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Psychology.EliteCME.com Page i Table of Contents

CE for Massachusetts Psychology All 20 Hrs ONLY Professionals $55 CHAPTER 1: ELEMENTS OF SOCIAL PSYCHOLOGY Page 1

Social psychology is the scientific study of how people’s thoughts, feelings, and behaviors are influenced by the actual, imagined, or implied presence of others. Social psychologists typically explain human behavior as a result of the interaction of mental states and immediate social situations. What if I Still Have Elements of Social Psychology Final Exam Page 40 Questions? CHAPTER 2: NARCISSISTIC PERSONALITY DISORDER - HAS IT No problem, we have several BECOME AN EPIDEMIC? Page 42 options for you to choose from! Online at Psychology.EliteCME. Narcissism has been examined by mental health professionals for years, and yet something has com you will see our robust FAQ occurred recently within our society that seems to have blurred narcissism traits with the clinical section that answers many of diagnosis of narcissistic personality disorder (NPD) and accepted societal behavior. This course will discuss NPD in detail. It will also examine the characteristics and the treatment of the disorder, your questions, simply click FAQ including ways to support those affected. in the upper right hand corner or Email us at [email protected] Narcissistic Personality Disorder - Has it Become an Epidemic? or call us toll free at 1-866-652- Final Exam Page 57 2119, Monday - Friday 9:00 am CHAPTER 3: SUICIDE ASSESSMENT AND PREVENTION FOR - 6:00 pm, EST. HEALTH PROFESSIONALS Page 58

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Page ii Psychology.EliteCME.com Chapter 1: Elements of Social Psychology

10 CE Hours

By: Wade T. Lijewski, Ph.D.

Learning objectives This workshop is designed to help you: ŠŠ Critique theories of education, religion, and political sociology. ŠŠ Describe the history and foundations of social psychology and ŠŠ Construct hypotheses and studies regarding group dynamics. sociology. ŠŠ Compare urban and rural sociological factors. ŠŠ Discuss social psychology and sociological theories. ŠŠ Describe the elements of racial and ethnic inequality. ŠŠ Apply the concepts of socialization. ŠŠ Assess and apply concepts of social change. Overview Social psychology is the scientific study of how people’s thoughts, social structure to a much greater extent. Nevertheless, sociological feelings, and behaviors are influenced by the actual, imagined, or approaches to social psychology remain an important counterpart to implied presence of others. By this definition,scientific refers to the psychological research in this area. empirical method of investigation. The terms thoughts, feelings, and In addition to the split between psychology and sociology, a somewhat behaviors include all psychological variables that are measurable in a less pronounced difference in emphasis between American social human being. The statement that others’ presence may be imagined or psychologists and European social psychologists has emerged. As a implied suggests that people are prone to social influence even when broad generalization, American researchers traditionally have focused no one else is present, such as when watching television, or following more on the individual, whereas Europeans have paid more attention internalized cultural norms. to group level phenomena. Social psychologists typically explain human behavior as a result of Social cognition is a growing area of social psychology that studies the interaction of mental states and immediate social situations. In how people perceive, think about, and remember information about general, social psychologists have a preference for laboratory-based, others. Much research rests on the assertion that people think about empirical findings. Social psychology theories tend to be specific and other people differently from non-social targets. This assertion is focused, rather than global and general. The primary methods of data supported by the social cognitive deficits exhibited by people with collection are sample surveys, field observations, vignette studies, field Williams syndrome and autism. Person perception is the study of how experiments, and controlled experiments. people form impressions of others. The study of how people form Social psychologists are interested in the impact that the social beliefs about each other while interacting is known as interpersonal environment and group interactions have on attitudes and behaviors. perception. It is important to distinguish between social psychology and sociology. A major research topic in social cognition is attribution. Attributions While there are many similarities between the two, sociology tends to are the explanations people make for behavior, either their own examine social behavior and influences at a very broad-based level. behavior or the behavior of others. People can ascribe the locus Sociologists are interested in the institutions and cultures that influence of a behavior to either internal or external factors. An internal, or how people behave. Psychologists instead focus on situational dispositional, attribution assigns behavior to causes related to inner variables that affect social behavior. While psychology and sociology traits such as personality, disposition, character, or ability. An external, both study similar topics, they look at these topics from different or situational, attribution involves situational elements, such as the perspectives. weather. A second element ascribes the cause of behavior to either *Please Note* For the purpose of this workshop, the terms social stable or unstable factors. Finally, professionals also attribute causes of psychology, sociology, sociologists, and social psychologists are used behavior to either controllable or uncontrollable factors. interchangeably, as the two branches of the discipline interact with and Numerous biases in the attribution process have been discovered. For build upon one another throughout history and across theories and areas instance, the fundamental attribution error is the tendency to make of focus. One cannot discuss or truly understand one without the other. dispositional attributions for behavior, overestimating the influence of Social psychologists deal with the factors that lead people to behave in personality and underestimating the influence of situations. The actor- a given way in the presence of others, and look at the conditions under observer difference is a refinement of this bias, the tendency to make which certain behavior/actions and feelings occur. Social psychology dispositional attributions for other people’s behavior and situational is concerned with the way these feelings, thoughts, beliefs, intentions, attributions for personal behavior. and goals are constructed and how such psychological factors, in turn, The self-serving bias is the tendency to attribute dispositional causes influence interactions with others. for successes, and situational causes for failure, particularly when Social psychology is an interdisciplinary domain that bridges the gap self-esteem is threatened. This leads to assuming one’s successes are between psychology and sociology. During the years immediately from innate traits, and one’s failures are due to situations, including following World War II, frequent collaboration took place between other people. Other ways people protect their self-esteem include psychologists and sociologists. However, the two disciplines have by believing in a just world, blaming victims for their suffering, and become increasingly specialized and isolated from each other in making defensive attributions, which explain personal behavior in recent years, with sociologists focusing on “macro variables” such as ways that defend people from feelings of vulnerability and mortality.

