocultural perspective regards mental illness as the result of social, economic, and cultural factors. Evidence for this view comes from research that has demonstrated an increased risk of mental illness among people living in poverty. In addition, the incidence of mental illness rises in times of high unemployment. The shift in the world population from rural areas to cities—with their crowding, noise, pollution, decay, and social isolation—has also been implicated in causing relatively high rates of mental illness. Furthermore, rapid social change, which has particularly affected indigenous peoples throughout the world, brings about high rates of suicide and alcoholism. Refugees and victims of social disasters—warfare, displacement, genocide, violence—have a higher risk of mental illness, especially depression, anxiety, and post-traumatic stress disorder.
 Social scientists emphasize that the link between social ills and mental illness is correlational rather than causal. For example, although societies undergoing rapid social change often have high rates of suicide the specific causes have not been identified. Social and cultural factors may create relative risks for a population or class of people, but it is unclear how such factors raise the risk of mental illness for an individual.
 Psychiatrist Nancy C. Andreasen, chair of psychiatry at the University of Iowa College of Medicine in Iowa City and the author of The Broken Brain: The Biological Revolution in Psychiatry (1984), holds a National Medal of Science for her work on mental disorders. In this question-and-answer format, Andreasen touches on a variety of issues involving mental disorders. Is schizophrenia hereditary? How can you distinguish between a child with attention deficit hyperactivity disorder (ADHD) and a child who is simply more active than other children? Is mental decline inevitable with aging? Is medication available to treat obsessive-compulsive disorders? Andreasen discusses these and many other questions.
 There are no blood tests, imaging techniques, or other laboratory procedures that can reliably diagnose a mental illness. Thus, the diagnosis of mental illness is always a judgment or an interpretation by an observer based on the speech, ideas, behaviours, and experiences of the patient.
For the most part, mental health professionals determine the presence of mental illness in an individual by conducting an interview intended to reveal symptoms of abnormal behaviour. That is, the professional asks the patient questions about his or her mental state: ‘Do you hear voices of people who are not with you?’ ‘Have you felt depressed or lost interest in most activities?’ ‘Have you experienced a marked increase or decrease in your appetite?’ ‘Have you been sleeping less than normal?’ ‘Are you easily distracted?’ The answers to these questions will suggest other questions. Eventually, the clinician will feel that he or she has enough information to determine whether the patient is suffering from a mental illness and, if so, to make a diagnosis.
 The process of diagnosis is not as simple as it might seem. Patients often have difficulty remembering symptoms or feel reluctant to talk about their fantasies, sex life, or use of drugs and alcohol. Many patients suffer from more than one disorder at a time - for example, depression and anxiety, or schizophrenia and depression—and determining which symptoms constitute the primary problem is complex. In addition, symptoms may not be specific to mental illnesses. For example, brain tumours, malaria, and infections of the central nervous system can produce symptoms that mimic those of psychotic disorders.
 Another problem in diagnosis is that mental health professionals may interpret symptoms differently based on their personal or cultural biases. One study examined this effect by showing 300 American and British psychiatrists videotaped interviews of eight patients with mental illnesses. Although the psychiatrists’ diagnoses substantially agreed for patients with ‘textbook’ cases of schizophrenia, their diagnoses varied widely for patients who had symptoms of both schizophrenia and other disorders, depending on whether the psychiatrist was American or British. The risk of misdiagnosis is even greater when the mental health professional and the patient come from different cultural groups.
 Mental health professionals use a number of methods to treat people with mental illnesses. The two most common treatments by far are drug therapy and psychotherapy. In drug therapy, a person takes regular doses of a prescription medication intended to reduce symptoms of mental illness. Psychotherapy is the treatment of mental illness through verbal and nonverbal communication between the patient and a trained professional. A person can receive psychotherapy individually or in a group setting.
The type of treatment administered depends on the type and severity of the disorder. For example, doctors usually treat schizophrenia primarily with drugs, but specialized forms of psychotherapy may more effectively relieve phobias. For some mental illnesses, such as depression, the most effective treatment seems to be a combination of drug therapy and psychotherapy. Although some people with severe mental illnesses may never fully recover, most people with mental illnesses improve with treatment and can resume normal lives. Despite the availability of effective treatments, only about 40 percent of people with mental illnesses ever seek professional help.
 A variety of mental health professionals offer treatment for mental illness. These include psychiatrists, psychologists, psychotherapists, psychiatric social workers, and psychiatric nurses.
 Drugs introduced in the mid-1950's enabled many people who otherwise would have spent years in mental institutions to return to the community and live productive lives. Since then, advances in psychopharmacology have led to the development of drugs of even greater effectiveness. These drugs often relieve symptoms of schizophrenia, depression, anxiety, and other disorders. However, they may produce undesirable and sometimes serious side effects. In addition, relapse may occur when they are discontinued, so long-term use may be required. Drugs that control symptoms of mental illness are called psychotherapeutic drugs. The major categories of psychotherapeutic drugs include antipsychotic drugs, antianxiety drugs, antidepressant drugs, and antimanic drugs.
 Antipsychotic drugs, also called neuroleptics and major tranquillizers, control symptoms of psychosis, such as hallucinations and delusions, which characterize schizophrenia and related disorders. They can also prevent such symptoms from returning. Antipsychotic drugs may produce side effects ranging from dry mouth and blurred vision to tardive dyskinesia, a permanent condition that produces involuntary movements of the lips, mouth, and tongue.
 Antianxiety drugs, also called minor tranquillizers, reduce high levels of anxiety. They may help people with generalized anxiety disorder, panic disorder, and other anxiety disorders. Benzodiazepines, a class of drugs that includes diazepam (Valium), are the most widely prescribed antianxiety drugs. Benzodiazepines can be addictive and may cause drowsiness and impaired coordination during the day.
Antidepressant drugs help relieve symptoms of depression. Some antidepressant drugs can relieve symptoms of other disorders as well, such as panic disorder and obsessive-compulsive disorder. Antidepressant drugs comprise three major classes: tricyclics, monoamine oxidase inhibitors (MAO inhibitors), and selective serotonin reuptake inhibitors (SSRIs). Side effects of tricyclics may include dizziness upon standing, blurred vision, dry mouth, difficulty urinating, constipation, and drowsiness. People who take MAO inhibitors may experience some of the same side effects, and must follow a special diet that excludes certain foods. SSRIs generally produce fewer side effects, although these may include anxiety, drowsiness, and sexual dysfunction. One type of SSRI, fluoxetine (Prozac), is the most widely prescribed antidepressant drug.
 Antimanic drugs help control the mania that occurs as part of bipolar disorder. One of the most effective antimanic drugs is lithium carbonate, a natural mineral salt. Common side effects include nausea, stomach upset, vertigo, and increased thirst and urination. In addition, long-term use of lithium can damage the kidneys.
 Psychotherapy can be an effective treatment for many mental illnesses. Unlike drug therapy, psychotherapy produces no physical side effects, although it can cause psychological damage when improperly administered. On the other hand, psychotherapy may take longer than drugs to produce benefits. In addition, sessions may be expensive and time-consuming. In response to this complaint and demands from insurance companies to reduce the costs of mental health treatment, many therapists have started providing therapy of shorter duration.
 Psychotherapy encompasses a wide range of techniques and practices. Some forms of psychotherapy, such as psychodynamic therapy and humanistic therapy, focus on helping people understand the internal motivations for their problematic behaviour. Other forms of therapy, such as behavioural therapy and cognitive therapy, focus on the behaviour itself and teach people skills to correct it. The majority of therapists today incorporate treatment techniques from a number of theoretical perspectives. For example, cognitive-behavioural therapy combines aspects of cognitive therapy and behavioural therapy.
Psychodynamic therapy is one of the most common forms of psychotherapy. The therapist focuses on a person’s past experiences as a source of internal, unconscious conflicts and tries to help the person resolve those conflicts. Some therapists may use hypnosis to uncover repressed memories. Psychoanalysis, a technique developed by Freud, is one kind of psychodynamic therapy. In psychoanalysis, the person lies on a couch and says whatever comes to mind, a process called free association. The therapist interprets these thoughts along with the person’s dreams and memories. Classical psychoanalysis, which requires years of intensive treatment, is not as widely practised today as in previous years.
 Both humanistic therapy and existential therapy treat mental illnesses by helping people achieve personal growth and attain meaning in life. The best-known humanistic therapy is client-centred therapy, developed by Carl Rogers in the 1950s. In this technique, the therapist provides no advice but restates the observations and insights of the client (the person in treatment) in nonjudgmental terms. In addition, the therapist offers the person unconditional empathy and acceptance. Existential therapists help people confront basic questions about the meaning of their lives and guide them toward discovery of their own uniqueness.