Psychology.EliteCME.com Page 1 Researchers have found that mildly depressed individuals often lack probe beyond common-sense explanations such as “human nature” or this bias and actually have more realistic perceptions of reality (as “because it has always been done like that.” measured by the opinions of others). The following are some examples of questions that sociologists explore: Heuristics are cognitive short cuts. Instead of weighing all the evidence ●● Are men and women born to play different roles in society? when making a decision, people rely on heuristics to save time and ●● How much influence does society have on expectations of what it energy. The availability heuristic occurs when people estimate the is to be a man or a woman? probability of an outcome based on how easy that outcome is to ●● How does one account for war and conflict in society? imagine. As such, vivid or highly memorable possibilities will be ●● Why is there inequality among people? perceived as more likely than those that are harder to picture or are ●● How important is language in shaping one’s cultural identity? difficult to understand, resulting in a corresponding cognitive bias. Sociology not only asks questions about society. It also provides The representativeness heuristic is a shortcut people use to categorize training in how to answer such questions, through a combination of something based on how closely it matches a prototype they know of. thinking theoretically and undertaking applied research. Sociological Numerous other biases have been found by social cognition research takes many forms, but generally it involves field work that researchers. The hindsight bias is a false memory of having predicted takes the researcher out into the group or community being studied. events, or an exaggeration of actual predictions, after becoming aware Over the years, the discipline has developed a sophisticated set of of the outcome. The confirmation bias is a type of bias leading to the principles and practices to guide different sorts of research projects tendency to search for, or interpret information in a way that confirms and answer different sorts of research questions. Methods range from one’s preconceptions. major surveys of large numbers of people and statistical analysis, Another key concept in social cognition is the assumption that reality to in-depth interviews with individuals in order to understand their is too complex to easily discern. As a result, people tend to see the experiences and perceptions, to “participant observation”, where the world according to simplified schemas or images of reality. Schemas researcher spends time with the group being studied, participating in are generalized mental representations that organize knowledge and and observing the group’s daily activities. guide information processing. Schemas often operate automatically People have always asked critical questions about the way their society and unintentionally, and can lead to biases in perception and memory. functions. Historically, sociology emerged as an academic discipline in Expectations from schemas may lead people to see something that Europe, in the late 19th century, in response to the immense changes is not there. One experiment found that people are more likely to in social life as a result of economic developments (the industrial misperceive a weapon in the hands of an African-American man revolution, rapid urbanization, the growth of global markets) and than a Caucasian man. This type of schema is actually a stereotype, political transformation (the fall of absolute monarchies, revolution, a generalized set of beliefs about a particular group of people European colonialism, the rise of democracy). (when incorrect, an ultimate attribution error). Stereotypes often Is sociology a science? The term “science” refers to the body of relate to negative or preferential attitudes (prejudice) and behavior knowledge obtained by methods based on systematic observation. (discrimination). Schemas for behaviors (e.g., going to a restaurant, Just like other scientific disciplines, sociology involves the organized, doing laundry) are known as scripts. systematic study of phenomena (in this case, human behavior) in order Self-concept is a term that refers to the whole sum of beliefs that to enhance understanding. All scientists, whether studying mushrooms people have about themselves. However, what specifically does or murderers, attempt to collect precise information through the most self-concept consist of? According to Hazel Markus (1977), the objective methods possible. These scientists rely on careful recording self-concept is made up of cognitive molecules called self-schemas— of observations and accumulation of data. beliefs that people have about themselves that guide the processing of Natural science is the study of the physical features of nature and self-reliant information. For example, an athlete at a university would the ways in which they interact and change. Astronomy, biology, have multiple selves that would process different information pertinent chemistry, geology, and physics are all natural sciences. to each self: the student would be one “self,” who would process information pertinent to a student (taking notes in class, completing Social science is the study of the social features of humans and the ways a homework assignment, etc.); the athlete would be the “self” in which they interact and change. The social sciences include sociology, who processes information about things related to being an athlete anthropology, economics, history, psychology, and political science. (recognizing an incoming pass, aiming a shot, etc.). In attempting to understand social behavior, sociologists rely on an These “selves” are part of one’s identity, and the self-reliant unusual type of creative thinking. A leading sociologist, C. Wright Mills, information is the information that relies on the proper “self” to described such thinking as the sociological imagination, which can be process and react on it. If a “self” is not part of a person’s identity, then described as an awareness of the relationship between an individual and it is much more difficult for one to react. For example, a civilian may the wider society. This awareness allows all people (not just sociologists) not know how to handle a hostile threat in the same way that a trained to comprehend the links between immediate, personal social settings Marine would. Marines possess a “self” that would enable them to and the remote, impersonal social world that surrounds and helps to process the information about the hostile threat and react accordingly, shape individuals. Barbara Ehrenreich certainly used a sociological whereas civilians may not contain that self, disabling them from imagination when she studied low-wage workers (Mills, 2000). properly processing the information from the hostile threat and, A key element in the sociological imagination is the ability to view one’s furthermore, debilitating them from acting accordingly. own society as an outsider would, rather than only from the perspective Sociology is commonly known as the systematic study of social of personal experiences and cultural biases. Consider something as behavior and human groups. It focuses on social relationships; how simple as sporting events. The sociological imagination allows people to those relationships influence people’s behavior; and how societies, the go beyond personal experiences and observations to understand broader sum total of those relationships, develop and change. public issues. Divorce, for example, is unquestionably a personal hardship for a husband and wife who split apart. Sociologists are interested in understanding how people interact, and explaining why and how these interactions take the form that they do The sociological imagination is an empowering tool. It allows people and have changed over time. In exploring these issues, sociologists to look beyond a limited understanding of human behavior to see the world and its people in a new way and through a broader lens than

Page 2 Psychology.EliteCME.com one might otherwise use. It may be as simple as understanding why a the cultural superstructure). Max Weber critiqued Marxist economic roommate prefers country music to hip-hop, or it may open up a whole determinism, arguing that social stratification is not based purely on different way of understanding other populations in the world. economic inequalities, but on other status and power differentials. For example, in the aftermath of the terrorist attacks on the United According to Weber, stratification may occur amongst at least three States on September 11, 2001, many citizens wanted to understand complex variables: how Muslims throughout the world perceived their country, and why. 1. Property (class): A person’s economic position in a society, based Social stratification is the hierarchical arrangement of individuals on birth and individual achievement. Weber differs from Marx into social classes, and divisions within a society. Modern Western in that he does not see this as the supreme factor in stratification. societies’ stratification traditionally relates to cultural and economic Weber noted how managers of corporations or industries control classes arranged in three main layers: upper class, middle class, and firms they do not own; Marx would have placed such a person in lower class, but each class may be further subdivided into smaller the proletariat. classes, such as by occupation. 2. Prestige (status): A person’s prestige, or popularity in a society. This could be determined by the kind of job this person does or Karl Marx distinguished social classes by their connection to the level of wealth. means of production in the capitalist system: the bourgeoisie own the 3. Power (political party): A person’s ability to get their way despite means, but this effectively includes the proletariat itself as the workers the resistance of others. can only sell their own labor power (forming the material base of

History of social psychology and sociology The discipline of social psychology began in the United States at the addicted to smoking cigarettes but also suspects it could be detrimental dawn of the 20th century. The first published study in this area was to his health suffers from cognitive dissonance. an experiment in 1898 by Norman Triplett on the phenomenon of Festinger suggests that people are motivated to reduce this dissonance social facilitation. Texts focusing on social psychology first emerged until their cognition is in harmony with itself. People strive for mental at the start of the 20th century. The first notable book in English was consistency. People use four main methods to reduce or eliminate published by William McDougall in 1908 (An Introduction to Social dissonance: (1) Changing their minds about one of the facets of Psychology), which included chapters on emotion and sentiment, cognition, (2) reducing the importance of a cognition, (3) increasing morality, character and religion, quite different to those incorporated in the overlap between the two, and (4) re-evaluating the cost/reward the field today. He believed that social behavior was innate/instinctive ratio. Revisiting the example of the smoker, he can either quit smoking, and therefore individual, hence his choice of topics. This belief is not reduce the importance of his health, convince himself he is not at risk, or the principle upheld in modern social psychology, however. evaluate the reward of his smoking to be worth the cost of his health. Allport’s work (1924) underpins current thinking to a greater degree, In the 1960s, interest was growing in new topics, such as cognitive as he acknowledged that social behavior results from interactions dissonance, bystander intervention, and aggression. By the 1970s, between people. He also took a methodological approach, discussing however, social psychology in America had reached a crisis. There actual research and emphasizing that the field was one of a “science … was heated debate over the ethics of laboratory experimentation and which studies the behavior of the individual in so far as his behavior whether or not attitudes really predicted behavior. This was also the stimulates other individuals, or is itself a reaction to this behavior” time when a radical situationist approach challenged the relevance of (1942: p. 12). His book also dealt with topics still evident today, such self and personality in psychology. as emotion, conformity and the effects of an audience on others. Social psychology reached a more mature level in both theories and Murchison (1935) published the first handbook on social psychology methods during the 1980s and 1990s. Careful ethical standards now in 1935. Murphy & Murphy (1931) produced a book summarizing the regulate research. Pluralistic and multi-cultural perspectives have findings of 1,000 studies in social psychology. A text by Klineberg emerged. Modern researchers are interested in many phenomena, (1940) looked at the interaction between social context and personality but attribution, social cognition, and the self-concept are perhaps the development; by the 1950s a number of texts were available on the greatest areas of growth in recent years. Social psychologists have subject. also maintained their applied interests with contributions in health, During the 1930s, many Gestalt psychologists, most notably Kurt environmental, and legal psychology. Lewin, fled to the United States from Nazi Germany. They were The early history of sociology is a history of ideas developed in instrumental in developing the field as something separate from the the European tradition, while the sociological approach of the last behavioral and psychoanalytic schools that were dominant during 150 years involved the development of concepts, methodology, and that time, and social psychology has always maintained the legacy of theories, especially in the United States (Goudsblom & Heilbron, their interests in perception and cognition. Attitudes and small group 2001). As American sociologists trained in the traditional theory and phenomena were the most commonly studied topics in this era. methods developed during the first eight decades of the 20th century, During World War II, social psychologists studied persuasion and they acknowledged an intellectual debt to the European founders. propaganda for the U.S. military. After the war, researchers became But beyond an earnest recognition of the classic work of the early interested in a variety of social problems, including gender issues and founders, including Auguste Comte, Émile Durkheim, Alexis de racial prejudice. Most notable, revealing, and contentious of them all Tocqueville, Frederic LePlay, Marcell Mauss, Max Weber, Karl Marx, were the Stanley Milgram shock experiments on obedience to authority. and Harriet Martineau, most of whom were attracted to the European Leon Festinger originally proposed the Theory of Cognitive Dissonance environment that included the liberalism, radicalism, and conservatism in 1956. He theorized that human beings constantly strive for mental of the early to mid-19th century (Nisbet, 1966; Friedrichs, 1970) consistency. People’s cognition (thoughts, beliefs, or attitudes) can be and to what C. Wright Mills (1959) refers to as the sociological in agreement, unrelated, or in disagreement with each other. People’s imagination that enables people to grasp history and biography and cognition can also be in agreement or disagreement with their behaviors. the relations between the two within society. The current approach to When people detect conflicting cognition, or dissonance, it gives them a sociology is deeply embedded with and indebted to those individuals sense of incompleteness and discomfort. For example, a person who is who established the Chicago, Harvard, Iowa, and Berkeley schools of thought. Similarly, practitioners’ approach to the discipline of