 Psychotherapists who practice behavioural therapy do not focus on a person’s past experiences or inner life. Instead, they help the person to change patterns of abnormal behaviour by applying established principles of conditioning and learning. Behavioural therapy has proven effective in the treatment of phobias, obsessive-compulsive disorder, and other disorders. The goal of cognitive therapy is to identify patterns of irrational thinking that cause a person to behave abnormally. The therapist teaches skills that enable the person to recognize the irrationality of the thoughts. The person eventually learns to perceive people, situations, and himself or herself in a more realistic way and develops improved problem-solving and coping skills. Psychotherapists use cognitive therapy to treat depression, panic disorder, and some personality disorders.
 Rehabilitation programs assist people with severe mental illnesses in learning independent living skills and in obtaining community services. Counsellors may teach them personal hygiene skills, home cleaning and maintenance, meal preparation, social skills, and employment skills. In addition, case managers or social workers may help people with mental illnesses obtain employment, medical care, housing, education, and social services. Some intensive rehabilitation programs strive to provide active follow-up and social support to prevent hospitalization.
 Therapists often use play therapy to treat young children with depression, anxiety disorders, and problems stemming from child abuse and neglect. The therapist spends time with the child in a playroom filled with dolls, puppets, and drawing materials, which the child may use to act out personal and family conflicts. The therapist helps the child recognize and confront his or her feelings.
 In group therapy, a number of people gather together to discuss problems under the guidance of a therapist. By sharing their feelings and experiences with others, group members learn their problems are not unique, receive emotional support, and learn ways to cope with their problems. Psychodrama is a type of group therapy in which participants act out emotional conflicts, often on a stage, with the goals of increasing their understanding of their behaviours and resolving conflicts. Group therapy generally costs less per person than individual psychotherapy.
 Family intervention programs help families learn to cope with and manage a family member’s chronic mental illness, such as schizophrenia. Family members learn to monitor the illness, help with daily life problems, ensure adherence to medication, and cope with stigma.
 Electroconvulsive therapy (ECT) is a treatment for severe depression in which an electrical current is passed through the patient’s brain for one or two seconds to induce a controlled seizure. The treatments are repeated over a period of several weeks. For unknown reasons, ECT often relieves severe depression even when drug therapy and psychotherapy have failed. The treatment has created controversy because its side effects may include confusion and memory loss. Both of these effects, however, are usually temporary.
 Even more controversial than ECT is psychosurgery, the surgical removal or destruction of sections of the brain in order to reduce severe and chronic psychiatric symptoms. The best known example of psychosurgery is the lobotomy, a procedure developed by Portuguese neurologist António Egas Moniz that was widely performed in the 1940s and early 1950s. Psychosurgery is now rarely performed because no research has proven it effective and because it can produce drastic changes in personality and behaviour.
 A significant portion of the homeless population in the United States suffers from a chronic mental illness, such as schizophrenia. The shortage of mental health treatment centres in many cities may partly account for the large number of mentally ill people who are homeless or in jail.
 Treatment for mental illness takes places in a number of settings. Mental hospitals or psychiatric wards in general hospitals are used to treat patients in acute phases of their illnesses and when the severity of their symptoms requires constant supervision. Most individuals who suffer from severe mental illness, however, do not require such close attention, and they can usually receive treatment in community settings.
 Often, patients who have just completed a period of hospitalization go to group homes or halfway houses before returning to independent living. These facilities offer patients the opportunity to take part in group activities and to receive training in social and job skills. In supportive housing, mentally ill individuals can live independently in an environment that offers an array of mental health and social services. Some people with chronic and severe mental illnesses require care in long-term facilities, such as nursing homes, where they can receive close supervision.
 Unfortunately, many areas have a shortage of treatment centres, especially community mental health centres and supportive housing environments. This shortage may partly account for the large number of mentally ill people who are homeless or in jail. The shaman, right, of this tribe in Mexico applies healing techniques during a ceremony. In many cultures, shamans are considered to have the power to communicate with the spirit world and to heal the sick, including people with mental illnesses.
 Most non-Western countries still lack adequate treatment facilities and services for the mentally ill. In China, with its 1.2 billion people, there are 4.5 million patients with schizophrenia, but only about 100,000 beds for the mentally ill and fewer than 10,000 psychiatrists. On the other hand, there are hundreds of thousands of traditional healers, many of whom treat mentally ill patients. Other people with mental illnesses receive treatment from general physicians. In most countries of sub-Saharan Africa, psychiatric services are so limited that most people with mental illnesses receive little if any professional care. Some developing countries, however, have begun substantial reform and expansion of mental health services.
 Evidence for trepanning, the surgical procedure of cutting a hole in the skull, dates back 4,000 to 5,000 years. Some anthropologists speculate that Stone Age societies performed trepanning on people with mental illnesses to release evil spirits or demons from their heads. In the absence of written records, however, it is impossible to know why the operation was performed.
 The literature of ancient Greece and Rome contains evidence of the belief that spirits or demons cause mental illness. In the 5th century bc the Greek historian Herodotus wrote an account of a king who was driven mad by evil spirits. The legend of Hercules describes how, driven insane by a curse, he killed his own children. The Roman poets Virgil and Ovid repeated these themes in their works. The early Babylonian, Chinese, and Egyptian civilizations also viewed mental illness as possession, and used exorcism—which sometimes involved beatings, restraint, and starvation - to drive the evil spirits from their victim.
 Not all ancient scholars agreed with this theory of mental illness. The Greek physician Hippocrates believed that all illnesses, including mental illnesses, had natural origins. For example, he rejected the prevailing notion that epilepsy had its origins in the divine or sacred, viewing it as a disease of the brain. Hippocrates classified mental illnesses into categories that included mania, melancholia (depression), and phrenitis (brain fever), and he advocated humane treatment that included rest, bathing, exercise, and dieting. The Greek philosopher Plato, although adhering to a somewhat supernatural view of mental illness, believed that childhood experiences shaped adult behaviours, anticipating modern psychodynamic theories by more than 2000 years.
 The Middle Ages in Europe, from the fall of the Roman empire in the 5th century ad to about the 15th century, was a period in which religious beliefs, specifically Christianity, dominated concepts of mental illness. Much of society believed that mentally ill people were possessed by the devil or demons, or accused them of being witches and infecting others with madness. Thus, instead of receiving care from physicians, the mentally ill became objects of religious inquisition and barbaric treatment. On the other hand, some historians of medicine cite evidence that even in the Middle Ages, many people believed mental illness to have its basis in physical and psychological disturbances, such as imbalances in the four bodily humours (blood, black bile, yellow bile, and phlegm), poor diet, and grief.
 The Islamic world of North Africa, Spain, and the Middle East generally held far more humane attitudes toward people with mental illnesses. Following the belief that God loved insane people, communities began establishing asylums beginning in the 8th century ad, first in Baghdad and later in Cairo, Damascus, and Fez. The asylums offered patients special diets, baths, drugs, music, and pleasant surroundings.
 The Renaissance, which began in Italy in the 14th century and spread throughout Europe in the 16th and 17th centuries, brought both deterioration and progress in perceptions of mental illness. On the one hand, witch-hunts and executions escalated throughout Europe, and the mentally ill were among those persecuted. The infamous Malleus Maleficarum (the witches hammer), which served as a handbook for inquisitors, claimed that witches could be identified by delusions, hallucinations, or other peculiar behaviour. To make matters worse, many of the most eminent physicians of the time fervently advocated these beliefs.
 On the other hand, some scholars vigorously protested these supernatural views and called renewed attention to more rational explanations of behaviour. In the early 16th century, for example, the Swiss physician Paracelsus returned to the views of Hippocrates, asserting that mental illnesses were due to natural causes. Later in the century, German physician Johann Weyer argued that witches were actually mentally disturbed people in need of humane medical treatment.
 French physician Philippe Pinel supervises the unchaining of mentally ill patients in 1794 at La Salpêtrière, a large hospital in Paris. Pinel believed in treating mentally ill people with compassion and patience, rather than with cruelty and violence. This painting, Pinel Frees the Insane from Their Chains, was completed by French artist Tony Robert-Fleury in 1876.
 Physicians in the 18th and 19th centuries used crude devices to treat mental illness, none of which offered any real relief. The circulating swing, top left, was used to spin depressed patients at high speed. American physician Benjamin Rush devised the tranquillizing chair, top right, to calm people with mania. The crib, bottom, was widely used to restrain violent patients.
 During the Age of Enlightenment, in the 18th and early 19th centuries, people with mental illnesses continued to suffer from poor treatment. For the most part, they were left to wander the countryside or committed to institutions. In either case, conditions were generally wretched. One mental hospital, the Hospital of Saint Mary of Bethlehem in London, England, became notorious for its noisy, chaotic conditions and cruel treatment of patients.
 The Hospital of Saint Mary of Bethlehem, a London mental hospital commonly known as Bedlam, sold admission tickets to the public in the 18th century, becoming a popular tourist attraction. In this engraving by English artist William Hogarth, part of his series A Rake’s Progress (1735), two women (seen in the background) tour the hospital, watching the mentally ill patients for their amusement. The hospital became notorious for its miserable conditions and cruel treatment of patients.
 Yet as the public’s awareness of such conditions grew, improvements in care and treatment began to appear. In 1789 Vincenzo Chiarugi, superintendent of a mental hospital in Florence, Italy, introduced hospital regulations that provided patients with high standards of hygiene, recreation and work opportunities, and minimal restraint. At nearly the same time, Jean-Baptiste Pussin, superintendent of a ward for ‘incurable’ mental patients at La Bicêtre hospital in Paris, France, forbade staff to beat patients and released patients from shackles. Philippe Pinel continued these reforms upon becoming chief physician of La Bicêtre’s ward for the mentally ill in 1793. Pinel began to keep case histories of patients and developed the concept of ‘moral treatment,’ which involved treating patients with kindness and sensitivity, and without cruelty or violence. In 1796 a Quaker named William Tuke established the York Retreat in rural England, which became a model of compassionate care. The retreat enabled people with mental illnesses to rest peacefully, talk about their problems, and work. Eventually these humane techniques became widespread in Europe.
 In 1908, after his release from a mental asylum, Clifford Whittingham Beers wrote A Mind That Found Itself, which exposed the poor conditions he had suffered while confined. He went on to establish several organizations dedicated to the promotion of mental health reforms in the United States.
 People living in the colonies of North America in the 17th and 18th centuries generally explained bizarre or deviant behaviour as God’s will or the work of the devil. Some people with mental illnesses received care from their families, but most were jailed or confined in almshouses with the poor and infirm. By the mid-18th century, however, American physicians came to view mental illnesses as diseases of the brain, and advocated specialized facilities to treat the mentally ill. The Pennsylvania Hospital in Philadelphia, which opened in 1752, became the first hospital in the American colonies to admit people with mental illnesses, housing them in a separate ward. However, in the hospital’s early years, mentally ill patients were chained to the walls of dark, cold cells.
 After suffering a mental breakdown in 1900, Clifford Beers, an aspiring American businessman, spent the next three years in treatment at various mental hospitals. Upon his recovery, Beers wrote A Mind That Found Itself (1908), which chronicled the hardships he endured and revealed the callousness of many hospital attendants to the suffering of patients. The book aroused public concern about the care of people with mental illnesses and launched a worldwide movement for mental health. In the following excerpt, Beers describes his experiences in the violent ward of a state hospital. The passage also reveals the delusions brought about by his state of ‘elation,’ or mania.
 In the 1780s American physician Benjamin Rush instituted changes at the Pennsylvania Hospital that greatly improved conditions for mentally ill patients. Although he endorsed the continued use of restraints, punishment, and bleeding, he also arranged for heat and better ventilation in the wards, separation of violent patients from other patients, and programs that offered work, exercise, and recreation to patients. Between 1817 and 1828, following the examples of Tuke and Pinel, a number of institutions opened that devoted themselves exclusively to the care of mentally ill people. The first private mental hospital in the United States was the Asylum for the Relief of Persons Deprived of the Use of Their Reason (now Friends Hospital), opened by Quakers in 1817 in what is now Philadelphia. Other privately established institutions soon followed, and state-sponsored hospitals—in Kentucky, New York, Virginia, and South Carolina—-opened beginning in 1824.
 Nevertheless, circumstances for most mentally ill people in the United States, especially those who were poor, remained dreadful. In 1841 Dorothea Dix, a Boston schoolteacher, began a campaign to make the public aware of the plight of mentally ill people. By 1880, as a direct result of her efforts, 32 psychiatric hospitals for the poor had opened. Increasingly, society viewed psychiatric institutions as the most appropriate form of care for people with mental illnesses. However, by the late 19th century, conditions in these institutions had deteriorated. Overcrowded and understaffed, psychiatric hospitals had shifted their treatment approach from moral therapy to warehousing and punishment. In 1908 Clifford Whittingham Beers aroused new concern for mentally ill individuals with the publication of A Mind That Found Itself, an account of his experiences as a mental patient. In 1909 Beers founded the National Committee for Mental Hygiene, which worked to prevent mental illness and ensure humane treatment of the mentally ill.
 Following World War II (1939-1945), a movement emerged in the United States to reform the system of psychiatric hospitals, in which hundreds of thousands of mentally ill persons lived in isolation for years or decades. Many mental health professionals - seeing that large state institutions caused as much, if not more, harm to patients than mental illnesses themselves - came to believe that only patients with severe symptoms should be hospitalized. In addition, the development in the 1950s of antipsychotic drugs, which helped to control bizarre and violent behaviour, allowed more patients to be treated in the community. In combination, these factors led to the de-institutionalization movement: the release, over the next four decades, of hundreds of thousands of patients from state mental hospitals. In 1950, 513,000 patients resided in these institutions. By 1965 there were 475,000, and by 1990 state mental hospitals housed only 92,000 patients on any given night. Many patients who were released returned to their families, although many were transferred to questionable conditions in nursing homes or board-and-care homes. Many patients had no place to go and began to live on the streets.
 The National Mental Health Act of 1946 created the National Institute of Mental Health as a center for research and funding of research on mental illness. In 1955 Congress created a commission to investigate the state of mental health care, treatment, and prevention. In 1963, as a result of the commission’s findings, Congress passed the Community Mental Health Centres Act, which authorized the construction of community mental health centres throughout the country. Implementation of these centres was not as extensive as originally planned, and many people with severe mental illnesses failed to receive care of any kind.
 One of the most important developments in the field of mental health in the United States has been the establishment of advocacy and support groups. The National Alliance for the Mentally Ill (NAMI), one of the most influential of these groups, was founded in 1972. NAMI’s goal is to improve the lives of people with severe mental illnesses and their families by eliminating discrimination in housing and employment and by improving access to essential treatments and programs.
 During the 1980s, all levels of government in the United States cut back on funding for social services. For example, the Social Security Administration discontinued benefits for approximately 300,000 people between 1981 and 1983. Of these, an estimated 100,000 were people with mental illnesses. Although the government eventually restored Social Security benefits to many of these people, the interruption of services caused widespread hardship.
 The emergence of managed care in the 1990s as a way to contain health care costs had a tremendous impact on mental health care in the United States. Health insurance companies and health maintenance organizations increasingly scrutinized the effectiveness of various psychotherapies and drug treatments and put stricter limits on mental health care. In response to these restrictions, Congress passed the Mental Health Parity Act of 1996. This law required private medical plans that offer mental health coverage to set equal yearly and lifetime payment limits for coverage of both mental and physical illnesses.
 In 1997 the U.S. Equal Employment Opportunity Commission issued new guidelines intended to prevent discrimination against people with mental illnesses in the workplace. The rules, based on the Americans with Disabilities Act of 1990, prohibit employers from asking job applicants if they have a history of mental illness and require employers to provide reasonable accommodations to workers with mental illnesses.
 In recent years international agencies, led by the World Health Organization (WHO) of the United Nations (UN) have developed mental health policies that seek to reduce the huge burden of mental illness worldwide. These agencies are working to improve the quality of mental health services in Africa, Asia, Latin America, the Middle East, and elsewhere by educating governments on prevention and treatment of mental illness and on the rights of the mentally ill.
 Bipolar Disorder, mental illness in which a person’s mood alternates between extreme mania and depression. Bipolar disorder is also called manic-depressive illness. When manic, people with bipolar disorder feel intensely elated, self-important, energetic, and irritable. When depressed, they experience painful sadness, negative thinking, and indifference to things that used to bring them happiness.