Psychology.EliteCME.com Page 3 sociology (p. I-3) is reflected in these distinctive American scholarly then, to imagine that, as Bramson (1961) notes, “For many American perspectives. sociologists these problems evoked a moral response” (p. 75). Thus, The American tradition of sociology has focused on social policy the process of solving the problems of society was attempted by issues relating to social problems, the recognition of which grew out of application of the conventional morality and the validation of Christian the dynamic periods of social transformation wrought by the Industrial principles of piety rather than reform or progress. Revolution, the Progressive Era, world crises engendered by war, Sociology was born as a result of a process that directed a method of worldwide population shifts, growing mechanization, and the efforts inquiry away from philosophy and toward positivism (MacIver, 1934). of sociologists to create a specific niche for the discipline within a Sociology resulted from a process caused by two major forces: the growing scientific community. This effort occurred first in North Industrial Revolution and the French Revolution. The events, changes, America and Western Europe and then, similar to cultural transitions and ideas that emerged from these two revolutions are found in the of the past, within a global context. In every instance, the motives 19th-century thought pertaining to social order (Eisenstadt, 1968). rooted within a science of society lie in the attempt to understand and Within the contemporary context, sociologists are interested in offer proposals for solutions to whatever problems gain significant human social interaction as people take one another into account as attention at a particular point in time. each behaves toward the other. Sociologists also take into analytical Theories can be thought of as attempts to explain events, forces, consideration the systemic units of interaction within social groups, materials, ideas, or behavior in a comprehensive manner. In sociology, social relations, and social organizations. a theory is a set of statements that seeks to explain problems, actions, Touraine (1990) suggests that sociology is an interpretation of social or behavior. An effective theory may have both explanatory and experience and is thus a part of the reality that the practitioners of predictive power. That is, it can help people to see the relationships the discipline attempt to observe and explain. Additionally, sociology among seemingly isolated phenomena, as well as to understand how is a discipline that demystifies its subject matter, and as Dennis H. one type of change in an environment leads to other changes. Wrong (1990) notes, it debunks popular beliefs, holds skeptical and Goudsblom and Heilbron (2001) pose that sociology represents a great critical views of the institutions that are studied (Smelser, 1990), and diversity, or what some analysts may refer to as fragmentation, because challenges myth making (Best, 2001). the discipline matured as a part of the processes affecting societies The early history of sociology is a series of ideas developed in the and cultures worldwide throughout the 19th and 20th centuries. As a European tradition, whereas the sociological approach of the last new era and a new stage of academic development emerges, it remains 150 years involved the development of concepts, methodology, and important that professionals recognize the sociological heritage as theories, especially in the United States (Goudsblom & Heilbron, identified and discussed by these analysts. 2001). As American sociologists trained in the traditional theory and The five stages that sociology has experienced to date are: methods developed during the first eight decades of the 20th century, ●● The pre-disciplinary stage prior to 1830, further identified as professionals acknowledge an intellectual debt to the European founders. “protosociologies.” However, beyond an earnest recognition of the classic work of the ●● The formation of the intellectual discipline, 1830–1890. early founders, including Auguste Comte, Émile Durkheim, Alexis de ●● The formation of an academic discipline with diverging national Tocqueville, Frederic LePlay, Marcell Mauss, Max Weber, Karl Marx, traditions, 1890–1930. and Harriet Martineau, most of whom were attracted to the European ●● The establishment of an international academic discipline, environment that included the liberalism, radicalism, and conservatism 1930–1970. of the early to mid-19th century (Nisbet, 1966; Friedrichs, 1970) ●● A period of crisis, fragmentation, and attempts to develop a new and to what C. Wright Mills (1959) refers to as the sociological synthesis, 1970–2000 (Goudsblom and Heilbron, 2001). imagination that “enables us to grasp history and biography and the Consistent with the fifth stage, for almost four decades, professionals relations between the two within society” (p. 6), the approach to have witnessed major changes in the substantive topics that experience sociology is deeply embedded with and indebted to those individuals sociological inquiry both in the United States and, given the influence who established the Chicago, Harvard, Iowa, and Berkeley schools of on the discipline by Canadian, European, and Scandinavian scholars, thought. Similarly, practitioners’ approach to the discipline of sociology internationally. Among the areas more fully developed that might (p. I-3) reflects these distinctive American scholarly perspectives. be identified as fragmentation are many of the most interesting Traditionally, American sociology has focused on social policy issues sociological topics, including deviant behavior, the family, religion, relating to social problems, the recognition of which grew out of the gender, aging, health, the environment, science and technology, among dynamic periods of social transformation wrought by the Industrial so many seemingly unrelated topics. Revolution, the Progressive Era, world crises engendered by war, The unique conceptual paradigms of sociology serve as a template worldwide population shifts, increasing mechanization, and the effort or pattern for seeing the social world in a distinctive way. Every of sociologists to create a specific niche for the discipline within a discipline and every occupation employs templates or patterns to growing scientific community. This effort occurred first in North see and accomplish things in a unique fashion. Disciplines such as America and Western Europe and then, similar to cultural transitions sociology rely on intellectual templates based on certain conceptual of the past, within a global context. In every instance, the motives schemes or paradigms that have evolved through the development of a embedded within a science of society lie in the attempt to understand body of knowledge in those disciplines. and offer proposals for solutions to whatever problems gain significant In its early era of the mid- to late 19th century, sociology was attention at a particular point in time. understood to represent anything relating to the study of social Early social scientists did not hold any special talents other than problems. Indeed, it was thought that the methods of the social receiving training in theology. This situation was similar in the United sciences could be applied to social problems and used to develop States as well. It is not difficult, then, to imagine that, as Bramson (1961) solutions (Bernard & Bernard, 1943). In focusing on such substance, notes, “For many American sociologists these problems evoked a moral O’Neill (1967) notes that periodicals of this early period had a response” (p. 75). Thus, the process of solving the problems of society sociological section in which news items relating to family matters, was attempted by application of the conventional morality and the poverty, and labor often appeared. These early social scientists did validation of Christian principles of piety rather than reform or progress. not hold any special talents other than their training in theology. This situation was similar in the United States as well. It is not difficult,

Page 4 Psychology.EliteCME.com Identified with European conservatism, which became infused by and integration, social function, and social control are themselves a part of with science, the visionary perspective promoted by Auguste Comte the history of the reaction to the ideals of the French Revolution. during the 1830’s in his six-volume Positive Philosophy, which was What conservative critics saw as resulting from these movements later condensed into two volumes, was based on the medieval model was not the progressive liberation of individuals, but increasing of European society. This model of family, community, authority, insecurity and alienation, the breakdown of traditional associations tradition, and the sacred became the core of scientific sociology that and group ties. For social scientists of the early 19th century, many served notice that a science of society was essential to provide for more problems of the time were much more well defined than is the case in than commonsense analysis and to reestablish social order (MacIver, the contemporary experience. Comte was fervently religious, and he 1934). Although unsuccessful in his quest to secure a professorship, believed those interested in science would constitute a “priesthood of Auguste Comte was a positivist, mathematician, and promoter of the positivism” that would ultimately lead to a new social order. scientific identity of the engineering profession (Noble, 1999). A theist in spite of himself, Comte declared that the existence of Comte argued that positivism and the still-to-be-identified the Great Being “is deeply stamped on all its creations, in moral, in area of “sociology” would serve as a means of supporting his the arts and sciences, in industry,” and he insisted, as had previous intention to create a unique perspective of human relations and a like-minded prophets since Erigena, that all such manifestations of system to reestablish the social order and organization of society. divinity were equally vital means of mankind’s regeneration. Comte Reestablishment of this new social order was to proceed in accordance was convinced that people like himself, science-minded engineering with the positivist stage of evolution with its ineluctable natural laws savants occupied with the study of the sciences of observation, were that could and would be established through engaging the scientific the only men whose capacity and intellectual culture fulfilled the perspective. Along with the arts, the science of sociology, according necessary conditions. to Comte, was to emerge as the queen of the sciences, the scientia scientorum, and would ultimately supplant biology and cosmology. The legacy of this enthusiastic perspective is that sociology has been at the heart of the positivists’ contribution to understanding the human If the restoration of order in French society was a preoccupation condition. It was also to serve in part as a basis for the reactions of for many early 19th-century scholars, including Auguste Comte, conflict theorist Karl Marx, especially as these writings referred to it was also the case, as Bramson (1961) notes, that many key the religious opiate of the masses deemed by Comte as critical to the concepts of sociology illustrated this concern with the maintenance reorganization of society (Noble, 1999). The discipline continues to and conservation of order; ideas such as status, hierarchy ritual, present an array of perspectives that have served to stimulate much controversy within both society and the discipline.

The foundation of social science: Statistical studies Perhaps it is ironic that the distinctive difference between the European insurance industry, other commercial activities, and political necessity theoretical sociology and the empirical sociology practiced in the (Lecuyer & Oberschall, 1968; Reiss, 1968). English political United States was advanced by events in Europe. Indeed, the origin arithmeticians were destined to be followed by the efforts of the moral of empirical sociology is rooted in Europe. Statistical studies began in statisticians who engaged in data gathering in Belgium and France. the 1660s, thereby preceding the birth of all other social sciences by a As early as 1831, to build on the early efforts of the practitioners couple of centuries. of “political arithmetic” that first began in the 1660s, the Belgian, Early statistical gatherers and analysts were involved in “political Adolphe Quetelet and the Frenchman, Andre Michel de Guerry de arithmetic,” or the gathering of data considered relevant to public Champneufengaged in government-sponsored data-gathering activity policy matters of the state. As noted by Reiss (1968), the gathering pertaining to data on moral topics, including suicide, prostitution, and of such data may have been accelerated to meet the needs of the illegitimacy. Such activities would demonstrate quite instrumental in newly emerging insurance industry and other commercial activities the establishment of the empirical social sciences. Even many of the of the time. However, it was the early work of the moral statisticians methodologies developed during this same period of the early 19th interested in reestablishing social order in the emerging industrial century, as well as awareness of significant ecological methodological societies that was to lay the quantitative foundation for the discipline, issues such as statistical interactions, the ecological fallacy, and especially the early scientific work of the French sociologist Émile spuriousness, were developed by early moral statisticians such as Durkheim (Whitt, 2001). Andre-Michel de Guerry and Adolphe Quetelet. Later on during the The second stage in the early history of quantification may have same century, the work of Henry Morselli, Enrico Ferri, and Alfred related to the development of probability theory, the rise of the Maury served the needs of aspiring European sociologists and even later members of the Chicago School of Sociology (Whitt, 2001).

SOCIAL PSYCHOLOGISTS, SOCIOLOGICAL THEORISTS, AND THEIR THEORIES Social psychology Social psychology theories attribution began with the work of Fritz Heider in the early part of Attribution theory—is concerned with the ways in which people the 20th century, subsequently developed by others such as Harold explain (or attribute) the behavior of others. The theory divides Kelley and Bernard Weiner. the way people attribute causes to events into two types. External, Three-dimensional model of attribution or “situational,” attributions assign causality to an outside factor, Bernard Weiner proposed that individuals have initial affective such as the weather. Internal, or “dispositional,” attributions assign responses to the potential consequences of the intrinsic or extrinsic causality to factors within the person, such as ability or personality. motives of the actor, which in turn influence future behavior. That is, Attribution is a concept in social psychology that addresses the a person’s own perceptions or attributions as to why they succeeded processes by which individuals explain the causes of behavior and or failed at an activity determine the amount of effort the person will events; attribution theory is an umbrella term for various models engage in activities in the future. Weiner suggests that individuals that attempt to explain those processes. Psychological research into exert their attribution search and cognitively evaluate casual properties