 American psychiatrist Kay Redfield Jamison is regarded as one of the world’s leading authorities on bipolar disorder, also known as manic-depressive illness. In her book An Unquiet Mind: A Memoir of Moods and Madness (1995), Jamison reveals her own struggle against the illness, which caused her to experience violent mood swings. In this excerpt, she describes her initial resistance to taking medication that, while necessary to prevent debilitating depression, extinguished the exhilarating highs of mania. ‘An Unquiet Mind’ written and read by Kay Redfield Jamison (Cat.# Random House Audio Books RH 431) (c) Alfred A. Knopf, Inc. (p)1995 Random House Audio Books http://www.randomhouse.com/.
 Emission tomography scans of the brain of a person with bipolar disorder show the individual shifting from depression, top row, to mania, middle row, and back to depression, bottom row, over the course of 10 days. Blue and green indicate low levels of brain activity, while red, orange, and yellow indicate high levels of brain activity.
 American author Ernest Hemingway suffered from bipolar disorder (manic-depressive illness) and committed suicide at the age of 61, during a period of depression. The author’s father, brother, and a sister all committed suicide, and in 1996 Hemingway’s granddaughter, American actor and model Margaux Hemingway, also committed suicide. Scientific research on suicide suggests that genetic and biological factors play a role in suicidal behaviour.
 Bipolar disorder is much less common than depression. In North America and Europe, about 1 percent of people experience bipolar disorder during their lives. Rates of bipolar disorder are similar throughout the world. In comparison, at least 8 percent of people experience serious depression during their lives. Bipolar disorder affects men and women about equally and is somewhat more common in higher socioeconomic classes. At least 15 percent of people with bipolar disorder commit suicide. This rate roughly equals the rate for people with major depression, the most severe form of depression.
 Bipolar disorder is a mental illness that causes mood swings. In the manic phase, a person might feel ecstatic, self-important, and energetic. But when the person becomes depressed, the mood shifts to extreme sadness, negative thinking, and apathy. Some studies indicate that the disease occurs at unusually high rates in creative people, such as artists, writers, and musicians. But some researchers contend that the methodology of these studies was flawed and their results were misleading. In this October 1996 DiscoverMagazine article, anthropologist Jo Ann C. Gutin presents the results of several studies that explore the link between creativity and mental illness.
 Some research suggests that highly creative people—such as artists, composers, writers, and poets—show unusually high rates of bipolar disorder, and that periods of mania fuel their creativity. Famous artists and writers who probably suffered from bipolar disorder include poets Lord Byron and Anne Sexton, novelists Virginia Woolf and Ernest Hemingway, composers Peter Ilyich Tchaikovsky and Sergey Rachmaninoff, and painters Amedeo Modigliani and Jackson Pollock. Critics of this research note that many creative people do not suffer from bipolar disorder, and that most people with bipolar disorder are not especially creative.
 Bipolar disorder usually begins in a person’s late teens or 20's. Men usually experience mania as the first mood episode, whereas women typically experience depression first. Episodes of mania and depression usually last from several weeks to several months. On average, people with untreated bipolar disorder experience four episodes of mania or depression over any ten-year period. Many people with bipolar disorder function normally between episodes. In ‘rapid-cycling’ bipolar disorder, however, which represents 5 to 15 percent of all cases, a person experiences four or more mood episodes within a year and may have little or no normal functioning in between episodes. In rare cases, swings between mania and depression occur over a period of days.
 In another type of bipolar disorder, a person experiences major depression and hypomanic episodes, or episodes of milder mania. In a related disorder called cyclothymic disorder, a person’s mood alternates between mild depression and mild mania. Some people with cyclothymic disorder later develop full-blown bipolar disorder. Bipolar disorder may also follow a seasonal pattern, with a person typically experiencing depression in the fall and winter and mania in the spring or summer.
 People in the depressive phase of bipolar disorder feel intensely sad or profoundly indifferent to work, activities, and people that once brought them pleasure. They think slowly, concentrate poorly, feel tired, and experience changes - usually an increase - in their appetite and sleep. They often feel a sense of worthlessness or helplessness. In addition, they may feel pessimistic or hopeless about the future and may think about or attempt suicide. In some cases of severe depression, people may experience psychotic symptoms, such as delusions (false beliefs) or hallucinations (false sensory perceptions).
 In the manic phase of bipolar disorder, people feel intensely and inappropriately happy, self-important, and irritable. In this highly energized state they sleep less, have racing thoughts, and talk in rapid-fire speech that goes off in many directions. They have inflated self-esteem and confidence and may even have delusions of grandeur. Mania may make people impatient and abrasive, and when frustrated, physically abusive. They often behave in socially inappropriate ways, think irrationally, and show impaired judgment. For example, they may take aeroplane trips all over the country, make indecent sexual advances, and formulate grandiose plans involving indiscriminate investments of money. The self-destructive behaviour of mania includes excessive gambling, buying outrageously expensive gifts, abusing alcohol or other drugs, and provoking confrontations with obnoxious or combative behaviour.
 Clinical depression is one of the most common forms of mental illness. Although depression can be treated with psychotherapy, many scientists believe there are biological causes for the disease. In this June 1998 Scientific American article, neurobiologist Charles B. Nemeroff discusses the connection between biochemical changes in the brain and depression.
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 The genes that a person inherits seem to have a strong influence on whether the person will develop bipolar disorder. Studies of twins provide evidence for this genetic influence. Among genetically identical twins where one twin has bipolar disorder, the other twin has the disorder in more than 70 percent of cases. But among pairs of fraternal twins, who have about half their genes in common, both twins have bipolar disorder in less than 15 percent of cases in which one twin has the disorder. The degree of genetic similarity seems to account for the difference between identical and fraternal twins. Further evidence for a genetic influence comes from studies of adopted children with bipolar disorder. These studies show that biological relatives of the children have a higher incidence of bipolar disorder than do people in the general population. Thus, bipolar disorder seems to run in families for genetic reasons.
 Personal or work-related stress can trigger a manic episode, but this usually occurs in people with a genetic vulnerability. Other factors - such as prenatal development, childhood experiences, and social conditions—seem to have relatively little influence in causing bipolar disorder. One study examined the children of identical twins in which only one member of each pair of twins had bipolar disorder. The study found that regardless of whether the parent had bipolar disorder or not, all of the children had the same high 10-percent rate of bipolar disorder. This observation clearly suggests that risk for bipolar illness comes from genetic influence, not from exposure to a parent’s bipolar illness or from family problems caused by that illness.
 Different therapies may shorten, delay, or even prevent the extreme moods caused by bipolar disorder. Lithium carbonate, a natural mineral salt, can help control both mania and depression in bipolar disorder. The drug generally takes two to three weeks to become effective. People with bipolar disorder may take lithium during periods of relatively normal mood to delay or prevent subsequent episodes of mania or depression. Common side effects of lithium include nausea, increased thirst and urination, vertigo, loss of appetite, and muscle weakness. In addition, long-term use can impair functioning of the kidneys. For this reason, doctors do not prescribe lithium to bipolar patients with kidney disease. Many people find the side effects so unpleasant that they stop taking the medication, which often results in relapse.
 From 20 to 40 percent of people do not respond to lithium therapy. For these people, two anticonvulsant drugs may help dampen severe manic episodes: carbamazepine (Tegretol) and valproate (Depakene). The use of traditional antidepressants to treat bipolar disorder carries risks of triggering a manic episode or a rapid-cycling pattern.
 Schizophrenia, severe mental illness characterized by a variety of symptoms, including loss of contact with reality, bizarre behaviour, disorganized thinking and speech, decreased emotional expressiveness, and social withdrawal. Usually only some of these symptoms occur in any one person. The term schizophrenia comes from Greek words meaning ‘split mind.’ However, contrary to common belief, schizophrenia does not refer to a person with a split personality or multiple personality. (For a description of a mental illness in which a person has multiple personalities, such are attributive among the dissociative identity disorders. To observers, schizophrenia may seem like madness or insanity.
 Perhaps more than any other mental illness, schizophrenia has a debilitating effect on the lives of the people who suffer from it. A person with schizophrenia may have difficulty telling the difference between real and unreal experiences, logical and illogical thoughts, or appropriate and inappropriate behaviour. Schizophrenia seriously impairs a person’s ability to work, go to school, enjoy relationships with others, or take care of oneself. In addition, people with schizophrenia frequently require hospitalization because they pose a danger to themselves. About 10 percent of people with schizophrenia commit suicide, and many others attempt suicide. Once people develop schizophrenia, they usually suffer from the illness for the rest of their lives. Although there is no cure, treatment can help many people with schizophrenia lead productive lives.
 Schizophrenia also carries an enormous cost to society. People with schizophrenia occupy about one-third of all beds in psychiatric hospitals in the United States. In addition, people with schizophrenia account for at least 10 percent of the homeless population in the United States. The National Institute of Mental Health has estimated that schizophrenia costs the United States tens of billions of dollars each year in direct treatment, social services, and lost productivity.
 Approximately 1 percent of people develop schizophrenia at some time during their lives. Experts estimate that about 1.8 million people in the United States have schizophrenia. The prevalence of schizophrenia is the same regardless of sex, race, and culture. Although women are just as likely as men to develop schizophrenia, women tend to experience the illness less severely, with fewer hospitalizations and better social functioning in the community.

 Schizophrenia usually develops in late adolescence or early adulthood, between the ages of 15 and 30. Much less commonly, schizophrenia develops later in life. The illness may begin abruptly, but it usually develops slowly over months or years. Mental health professionals diagnose schizophrenia based on an interview with the patient in which they determine whether the person has experienced specific symptoms of the illness.
 Symptoms and functioning in people with schizophrenia tend to vary over time, sometimes worsening and other times improving. For many patients the symptoms gradually become less severe as they grow older. About 25 percent of people with schizophrenia become symptom-free later in their lives.
 A variety of symptoms characterize schizophrenia. The most prominent include symptoms of psychosis—such as delusions and hallucinations—as well as bizarre behaviour, strange movements, and disorganized thinking and speech. Many people with schizophrenia do not recognize that their mental functioning is disturbed.
 Some people with schizophrenia experience delusions of persecution—false beliefs that other people are plotting against them. This interview between a patient with schizophrenia and his therapist illustrates the paranoia that can affect people with this illness.
 Delusions are false beliefs that appear obviously untrue to other people. For example, a person with schizophrenia may believe that he is the king of England when he is not. People with schizophrenia may have delusions that others, such as the police or the FBI, are plotting against them or spying on them. They may believe that aliens are controlling their thoughts or that their own thoughts are being broadcast to the world so that other people can hear them.
 People with schizophrenia may also experience hallucinations (false sensory perceptions). People with hallucinations see, hear, smell, feel, or taste things that are not really there. Auditory hallucinations, such as hearing voices when no one else is around, are especially common in schizophrenia. These hallucinations may include two or more voices conversing with each other, voices that continually comment on the person’s life, or voices that command the person to do something.
 People with schizophrenia often behave bizarrely. They may talk to themselves, walk backward, laugh suddenly without explanation, make funny faces, or masturbate in public. In rare cases, they maintain a rigid, bizarre pose for hours on end. Alternately, they may engage in constant random or repetitive movements.
 People with schizophrenia sometimes talk in incoherent or nonsensical ways, which suggests confused or disorganized thinking. In conversation they may jump from topic to topic or string together loosely associated phrases. They may combine words and phrases in meaningless ways or make up new words. In addition, they may show poverty of speech, in which they talk less and more slowly than other people, fail to answer questions or reply only briefly, or suddenly stop talking in the middle of speech.
 Another common characteristic of schizophrenia is social withdrawal. People with schizophrenia may avoid others or act as though others do not exist. They often show decreased emotional expressiveness. For example, they may talk in a low, monotonous voice, avoid eye contact with others, and display a blank facial expression. They may also have difficulties experiencing pleasure and may lack interest in participating in activities.
 Other symptoms of schizophrenia include difficulties with memory, attention span, abstract thinking, and planning ahead. People with schizophrenia commonly have problems with anxiety, depression, and suicidal thoughts. In addition, people with schizophrenia are much more likely to abuse or become dependent upon drugs or alcohol than other people. The use of alcohol and drugs often worsens the symptoms of schizophrenia, resulting in relapses and hospitalizations.
 Schizophrenia appears to result not from a single cause, but from a variety of factors. Most scientists believe that schizophrenia is a biological disease caused by genetic factors, an imbalance of chemicals in the brain, structural brain abnormalities, or abnormalities in the prenatal environment. In addition, stressful life events may contribute to the development of schizophrenia in those who are predisposed to the illness.
 Research shows that the more genetically related a person is to someone with schizophrenia, the greater the risk that person has of developing the illness. For example, children of one parent with schizophrenia have a 13 percent chance of developing the illness, whereas children of two parents with schizophrenia have a 46 percent chance of developing the disorder.
 Research suggests that the genes one inherits strongly influence one’s risk of developing schizophrenia. Studies of families have shown that the more closely one is related to someone with schizophrenia, the greater the risk one has of developing the illness. For example, the children of one parent with schizophrenia have about a 13 percent chance of developing the illness, and children of two parents with schizophrenia have about a 46 percent chance of eventually developing schizophrenia. This increased risk occurs even when such children are adopted and raised by mentally healthy parents. In comparison, children in the general population have only about a 1 percent chance of developing schizophrenia.
 Some evidence suggests that schizophrenia may result from an imbalance of chemicals in the brain called neurotransmitters. These chemicals enable neurons (brain cells) to communicate with each other. Some scientists suggest that schizophrenia results from excess activity of the neurotransmitter dopamine in certain parts of the brain or from an abnormal sensitivity to dopamine. Support for this hypothesis comes from antipsychotic drugs, which reduce psychotic symptoms in schizophrenia by blocking brain receptors for dopamine. In addition, amphetamines, which increase dopamine activity, intensify psychotic symptoms in people with schizophrenia. Despite these findings, many experts believe that excess dopamine activity alone cannot account for schizophrenia. Other neurotransmitters, such as serotonin and norepinephrine, may play important roles as well.
 Brain imaging techniques, such as magnetic resonance imaging and positron-emission tomography, have led researchers to discover specific structural abnormalities in the brains of people with schizophrenia. For example, people with chronic schizophrenia tend to have enlarged brain ventricles (cavities in the brain that contain cerebrospinal fluid). They also have a smaller overall volume of brain tissue compared to mentally healthy people. Other people with schizophrenia show abnormally low activity in the frontal lobe of the brain, which governs abstract thought, planning, and judgment. Research has identified possible abnormalities in many other parts of the brain, including the temporal lobes, basal ganglia, thalamus, hippocampus, and superior temporal gyrus. These defects may partially explain the abnormal thoughts, perceptions, and behaviours that characterize schizophrenia.
 Evidence suggests that factors in the prenatal environment and during birth can increase the risk of a person later developing schizophrenia. These events are believed to affect the brain development of the fetus during a critical period. For example, pregnant women who have been exposed to the influenza virus or who have poor nutrition have a slightly increased chance of giving birth to a child who later develops schizophrenia. In addition, obstetric complications during the birth of a child—for example, delivery with forceps—can slightly increase the chances of the child later developing schizophrenia.
 Although scientists favour a biological cause of schizophrenia, stress in the environment may affect the onset and course of the illness. Stressful life circumstances—such as growing up and living in poverty, the death of a loved one, an important change in jobs or relationships, or chronic tension and hostility at home—can increase the chances of schizophrenia in a person biologically predisposed to the disease. In addition, stressful events can trigger a relapse of symptoms in a person who already has the illness. Individuals who have effective skills for managing stress may be less susceptible to its negative effects. Psychological and social rehabilitation can help patients develop more effective skills for dealing with stress.
 Although there is no cure for schizophrenia, effective treatment exists that can improve the long-term course of the illness. With many years of treatment and rehabilitation, significant numbers of people with schizophrenia experience partial or full remission of their symptoms.
 Treatment of schizophrenia usually involves a combination of medication, rehabilitation, and treatment of other problems the person may have. Antipsychotic drugs (also called neuroleptics) are the most frequently used medications for treatment of schizophrenia. Psychological and social rehabilitation programs may help people with schizophrenia function in the community and reduce stress related to their symptoms. Treatment of secondary problems, such as substance abuse and infectious diseases, is also an important part of an overall treatment program.
 Antipsychotic medications, developed in the mid-1950s, can dramatically improve the quality of life for people with schizophrenia. The drugs reduce or eliminate psychotic symptoms such as hallucinations and delusions. The medications can also help prevent these symptoms from returning. Common antipsychotic drugs include risperidone (Risperdal), olanzapine (Zyprexa), clozapine (Clozaril), quetiapine (Seroquel), haloperidol (Haldol), thioridazine (Mellaril), chlorpromazine (Thorazine), fluphenazine (Prolixin), and trifluoperazine (Stelazine). People with schizophrenia usually must take medication for the rest of their lives to control psychotic symptoms. Antipsychotic medications appear to be less effective at treating other symptoms of schizophrenia, such as social withdrawal and apathy.