Psychology.EliteCME.com Page 5 on the behaviors they experience. When attributions lead to positive continue believing that their social, political, and economic affect and high expectancy of future success, such attributions should systems are legitimate and just. result in greater willingness to approach similar achievement tasks in ●● Terror management theory—suggests that human mortality the future than those attributions that produce negative affect and low causes existential dread and terror, and that much of human expectancy of future success. Eventually, such affective and cognitive behavior exists as a buffer against this dread (i.e., self-esteem and assessment influences future behavior when individuals encounter worldviews). similar situations. ●● Triangular theory of love—formulated by Sternberg, it Weiner’s achievement attribution has three categories: characterizes love in an interpersonal relationship on three 1. Stable theory (stable and unstable). different scales: intimacy, passion, and commitment. Different 2. Locus of control (internal and external). stages and types of love can be categorized by different 3. Controllability (controllable or uncontrollable). combinations of these three elements. Stability influences individuals’ expectancy about their future; control Social judgment theory (SJT) suggests that when people are presented is related with individuals’ persistence on mission; causality influences with an idea or any kind of persuasive proposal, their natural reaction emotional responses to the outcome of task. is to immediately seek a way to sort the information subconsciously ●● Cognitive dissonance—originally based on the concept of cognitive and react to it. People evaluate the information and compare it with consistency, but is now more related to self-concept theory. When the attitudes they already have, which is called the initial attitude people do something that violates their view of themselves, this or anchor point. When attempting to sort the incoming persuasive causes an uncomfortable state of dissonance that motivates a change information, an audience will evaluate whether it lands in their latitude in either attitudes or behavior (Festinger, 1957). of acceptance, latitude of non-commitment or indifference, or the ●● Drive theory—posits that the presence of an audience causes latitude of rejection. arousal which creates dominant or typical responses in the context The size of these latitudes vary from topic to topic. People’s “ego- of the situation. involvement” generally plays one of the largest roles in determining ●● Elaboration likelihood model—maintains that information the size of these latitudes. When a topic closely connects to how processing, often in the case of a persuasion attempt can be people define and perceive themselves, or deals with anything divided into two separate processes based on the “likelihood of individuals care passionately about, latitudes of acceptance and cognitive elaborations,” that is, whether people think critically non-commitment are likely to become much smaller and attitude about the content of a message, or respond to superficial aspects of of rejection becomes much larger. A person’s anchor point is the message and other immediate cues. considered to be the center of his latitude of acceptance, the position ●● Observational learning (social learning)—suggests that behavior most acceptable to him. An audience is likely to distort incoming can be acquired by observation and imitation of others, unlike information to fit into their unique latitudes. If something falls traditional learning theories which require reinforcement or within the latitude of acceptance, the subject tends to assimilate the punishment for learning to occur. information and consider it closer to his anchor point than it really is. ●● Schemata theory—focuses on “schemas,” which are cognitive Inversely, if something falls within the latitude of rejection, the subject structures that organize knowledge and guide information tends to contrast the information and convince himself the information processing. They take the form of generalized beliefs that can is farther away from his anchor point than it really is. operate automatically and lead to biases in perception and memory. When people aim to persuade an individual target or an entire ●● Self-perception theory—emphasizes that people observe audience, they must first learn the average latitudes of acceptance, themselves in the same manner that they observe others, and draw non-commitment, and rejection of their audience. Ideally, they should conclusions about likes and dislikes. Extrinsic self-perceptions can use persuasive information that lands near the boundary of the latitude lead to the over-justification effect. of acceptance if the goal is to change the audience’s anchor point. ●● Self-verification theory—focuses on people’s desire to be known Repeatedly suggesting ideas on the fringe of the acceptance latitude and understood by others. The key assumption is that once people will cause people to gradually adjust their anchor points, while develop firmly held beliefs about themselves, they come to prefer suggesting ideas in the rejection latitude or even the non-commitment that others see them as they see themselves. latitude will not result in any change to the audience’s anchor point. ●● Social comparison theory—suggests that humans gain information about themselves, and make inferences that are Persuasion lies beneath the umbrella term of influence. In other words, relevant to self-esteem, by comparison to relevant others. persuasion is influence, but it requires communication, whereas ●● Social exchange theory—an economic social theory that assumes influence does not necessarily. Persuasion can attempt to influence human relationships are based on rational choice and cost-benefit the beliefs, attitudes, intentions, motivations, or behaviors. Persuasion analyses. If one partner’s costs begin to outweigh the benefits, that is a process aimed at changing a person’s (or a group’s) attitude or person may leave the relationship, especially if good alternatives behavior toward some event, idea, object, or other person(s), by using are available. written or spoken words to convey information, feelings, or reasoning, ●● Social identity theory—developed by Henri Tajfel, it examines or a combination thereof. Persuasion is also a tool people frequently how categorizing people (including oneself) into in-groups or out- use to pursuit personal gain, such as in election campaigning, giving a groups affects perceptions, attitudes, and behavior. sales pitch, or in trial advocacy. ●● Social penetration theory—proposes that as relationships Persuasion can also be interpreted as using personal or positional develop, interpersonal communication moves from relatively resources to change other people’s behaviors or attitudes. Systematic shallow, non-intimate levels to deeper, more intimate ones. persuasion is the process through which attitudes or beliefs are Psychologists Irwin Altman and Dalmas Taylor formulated the changed by appeals to logic and reason. Heuristic persuasion, on theory in 1973 to provide an understanding of the closeness the other hand, is the process through which attitudes or beliefs are between two individuals. changed because of appeals to habit or emotion. ●● Socioemotional selectivity theory—posits that as people age and their perceived time left in life decreases, they shift from focusing Conditioning plays a huge part in the concept of persuasion. It more on information-seeking goals to focusing on emotional goals. often involves leading people into taking certain actions of their own, ●● System justification theory—proposes that people have a rather than giving direct commands. For example, advertisements motivation to defend and bolster the status quo, in order to achieve this by attempting to connect a positive emotion to a brand or

Page 6 Psychology.EliteCME.com product logo. Advertisers may create commercials that make people people sometimes recall a memory from a certain smell or sound, the laugh, use a sexual undertone, contain uplifting images and/or music objective of some ads is solely to bring back certain emotions when etc., and then end the commercial with a brand or product logo. Great consumers see their logo in a local store. The hope is that repeating the examples of this are professional athletes. They are paid to connect message several times will increase the likelihood that will purchase themselves to things that directly relate to their roles; sport shoes, the product, because they already connects it with a good emotion and tennis rackets, golf balls, or completely irrelevant things like soft a positive experience. Stefano DellaVigna and Matthew Gentzkow drinks, popcorn poppers, or panty hose. The important thing for the did a comprehensive study on the effects of persuasion in different advertiser is to establish a connection to the consumer. domains. They discovered that persuasion has little or no effect on Advertisers want to affect how people view certain products, knowing advertisement; however, there was a substantial effect of persuasion on that consumers make most purchases on the basis of emotion. Just like voting if there was face-to-face contact.

Sociology August Comte (1798-1857) Emile Durkheim (1858-1917) Comte grew up in the shadow of the French Revolution. He believed Durkheim was a Frenchman, who along with Marx and Weber, is that if people understood how society operates, it would enable them commonly cited as one of the principal architects of modern social to build a better future for themselves. He believed it was important for science. Durkheim developed a functionalist theory to explain that people to understand how society is held together and how it changes. different people do different things and are rewarded differently based He identified three stages of society on Earth: on the value of the person’s functional contribution. He believed that 1. Theological stage—early era through Medieval times, when social development can be explained by increased differentiation of people explained events by theology. functions or division of labor. 2. Metaphysical stage—the Renaissance, when people explained He developed the idea of anomie, which is a mismatch between events as natural. personal or small group standards and the larger societal standards. 3. Scientific stage—Renaissance to current time, people use science He also believed anomie could result from the lack of a social ethics, to explain events. which then produces moral deregulation or the lack of a moral code. Comte proposed positivism as a means to understand the world. He believed this leads to an absence of legitimate aspirations or goals. Positivism states that the only authentic knowledge is based on sense Anomie is generally associated with low regulation, but Durkheim experience and positive verification. This is also the basis of the also believed that overly rigid totalitarian societies would also produce scientific method. He believed that society conforms to invariable anomic individuals. laws, similar to physical laws such as the law of gravity. Comte and Jane Addams (1860-1935) Marx developed different sociological theories, but they both agreed Addams was a social activist who established Hull House, a settlement society cannot be understood solely in terms of personal choice. house for immigrants in Chicago. She also established an adult night Karl Marx (1818-1883) school which was the forerunner of university extension courses Marx was a German philosopher, historian, sociologist, political offered today. Addams worked toward goals concerning the first theorist, and economist whose ideas are credited as the foundation juvenile-court law, tenement-house regulation, an eight-hour working of modern communism. He observed and commented on social day for women, factory inspection, and workers’ compensation. circumstances, particularly capitalist society and its class struggle. He She advocated research aimed at determining the causes of poverty developed conflict theory based on these observations. Marx, along and crime, and supported women’s suffrage. She was a strong advocate with Durkheim and Weber, commonly cited as the principal architects of justice for immigrants and blacks, and was a charter member of the of modern social science. NAACP. Marx observed that industrialism replaced feudalism. He believed that Addams is best known for her activities in applied sociology. Her the Industrial Age workers would revolt, and industrialism would be hypothesis that physical and social landscapes could influence the fate replaced by socialism which would lead to a stateless, classless society of subcultures builds upon the theory of symbolic interactionism. called pure communism. He also believed that capitalism was unfair to the worker and tried to change society to create a more equitable She was a charter member of the American Sociological Society and economic structure. His comments were often critical, and he was one of the few women involved in the organization at that time. She later forced to move out of Germany and then France because of them. taught and lectured widely. She is known for her views of social justice. Marx developed the sociological idea of conflict theory. Addams also earned the Nobel Peace Prize in 1931 for her work. Herbert Spencer (1820-1903) George Mead (1863-1931) Spencer was a British philosopher who built upon structural Mead was an American sociologist whose ideas founded the functionalism by comparing society to the human body—both have symbolic interactionism school of thought in sociology. He believed structure and components with a function. The components work the emergence of the mind depended upon interaction between a together to keep the overall system working for the benefit of the whole. person and his or her social environment, and through the social act of communication a person comes to realize his or her potential for Spencer is also known for his application of the “survival of the fittest” thought or as Mead called it, “significantly symbolic behavior.” theory to sociology which later became known as Social Darwinism. He believed that success would come to the most intelligent, Mead believed the mind was the individualized focus of the ambitious, and productive people who quite properly would then communication process, a linguistic behavior. He believed there could advance their interests at the expense of the less able. Spencer believed be no mind or thought without language and that language was the it was important to not meddle with society, especially the free market product of social interaction. Therefore, according to Mead, mind is economy. Obviously, early industrialists approved of Spencer’s not merely a physical and biological process; it is an ongoing human theories and agreed that government regulation and any type of social social process. conscience was unnecessary and contrary to the natural laws.