 Antipsychotic drugs help reduce symptoms in 80 to 90 percent of people with schizophrenia. However, those who benefit often stop taking medication because they do not understand that they are ill or because of unpleasant side effects. Minor side effects include weight gain, dry mouth, blurred vision, restlessness, constipation, dizziness, and drowsiness. Other side effects are more serious and debilitating. These may include muscle spasms or cramps, tremors, and tardive dyskinesia, an irreversible condition marked by uncontrollable movements of the lips, mouth, and tongue. Newer drugs, such as clozapine, olanzapine, risperidone, and quetiapine, tend to produce fewer of these side effects. However, clozapine can cause agranulocytosis, a significant reduction in white blood cells necessary to fight infections. This condition can be fatal if not detected early enough. For this reason, people taking clozapine must have weekly tests to monitor their blood.
 Because many patients with schizophrenia continue to experience difficulties despite taking medication, psychological and social rehabilitation is often necessary. A variety of methods can be effective. Social skills training helps people with schizophrenia learn specific behaviours for functioning in society, such as making friends, purchasing items at a store, or initiating conversations. Behavioural training methods can also help them learn self-care skills such as personal hygiene, money management, and proper nutrition. In addition, cognitive-behavioural therapy, a type of psychotherapy, can help reduce persistent symptoms such as hallucinations, delusions, and social withdrawal.
 Family intervention programs can also benefit people with schizophrenia. These programs focus on helping family members understand the nature and treatment of schizophrenia, how to monitor the illness, and how to help the patient make progress toward personal goals and greater independence. They can also lower the stress experienced by everyone in the family and help prevent the patient from relapsing or being re-hospitalized.
 Because many patients have difficulty obtaining or keeping jobs, supported employment programs that help patients find and maintain jobs are a helpful part of rehabilitation. In these programs, the patient works alongside people without disabilities and earns competitive wages. An employment specialist (or vocational specialist) helps the person maintain their job by, for example, training the person in specific skills, helping the employer accommodate the person, arranging transportation, and monitoring performance. These programs are most effective when the supported employment is closely integrated with other aspects of treatment, such as medication and monitoring of symptoms.
 Some people with schizophrenia are vulnerable to frequent crises because they do not regularly go to mental health centres to receive the treatment they need. These individuals often relapse and face re-hospitalization. To ensure that such patients take their medication and receive appropriate psychological and social rehabilitation, assertive community treatment (ACT) programs have been developed that deliver treatment to patients in natural settings, such as in their homes, in restaurants, or on the street.
 People with schizophrenia often have other medical problems, so an effective treatment program must attend to these as well. One of the most common associated problems is substance abuse. Successful treatment of substance abuse in patients with schizophrenia requires careful coordination with their mental health care, so that the same clinicians are treating both disorders at the same time.
 The high rate of substance abuse in patients with schizophrenia contributes to a high prevalence of infectious diseases, including hepatitis B and C and the human immunodeficiency virus (HIV). Assessment, education, and treatment or management of these illnesses is critical for the long-term health of patients.
 Other problems frequently associated with schizophrenia include housing instability and homelessness, legal problems, violence, trauma and post-traumatic stress disorder, anxiety, depression, and suicide attempts. Close monitoring and psychotherapeutic interventions are often helpful in addressing these problems.
 Several other psychiatric disorders are closely related to schizophrenia. In schizoaffective disorder, a person shows symptoms of schizophrenia combined with either mania or severe depression. Schizophreniform disorder refers to an illness in which a person experiences schizophrenic symptoms for more than one month but fewer than six months. In schizotypal personality disorder, a person engages in odd thinking, speech, and behaviour, but usually does not lose contact with reality. Sometimes mental health professionals refer to these disorders together as schizophrenia-spectrum disorders.
 Neurosis, in psychoanalysis, a mental illness characterized by anxiety and disturbances in one’s personality. Generally, only psychologists who adhere to a psychoanalytic or psychodynamic model of abnormal behaviour use the term neurosis. Psychiatrists and psychologists no longer accept the term as a formal diagnosis. Laypersons sometimes use the word neurotic to describe an emotionally unstable person.
 Scottish physician William Cullen coined the term neurosis near the end of the 18th century to describe a wide variety of nervous behaviours with no apparent physical cause. Austrian psychoanalyst Sigmund Freud and his followers popularized the word in the late 19th and early 20th centuries. Freud defined neurosis as one class of mental illnesses. In his view, people became neurotic when their conscious mind repressed inappropriate fantasies of the unconscious mind.
 Until 1980 neurosis appeared as a specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, a handbook for mental health professionals. Neurosis encompassed a variety of mental illnesses, including dissociative disorders, anxiety disorders, and phobias.
 In the psychoanalytic model, neurosis differs from psychosis, another general term used to describe mental illnesses. Individuals with neuroses can function at work and in social situations, whereas people with psychoses find it quite difficult to function adequately. People with neuroses do not grossly distort or misinterpret reality as those with psychoses do. In addition, neurotic individuals recognize that their mental functioning is disturbed while psychotic individuals usually do not. Most mental health professionals now use the term psychosis to refer to symptoms such as hallucinations, delusions, and bizarre behaviour.
 Psychosis, mental illness in which a person loses contact with reality and has difficulty functioning in daily life. Psychotic symptoms can indicate severe mental illnesses, such as schizophrenia and bipolar disorder (manic-depressive illness). Unlike people with less severe psychological problems, psychotic individuals do not usually recognize that their mental functioning is disturbed.
 Mental health professionals generally divide psychotic symptoms into three broad types: hallucinations, delusions, and bizarre behaviour. Hallucinations refer to hearing, seeing, smelling, feeling, or tasting something when nothing in the environment actually caused that sensation. For example, a person experiencing an auditory hallucination might hear a voice calling her or his name even though no one else is actually present. A delusion is a false belief held by a person that appears obviously untrue to other people in that person’s culture. For example, a man may believe that Martians have implanted a microchip in his brain that controls his thoughts. Bizarre behaviour refers to behaviour in a person that is strange or incomprehensible to others who know the person. For example, hoarding unused scraps of tin because of their ‘magical properties’ would be a type of bizarre behaviour.
 Psychosis can occur in a number of mental illnesses. These include schizophrenia and schizophrenia-related disorders, bipolar disorder, paranoid personality disorder, and delusional disorder. Less commonly, psychotic symptoms occur in major depression (severe depression), dissociative disorders, and post-traumatic stress disorder.
 Psychotic symptoms can also result from substance abuse. Stimulants, such as cocaine and amphetamines, can cause psychotic symptoms, especially if taken in high doses or over long periods of time. Hallucinogenic substances, such as lysergic acid diethylamide (LSD), mescaline, and phencyclidine (PCP), can cause psychosis. Alcohol and marijuana can occasionally cause psychotic symptoms as well. Individuals with alcoholism may experience psychotic symptoms, especially hallucinations, as they withdraw from alcohol. Alcohol dependence over a long period of time can result in Korsakoff’s psychosis, a syndrome that may include psychotic symptoms and an inability to form new memories. Certain medical conditions can also cause psychosis. Syphilis, especially if untreated for many years, can lead to psychosis. Brain tumours can also lead to psychotic symptoms.
 Treatment of psychotic symptoms usually involves taking antipsychoticdrugs, also called neuroleptics. Common antipsychotic drugs include chlorpromazine (Thorazine), fluphenazine (Prolixin), thioridazine (Mellaril), trifluoperazine (Stelazine), clozapine (Clozaril), haloperidol (Haldol), olanzapine (Zyprexa), and risperidone (Risperdal). These medications can help reduce psychotic symptoms and prevent symptoms from returning. However, they can also cause severe side effects, such as muscle spasms, tremors, and tardive dyskinesia, a permanent condition marked by uncontrollable lip smacking, grimacing, and tongue movements. Psychotic symptoms in individuals with bipolar disorder may respond to other types of medication, including lithium, carbamazepine (Tegretol), and valproate (Depakene).
 Psychotic symptoms that occur as a result of substance abuse usually disappear gradually after the person stops using the substances. Physicians sometimes use antipsychotic medications temporarily to treat these individuals. Physicians have not discovered any effective treatments for Korsakoff’s psychosis. Psychotic symptoms resulting from medical conditions often disappear after treatment of the underlying medical problem.
 Collective Unconscious, in psychology, a shared pool of memories, ideas, and modes of thought. According to Swiss psychiatrist Carl Jung, it comes from the life experience of one's ancestors and from the entire human race. The collective unconscious coexists with the personal unconscious, which contains the material of individual experience, and may be regarded as an immense depository of ancient wisdom.
 Primal experiences are represented in the collective unconscious by archetypes, symbolic pictures, or personifications that appear in dreams and are the common elements in myths, fairy tales, and religious literature. Examples include the serpent, the sphinx, the Great Mother, the anima (representing the nature of woman), and the mandala (representing balanced wholeness, human or divine).
 Complex, group of repressed ideas that shape an individual’s response to think, feel, and act in a certain habitual pattern. Swiss psychiatrist Carl Jung, who originally coined the term complex, derived it from the Latin word complexus, meaning interweaving or braiding. Jung stated that a complex is a ‘grouping of psychic elements about emotionally toned contents,’ adding that it ‘consists of a nuclear element and a great number of secondarily constellated associations.’ The components of a complex may be present in consciousness or in the unconscious. Conflicts, frustrations, and threats to personal security encountered during infancy are then repressed into the unconscious, where they remain dormant, but not forgotten. These unconscious memories will govern an individual’s response to emotional conflict even into adult life, as the original trauma and its associated effect patterns thinking and behaviour to meet the new conflict.
 The Oedipus and Electra complexes as described by Sigmund Freud, and the inferiority complex as described by Alfred Adler, have been influential concepts within the context of psychoanalytic theory
 Id, in psychoanalytic theory, one of the three basic elements of personality, the others being the ego and the superego. The id can be equated with the unconscious of common usage, which is the reservoir of the instinctual drives of the individual, including biological urges, wishes, and affective motives. The id is dominated by the pleasure principle, through which the individual is pressed for immediate gratification of his or her desires. In strict Freudian theory the energy behind the instinctual drives of the id is known as the libido, a generalized force, basically sexual in nature, through which the sexual and psychosexual nature of the individual finds expression.
 Oedipus Complex, in psychoanalysis, a son’s largely unconscious sexual attraction toward his mother accompanied by jealousy toward his father. The term Oedipus complex, derived from the Greek legend of Oedipus, was first used in the late 1800s by Austrian psychiatrist Sigmund Freud, the founder of psychoanalysis. Freud thought that the Oedipus complex was the most important event of a boy’s childhood and had a great effect on his subsequent adult life. Freud claimed that in nearly all cases the boy represses the desire for his mother and the jealousy toward his father. As a result of this unconscious experience, Freud believed, a boy with an Oedipus complex feels guilt and experiences strong emotional conflicts.
 Freud thought that girls go through a similar experience, in which they are attracted to their father and become antagonistic toward their mother. He called this the Electra complex. According to Freud, if a woman remains under the influence of the Electra complex, she is likely to choose a husband with characteristics similar to those of her father.
 Superego, in psychoanalytic theory, one of the three basic constituents of the mind, the others being the id and the ego. As postulated by Sigmund Freud, the term designates the element of the mind that, in normal personalities, automatically modifies and inhibits those instinctual impulses or drives of the id that tend to produce antisocial actions and thoughts.
 According to psychoanalytic theory, the superego develops as the child gradually and unconsciously adopts the values and standards, first of his or her parents, and later of the social environment. According to modern Freudian psychoanalysts, the superego includes the positive ego, or conscious self-image, or ego ideal, that each individual develops
 Unconscious, in psychology, hypothetical region of the mind containing wishes, memories, fears, feelings, and ideas that are prevented from expression in conscious awareness. They manifest themselves, instead, by their influence on conscious processes and, most strikingly, by such anomalous phenomena as dreams and neurotic symptoms, yet not all mental activity of which the subject is unaware belongs to the unconscious; for example, thoughts that may be made conscious by a new focusing of attention are termed foreconscious or preconscious.
 The concept of the unconscious was first developed in the period from 1895 to 1900 by Sigmund Freud, who theorized that it consists of survivals of feelings experienced during infantile life, including both instinctual drives or libido and their modifications by the development of the superego. According to the Swiss psychoanalyst Carl Jung, the unconscious also consists of a racial unconscious that contains certain inherited, universal, archaic fantasies belonging to what Jung termed the collective unconscious.
 Most analyses of myths in the 18th and 19th centuries showed a tendency to reduce myths to some essential core—whether the seasonal cycles of nature, historical circumstances, or ritual. That core supposedly remained once the fanciful elements of the narratives had been stripped away. In the 20th century, investigators began to pay closer attention to the content of the narratives themselves. Austrian psychoanalyst Sigmund Freud held that myths—like dreams—condense the material of experience and represent it in symbols. Freud’s pupil Carl Jung took this psychological approach in a different direction. Jung viewed myths not as relics of the infancy of the human race, but as revelations of humanity’s tendency to draw on a collective store of what he called archetypes—a set of patterns in the unconscious mind that people in all cultures express through similar images and symbols. French anthropologist Claude Lévi-Strauss argued that the primary function of myths is to resolve contradictions between such basic sets of opposites as life and death, nature and culture, and self and society.
What has become clear is that myth-making is an extremely varied and complex human activity. As in other creative activities, an enormous number of social, environmental, and personal factors come into play that make it difficult to summarize or explain myth-making from a single vantage point. While every theory offers something illuminating and useful to the understanding of some myths or mythological traditions, it seems unlikely that anyone will ever devise a theory that accounts for every type of tale that is classified as myth.
 Mythology has exerted a pervasive influence on the arts in all parts of the world from the earliest times. In the Americas, people expressed mythological themes using materials such as sand (in the sandpaintings of the Navajo) and stone (in the jade masks of the Olmec). In Oceania, wood was a preferred material, used to created sculptures and masks. The indigenous peoples of Central and South America used ceramics for funerary urns and sculptures of gods and mythological figures. In ancient Europe as well, mythological themes were treated in a variety of media, including stone, wood, and metal.
 Some of the richest artistic traditions involving mythology are found in the cultures of West Africa. Particularly prominent in sculpture are the Nommo, celestial twins whose representations can be studied both in the way they have changed over time and in the way they vary across cultures. Despite the artistic value of pieces inspired by myth, it is misleading to isolate the art objects of myth-making cultures from their religious and intellectual context. The statuettes and masks of the Dogon people, for example, do not exist primarily to satisfy an aesthetic impulse, but to serve as instruments in religious acts.
 Even apart from cultures in which myth-making is bound up with ritual, myths have provided a wealth of material for the writer and artist since the beginning of recorded history. The divine characters employed by Homer in his epics—principally Zeus, Hera, Athena, Aphrodite, Apollo, and Ares—became the common property of poets throughout antiquity. In addition, Greek writers of tragedy drew upon the traditional body of myth to create such human characters as Agamemnon and Clytemnestra (in the Oresteia of Aeschylus); Antigone (in the play of the same name by Sophocles); and Electra (in plays by Sophocles and Euripides).
 The gods have also provided inspiration to many visual artists through the centuries. As an ideal of masculine beauty, Apollo figures prominently in artworks of all periods. The most famous representation of Apollo is the Apollo Belvedere, an ancient Roman sculpture copied from a Greek original, in the Vatican Museum in Rome. Many artists of the Renaissance and the Baroque Era (1600 to 1750) represented Apollo as well. The goddess Venus, equally renowned for beauty, has inspired many artists since ancient times. Italian Renaissance painter Sandro Botticelli copied an ancient sculpture in his famous painting Birth of Venus (after 1482, Uffizi Gallery, Florence, Italy).
 In literature and music the debt to mythological themes is equally pronounced. Antigone, a daughter of Oedipus, became famous in the play by Sophocles, which portrays the conflict between obedience to the laws of the state and to the higher laws of the gods. Among those who later used themes from her life are French playwrights Jean Cocteau (Antigone, 1922) and Jean Anouilh (Antigone, 1942) and German playwright Bertolt Brecht (Antigone, 1948). Electra, the unhappy daughter of Agamemnon who seeks to avenge her father’s murder, has been the subject of plays by French playwright Jean-Paul Sartre (The Flies, 1943) and American playwright Eugene O’Neill (Mourning Becomes Elektra, 1931), and of a celebrated opera by German composer Richard Strauss (Elektra, 1909). It is no exaggeration to say that art, music, and literature throughout the world would be unimaginably different without the influence of mythology.
 Psychiatry, branch of medicine specializing in mental illnesses. Psychiatrists not only diagnose and treat these disorders but also conduct research directed at understanding and preventing them.