Psychology.EliteCME.com Page 7 Mead believed that personality gradually emerges as a result of social problems most African-Americans experienced were the result of experiences. He believed the “self” is one dimension of personality Caucasian prejudice. and is composed of the individual’s self-conception. He believed Talcott Parsons (1902-1979) that first the self emerges from social experience and that the social Parsons was an American sociologist who sought to create one experience is based on the exchange of symbols such as understanding general theory about human social relationships by combining the words, gestures, and facial expression. He also believed that ideas of different disciplines. He endorsed the theory of structural understanding a person’s intentions requires imagining the situation functionalism in the development of his theories. He believed from the other person’s perspective. individual status reflected social values and developed ideas on social Charles Horton Cooley (1864-1929) stratification within society. Cooley was an American sociologist. He is best known for his idea of Parsons is well known for translating Weber’s work into English. He the looking-glass self. He believed humans have the capacity to reflect conducted a meta-analysis of the works of Max Weber and Vilfredo on their behavior and that people build, change, or maintain their Pareto, an Italian economist whose name was given to the Pareto behavior based how others evaluate their actions. He believed this principle, the 80-20 rule that states that 80 percent of the results or involved three steps. First, people imagine or develop an image of how effects come from 20 percent of the effort or causes. he they appear to another person. Second, people imagine or develop a concept of the other person’s judgment of their appearance. Third, Parsons was involved in the attempt to integrate social sciences into people develop an emotional response such as pride or mortification. one theoretical framework or grand theory. In the development of his action theory Parsons sought to identify the major functions societies He thought industrialization made people more individualistic and had to perform in order to survive and identified four functional competitive. He believed this led to the reduction of displays of imperatives every member of society performs: adaptation, goal concern for family and local neighborhoods. He was convinced of the attainment, integration and pattern maintenance. importance of primary groups, and called attention to the issue. Parsons viewed these action systems as operating at different levels, Max Weber (1864-1920) starting with the behavioral organism and building to the cultural Weber was a German sociologist who greatly influenced American system. He saw these levels hierarchically, with each of the lower values and made the greatest individual contribution to sociology. levels providing the impetus for the higher levels, with the higher Weber along with Durkheim and Marx are commonly cited as the levels controlling the lower levels. principal architects of the three major theories in sociology. Weber began his career by attending law school; then became a college Robert K. Merton (1910-2003) professor. He was influenced by his mother’s devout religious views Merton, an American sociologist, recognized that social patterns can as a Calvinist. He studied the relationship between the Calvinist belief serve many functions within the structure of society. For example, that personal wealth was an indication of God’s grace and the rewards there are manifest functions which are recognized and intended of industrial capitalism. This led to the theory about the protestant consequences. Latent functions are unrecognized and unintended ethic: that hard work leads to success which is a sign of salvation. consequences. Last, social dysfunction is the undesirable effect that results from social patterns. Weber shared many of the Marx’s views on social conflict, but believed that the transformative force of a society was symbolic interaction of Courtship and marriage is a social pattern that has the recognized major ideas about the world (beliefs, values, and ideas) rather than views and intended consequence of providing stable units in which to raise about materialistic wealth and power. He explored the use of an “ideal children, but the latent or unintended function increases male wealth type” which categorized behaviors and beliefs of different religions. Use and in many cultures limits options for females. of the “ideal type” helped Weber to compare the religions. Merton also coined many phrases commonly used today, such as Weber believed that pre-industrial societies valued tradition (sentiment self-fulfilling prophecy, role model, and unintended consequences. and beliefs passed from generation to generation) whereas industrial Self-fulfilling prophecy is a concept that explains how a belief or capitalism fosters rationality (deliberate matter-of-fact calculation of expectation, however accurate or incorrect, will affect the outcome of the most efficient means to accomplish a particular goal). He believed a situation or behavior of a person or group. For example if, someone that industrialization led to changes within society, such as the believes she will fail even though the facts indicate she should development of distinctive social institutions which provided for the succeed, the outcome is failure. political, educational, religious, economic, and health care needs. Pre- The term role model resulted from Merton’s theory of a reference industrial communities met these needs for their members. group that individuals compare themselves to, but to which they Industrialism also created a need for: may not belong. Another term, unintended consequences, was a term ●● Specialization. Merton used to describe the outcomes or results that were not intended ●● Personal discipline. by a particular action. ●● Awareness of time. C. Wright Mills (1916-1962) ●● Technical competence. Mills was an American sociologist who is known as the father of modern ●● Impersonality. conflict theory. He believed social structures don’t just happen; they are ●● Large-scale organizations. the outcome of struggles and negotiations between people with different W.E.B. DuBois (1868-1963) interests and different resources. People are then shaped by the larger DuBois was an American sociologist and the first African-American structures and unequal distribution of power and resources. to earn a doctorate at Harvard. He believed that social research should Mills authored The Power Elite and outlined his theory that the be linked to contemporary problems for the purpose of solving those interests of the elite often oppose the interests of the masses. He problems. He focused on the race issue. He wrote the book, The believed a key task of sociologists is to see social structures, personal Philadelphia Negro: A Social Study in 1899. His book described actions, and their interactions. circumstances, strengths, and weaknesses of African-Americans during the late 1800’s. He believed that African-Americans and Caucasians He developed the idea of sociological imagination, which he describes lived in two different social worlds that often resulted in conflict with as a mindset for thinking about society and sociology. He used this each other. He rejected the idea of black inferiority and believed the term to describe the ability to view one’s existence both in terms of a personal level and a broader world level and to understand the