 A psychiatrist is a doctor of medicine who has had four years of postgraduate training in psychiatry. Many psychiatrists take further training in psychoanalysis, child psychiatry, or other subspecialties. Psychiatrists treat patients in private practice, in general hospitals, or in specialized facilities for the mentally ill (psychiatric hospitals, outpatient clinics, or community mental health centres). Some spend part or all of their time doing research or administering mental health programs. By contrast, psychologists, who often work closely with psychiatrists and treat many of the same kinds of patients, are not trained in medicine; consequently, they neither diagnose physical illness nor administer drugs.
 The province of psychiatry is unusually broad for a medical specialty. Mental disorders may affect most aspects of a patient's life, including physical functioning, behaviour, emotions, thought, perception, interpersonal relationships, sexuality, work, and play. These disorders are caused by a poorly understood combination of biological, psychological, and social determinants. Psychiatry's task is to account for the diverse sources and manifestations of mental illness.
 Physicians in the Western world began specializing in the treatment of the mentally ill in the 19th century. Known as alienists, psychiatrists of that era worked in large asylums, practicing what was then called moral treatment, a humane approach aimed at quieting mental turmoil and restoring reason. During the second half of the century, psychiatrists abandoned this mode of treatment and, with it, the tacit recognition that mental illness is caused by both psychological and social influences. For a while, their attention focused almost exclusively on biological factors. Drugs and other forms of somatic (physical) treatment were common. The German psychiatrist Emil Kraepelin identified and classified mental disorders into a system that is the foundation for modern diagnostic practices. Another important figure was the Swiss psychiatrist Eugen Bleuler, who coined the word schizophrenia and described its characteristics.
 The discovery of unconscious sources of behaviour—an insight dominated by the psychoanalytic writings of Sigmund Freud in the early 20th century—enriched psychiatric thought and changed the direction of its practice. Attention shifted to processes within the individual psyche, and psychoanalysis came to be regarded as the preferred mode of treatment for most mental disorders. In the 1940s and 1950s emphasis shifted again: this time to the social and physical environment. Many psychiatrists had all but ignored biological influences, but others were studying those involved in mental illness and were using somatic forms of treatment such as electroconvulsive therapy (electric shock) and psychosurgery.
 Dramatic changes in the treatment of the mentally ill in the United States began in the mid-1950s with the introduction of the first effective drugs for treating psychotic symptoms. Along with drug treatment, new, more liberal and humane policies and treatment strategies were introduced into mental hospitals. More and more patients were treated in community settings in the 1960s and 1970s. Support for mental health research led to significant new discoveries, especially in the understanding of genetic and biochemical determinants in mental illness and the functioning of the brain. Thus, by the 1980s, psychiatry had once again shifted in emphasis to the biological, to the relative neglect of psychosocial influences in mental health and illness.  Psychiatrists use a variety of methods to detect specific disorders in their patients. The most fundamental is the psychiatric interview, during which the patient's psychiatric history is taken and mental status is evaluated. The psychiatric history is a picture of the patient's personality characteristics, relationships with others, and past and present experience with psychiatric problems—all told in the patient's words (sometimes supplemented by comments from other family members). Psychiatrists use mental-status examinations much as internists use physical examinations. They elicit and classify aspects of the patient's mental functioning.
 Some diagnostic methods rely on testing by other specialists. Psychologists administer intelligence and personality tests, as well as tests designed to detect damage to the brain or other parts of the central nervous system. Neurologists also test psychiatric patients for evidence of impairment of the nervous system. Other physicians sometimes examine patients who complain of physical symptoms. Psychiatric social workers explore family and community problems. The psychiatrist integrates all this information in making a diagnosis according to criteria established by the psychiatric profession.
 Psychiatric treatments fall into two classes: organic and nonorganic forms. Organic treatments, such as drugs, are those that affect the body directly. Nonorganic types of treatment improve the patient's functioning by psychological means, such as psychotherapy, or by altering the social environment.
 Pychotropic drugs are by far the most commonly used organic treatment. The first to be discovered were the antipsychotics, used primarily to treat schizophrenia. The phenothiazines are the most frequently prescribed class of antipsychotic drugs. Others are the thioxanthenes, butyrophenones, and indoles. All antipsychotic drugs diminish such symptoms as delusions, hallucinations, and thought disorder. Because they can reduce agitation, they are sometimes used to control manic excitement in manic-depressive patients and to calm geriatric patients. Some childhood behaviour disorders respond to these drugs.
 Despite their value, the antipsychotic drugs have drawbacks. The most serious is the neurological condition tardive dyskinesia, which occurs in patients who have taken the drugs over extended periods. The condition is characterized by abnormal movements of the tongue, mouth, and body. It is especially serious because its symptoms do not always disappear when the drug is stopped, and no known treatment for it has been developed.
 Most psychotropic drugs are chemically synthesized. Lithium carbonate, however, is a naturally occurring element used to prevent, or at least reduce, the severity of shifts of mood in manic-depression. It is especially effective in controlling mania. Psychiatrists must monitor lithium dosages carefully, because only a small margin exists between an effective dose and a toxic one.
 Three major classes of antidepressant drugs are used. The tricyclic and tetracyclic antidepressants, the most frequently prescribed, are used for the most common form of serious depression. Monoamine oxidase (MAO) inhibitors are used for so-called atypical depressions. Serotonin-selective reuptake inhibitors (SSRIs) are effective against both typical and atypical depressions. Although all three classes are quite effective in relieving depression in correctly matched patients, they also have disadvantages. The tricyclics and tetracyclics can take two to five weeks to become effective and can cause such side effects as oversedation and cardiac problems. MAO inhibitors can cause severe hypertension in patients who ingest certain types of food (such as cheese, beer, and wine) or drugs (such as cold medicines). SSRI drugs, such as fluoxetine (Prozac), take 2 to 12 weeks to become effective and can cause headaches, nausea, insomnia, and nervousness.
 Anxiety, tension, and insomnia are often treated with drugs that are commonly called minor tranquillizers. Barbiturates have been used for the longest time, but they produce more severe side effects and are more often abused than the newer classes of antianxiety drugs. Of the new drugs, the benzodiazepines are the most frequently prescribed, very often in nonpsychiatric settings.
 The stimulant drugs, such as amphetamine - a drug that is often abused—have legitimate uses in psychiatry. They help to control overactivity and lack of concentration in hyperactive children and to stimulate the victims of narcolepsy, a disorder characterized by sudden, uncontrollable episodes of sleep.
 Another organic treatment is electroconvulsive therapy, or ECT, in which seizures similar to those of epilepsy are produced by a current of electricity passed through the forehead. ECT is most commonly used to treat severe depressions that have not responded to drug treatment. It is also sometimes used to treat schizophrenia. Other forms of organic treatment are much less frequently used than drugs and ETC. They include the controversial technique psychosurgery, in which fibres in the brain are severed; this technique is now used very rarely.
 The most common nonorganic treatment is psychotherapy. Most psychotherapies conducted by psychiatrists are psychodynamic in orientation—that is, they focus on internal psychic conflict and its resolution as a means of restoring mental health. The prototypical psychodynamic therapy is psychoanalysis, which is aimed at untangling the sources of unconscious conflict in the past and restructuring the patient's personality. Psychoanalysis is the treatment in which the patient lies on a couch, with the psychoanalyst out of sight, and says whatever comes to mind. The patient relates dreams, fantasies, and memories, along with thoughts and feelings associated with them. The analyst helps the patient interpret these associations and the meaning of the patient's relationship to the analyst. Because it is lengthy and expensive, often several years in duration, classical psychoanalysis is now infrequently used.
 More common are shorter forms of psychotherapy that supplement psychoanalytic principles with other theoretical ideas and scientifically derived information. In these types of therapy, psychiatrists are more likely to give the patient advice and try to influence behaviour. Some use techniques derived from behaviour therapy, which is based on learning theory (although these methods are more commonly used by psychologists).
 Besides psychotherapy, the other major form of nonorganic treatment used in psychiatry is milieu therapy. Usually carried out in psychiatric wards, milieu therapy directs social relations among patients and staff toward therapeutic ends. Ward activities, too, are planned to serve specific therapeutic goals.
 In general, psychotherapy is relied on more heavily for the treatment of neuroses and other nonpsychotic conditions than it is for psychoses. In psychotic patients, who usually receive psychoactive drugs, psychotherapy is used to improve social and vocational functioning. Milieu therapy is limited to hospitalized patients. Increasingly, psychiatrists use a combination of organic and nonorganic techniques for all patients, depending on their diagnosis and response to treatment.