Page 8 Psychology.EliteCME.com connection between the two views within the context of biology or the Means of Consumption (2nd edition 2005, 3rd edition human nature, history, and the current social structure of society. This forthcoming), and Expressing America: A Critique of the Global means that a trouble of a person (biology) should be evaluated in terms Credit Card Society (1995). Ritzer is also a founding editor, with Don of the broader context of the society’s social structure and history. Slater, of Sage’s Journal of Consumer Culture. Mills provided the following example concerning unemployment. If Something vs. Nothing one man in a city of 100,000 is unemployed, that is a personal trouble According to Ritzer, “Something” is a locally conceived and controlled that may have a personal solution, but many unemployed people is a social form that is comparatively rich in distinctive, substantive content society issue and requires evaluation of the cause and solution within and is fairly unique. “Nothing” is a social form that is generally the social structure and history of the society. centrally conceived, controlled, and comparatively devoid of distinctive Rosabeth Moss Kantor (1943-Present) substantive content. Cantor is an American woman who earned her Ph.D. from the University Examples of “nothing”: McDonald’s, Wal-Mart, Starbucks, credit of Michigan in 1967. She is currently a professor at Harvard Business cards, and the Internet. School. She has written numerous books on business management techniques and, particularly, the management of change. She states smaller Examples of “something”: local sandwich shops, local hardware can be better because it creates ownership and connection. stores, family arts and crafts places, or a local breakfast café. She believes that shared responsibility, social inclusiveness, and Globalization opportunities for advancement improve overall performance. She is Ritzer defines globalization as involving a worldwide diffusion of known for her study in 1977 of tokenism and how being a minority practices, relations, and forms of social organization and the growth affects one’s performance due to enhanced visibility and performance of global consciousness. The concept of “something” vs. “nothing” pressure. Her study, Men and Women of the Corporation, became a plays a large part in understanding Ritzer’s Globalization. Society classic in critical management studies and bureaucracy analysis. is becoming bombarded with “nothing” and Ritzer seems to believe that the globalization of “nothing” is almost unstoppable. For Ritzer, George Ritzer (1940-Present) globalization typically leads to consumption of vast quantities of Ritzer is a sociologist who studies American patterns of consumption, serial social forms that have been centrally conceived and controlled. globalization, metatheory, and modern and postmodern social theory. In addition to The Globalization of Nothing, Ritzer has edited The Currently, Ritzer is a Distinguished Professor at the University of Blackwell Companion to Globalization (2007), written Globalization: Maryland, College Park. A Basic Text (2009), and edited an Encyclopedia of Globalization. Although known as a sociologist, Ritzer has never received a degree in Grobalization sociology proper. As Ritzer said in a later interview “I basically trained Grobalization involves three motor forces: capitalism, myself as a social theorist, and so I had to learn it all as I went.” McDonaldization, and Americanization. Furthermore, Ritzer found that not being trained in social theory was advantageous for him, simply because his reasoning was not limited to It is believed that grobalization creates a world where: a particular theoretical perspective. ●● Things are more and more the same everywhere. ●● Larger forces overwhelm the power of people to adapt and McDonaldization innovate in ways that preserve their autonomy. Ritzer’s idea of McDonaldization is an extension of Max Weber’s ●● Social processes are coercive, determining the nature of local (1864–1920) classical theory of the rationalization of modern society communities, which have little room to maneuver. and culture. Where Weber famously used the terminology of an “iron ●● Consumer goods and the media are key forces that largely dictate cage” to describe the stultifying, Kafka-esque effects of bureaucratized the nature of the self and the groups a person joins. life, Ritzer argues that the McDonald’s restaurant has become the better exemplar of current forms of instrumental rationality and its ultimately Glocalization irrational and harmful human consequences Mcdonaldization’s Glocalization is a combination of the words “globalization” and institutions are part of a general drive to rationalization. “localization” used to describe a product or service that is developed and distributed globally, but is also fashioned to accommodate the user These theories share four dimensions they are designed to increase: or consumer in a local market. Ritzer further explains glocalization as ●● Efficiency—Choosing the best, quickest, or least difficult means to a relatively benign process that is closest to the “something” end of a given end. things. It creates variety and heterogeneity within society. ●● Calculability—Emphasis on the quantitative aspects of the product being sold. Metatheory ●● Predictability—Involves the customer knowing what to expect Metatheory is often defined as the attainment of a deeper from a given producer of goods or services. understanding of theory, the creation of new theory, and the creation ●● Control—A way to keep a complicated system running smoothly. of an overarching theoretical perspective. There are three types of Rules and regulations that make efficiency, calculability, and metatheorizing. The first (Mu), aims at being a means of attaining predictability possible. McDonaldization is profitable, desirable, a deeper understanding of theory. The second (Mp), aims at being a and the cutting edge of technological advances. However, it creates prelude to theory development. The last (Mo), aims at being a source a disenchantment of the world and the replacement of magic and of perspectives that overarch sociological theory. surprise with efficiency and routine overall dehumanizing society. Influenced by Thomas Kuhn’s book The Structure of Scientific Consumption Revolutions (1962), Ritzer has long advocated the view that social An early admirer of Jean Baudrillard’s Consumer Society (1970), theory is improved by systematic, comparative, and reflexive attention Ritzer is a leading proponent of the study of consumption. In addition to implicit conceptual structures and oft-hidden assumptions. Key to The McDonaldization of Society, the most important sources for works include Sociology: A Multiple Paradigm Science (1975), Ritzer’s sociology of consumption are his edited Explorations in the Toward an Integrated Sociological Paradigm (1981), Metatheorizing Sociology of Consumption: Fast Food Restaurants, Credit Cards and in Sociology (1991), and Explorations in Social Theory: From Casinos (2001), Enchanting a Disenchanted World: Revolutionizing Metatheorizing to Rationalization (2001).

Psychology.EliteCME.com Page 9 CULTURE AND SOCIAL PSYCHOLOGY Culture is the totality of learned, socially transmitted customs, ●● Profession. knowledge, material objects, and behavior. It includes the ideas, ●● Workplace. values, and artifacts (for example, DVDs, comic books, and birth ●● Time and place (eras or generations). control devices) of groups of people. Patriotic attachment to the flag of ●● Broad geography (i.e., Western culture). the United States is an aspect of culture, as is a national passion for the ●● Narrow geography. tango in Argentina. ●● Ethnicity and ethnic culture. Aspects of human expression include both material culture and ●● Sexuality and gender identity-based cultures. ephemeral elements. These include: ●● Individual adoption of cultural style (i.e., Goth subculture). ●● Language and dialect. ●● Social class, caste, or socioeconomic status - High culture (usually ●● Religion. referring to artistic culture) might be differentiated from low ●● Technology. culture, folk culture, or middlebrow culture. ●● Cuisine. ●● Audience (i.e., pop culture). ●● Aesthetics (art, music, literature, fashion, and architecture). ●● Technology (i.e., cyber-culture, video game culture). ●● Values and ideology. Mutual communication (whether through technology or transportation ●● Social conventions, including norms, taboos, and etiquette. of people or goods) is an essential activity that maintains the ●● Gender roles. coherence of a cultural group. This explains why cultural boundaries ●● Recreational activities such as festivals and holidays. can follow divisions in language and geography, why globalization ●● Commercial practices. has created larger cultural spheres, and highlights the role of mass ●● Social structure. media in defining and maintaining culture. Education and tradition Cultural regions are often defined with respect to an ethno-linguistic communicate culture through time. group or religion; the larger cultural groupings are sometimes referred Norms are the established standards of behavior maintained by a to as “civilizations.” Subcultures have distinct aspects, but share a society. All societies have methods in place to encourage and enforce connection with a larger culture (whether by virtue of inhabiting the what it views as appropriate behavior while also discouraging and same society or by inheriting certain cultural elements). Individuals punishing what it considers improper behavior. can participate in multiple cultures and subcultures; countercultures ●● Formal norms generally have been written down and specify strict specifically reject at least some aspects of mainstream culture. punishments for violators. Cultural identities and subcultures can be defined along any of these ●● Informal norms are generally understood but not precisely lines, or others; such as: recorded. Standards of proper dress are a common example of informal norms.

Cultural universals All societies hold certain common practices and beliefs, known as the theories, since a variety of critical approaches to sociology are cultural universals. Many cultural universals are, in fact, adaptations central to current research communities. to meet essential human needs, such as people’s need for food, shelter, The fact that people share a similar culture with others helps to define and clothing. the group or society to which one belongs. A fairly large number of The sociology of culture emerged from the intersection between people are said to constitute a society when they live in the same sociology, as shaped by early theorists like Marx, Durkheim, and territory, are relatively independent of people outside their area, and Weber, and with the growing discipline of anthropology where participate in a common culture. Metropolitan Los Angeles is more researchers pioneered ethnographic strategies for describing and populous than at least 150 nations, yet sociologists do not consider analyzing a variety of cultures around the world. Part of the legacy of it a society in its own right. Rather, they see it as part of, as well as the early development of the field still exists in the methods, as much dependent on the larger society of the United States. of cultural sociological research is qualitative. It is also visible within

Innovation The process of introducing a new idea or object to a culture is known Sociologists use the term diffusion to refer to the process by which as innovation. Innovation interests sociologists because of the social a cultural item spreads from group to group or society to society. consequences of introducing something new. There are two forms of Diffusion can occur through a variety of means, among them innovation: discovery and invention. exploration, military conquest, missionary work, the influence of the Discovery involves making known or sharing the existence of an aspect mass media, tourism, and the Internet. of reality. Finding a DNA molecule and identifying a new moon within Technology in its many forms has increased the speed of cultural the solar system are both acts of discovery. A significant factor in the diffusion and broadened the distribution of cultural elements. Sociologist process of discovery is sharing new-found knowledge with others. Gerhard Lenski has defined technology as cultural information about An invention is created when existing cultural items are combined into how to use the material resources of the environment to satisfy human a form that did not exist before. The bow and arrow, the automobile, needs and desires (Nolan & Lenski 2004). Today’s technological and the television are all examples of inventions. developments no longer await publication in journals with limited circulation. Press conferences, often carried simultaneously on the Globalization is the worldwide integration of government policies, Internet, trumpet the new developments. cultures, social movements, and financial markets through trade and the exchange of ideas.

Page 10 Psychology.EliteCME.com Cultural studies Sociologist William F. Ogburn (1922) made a useful distinction may have been selected culturally. However, schoolchildren watching between the elements of material and non-material culture. television after school with their friends in order to “fit in” certainly ●● Material culture refers to the physical or technological aspects of qualifies, since there is no grounded reason for one’s participation in people’s daily lives, including food, houses, factories, and raw this practice. Recently, as capitalism has spread throughout the world materials. (through the process of globalization), cultural studies has begun to ●● Non-material culture refers to ways people use material objects analyze local and global forms of resistance to Western hegemony. and to customs, beliefs, philosophies, governments, and patterns French sociologist Pierre Bourdieu’s influential model of society and of communication. Generally, the non-material culture is more social relations has its roots in Marxist theories of class and conflict. resistant to change than the material culture. Bourdieu characterizes social relations in the context of what he calls In the United Kingdom, sociologists and other scholars influenced the field, which he described as a competitive system of social relations by Marxism, such as Stuart Hall and Raymond Williams, developed functioning according to its own specific logic or rules. The field is the cultural studies. Following 19th century Romantics, they identified site of struggle for power between the dominant and subordinate classes. “culture” with consumption goods and leisure activities, such as art, Within the field, legitimacy is either conferred or withdrawn. music, film, food, sports, and clothing. Bourdieu’s theory of practice is practical rather than discursive, In the United States, “cultural studies” focus largely on the study of embodied as well as cognitive and durable though adaptive. A valid popular culture, that is, the social meanings of mass-produced consumer concern that sets the agenda in Bourdieu’s theory of practice is how and leisure goods. The term was coined by Richard Hoggart in 1964 when action follows regular statistical patterns without the product of he founded the Birmingham Centre for Contemporary Cultural Studies, or accordance to rules, norms, and/or conscious intention. CCCS. Cultural studies can be viewed as a limited concentration scoped In the United States, Lindlof & Taylor (1997) claimed that cultural on the intricacies of consumerism, which belongs to a wider culture studies are grounded in a pragmatic, liberal-pluralist tradition. The sometimes referred to as “Western Civilization,” or “Globalism.” American version of cultural studies initially concerned itself more From the 1970s onward, Stuart Hall’s pioneering work, along with with understanding the subjective and appropriative side of audience his colleagues Paul Willis, Dick Hebdige, Tony Jefferson, and Angela reactions to, and uses of mass culture. McRobbie, created an international intellectual movement. As the field The distinction between American and British strands, however, developed it began to combine political economy, communication, has faded. Some researchers, especially in early British cultural sociology, social theory, literary theory, media theory, film/video studies, apply a Marxist model to the field. This strain of thinking has studies, cultural anthropology, philosophy, museum studies and art some influence from the Frankfurt School, but especially from the history to study cultural phenomena or cultural texts. In this field, structuralist Marxism of Louis Althusser and others. researchers often concentrate on how particular phenomena relate to matters of ideology, nationality, ethnicity, social class, and/or gender. The main focus of an orthodox Marxist approach focuses on the production of meaning. This model assumes a mass production of Cultural studies is concerned with the meaning and practices of culture and identifies power as residing with those producing cultural everyday life. These practices comprise the ways people do particular artifacts. In a Marxist view, those who control the means of production things, such as watching television, or eating out in a given culture. (the economic base) essentially control a culture. Other approaches to This field studies the meanings and uses people attribute to various cultural studies, such as feminist cultural studies and later American objects and practices. developments of the field, distance themselves from this view. They Specifically, culture involves those meanings and practices held criticize the Marxist assumption of a single, dominant meaning, shared independently of reason. Watching television in order to view a by all, for any cultural product. The non-Marxist approaches suggest public perspective on a historical event should not be thought of as that different ways of consuming cultural artifacts affect the meaning culture, unless referring to the medium of television itself, which of the product.

Socialization Socialization is the process by which children and adults learn from rewarding opportunities. Negative socialization occurs when others others. Humans begin learning from others during the early days of use punishment, harsh criticisms, or anger to try to “teach a lesson”; life, and most people continue their social learning all through life and often people come to dislike both negative socialization and the unless some mental or physical disability slows or stops the learning people who impose it. process. Sometimes the learning is fun, as when people learn a new Many mixes of positive and negative socialization exist and the more sport, art or musical technique from a friend. At other times, social positive social learning experiences people have, the happier they learning is painful, as when people learn not to drive too fast by tend to be. This is especially true if people learn useful information receiving a large fine for speeding. that helps them cope well with the challenges of life. A high ratio Natural socialization occurs when infants and youngsters explore, of negative to positive socialization can make a person unhappy, play, and discover the social world around them. Planned socialization defeated, or pessimistic about life. occurs when other people take actions designed to teach or train Prior socialization in life helps to explain a gigantic chunk of who others from infancy on. Natural socialization is easily seen when people are at present, such as what they think or feel, and where they looking at the young of almost any mammalian species. Planned plan to go in life. But people are not limited by the things given to socialization is mostly a human phenomenon; and all through history, them by former social learning experiences. People can take all of their people have been making plans for teaching or training others. Both remaining days and guide their future social learning in directions that natural and planned socialization can have good and bad features: It is they value. The more that people know about the socialization process, wise for people to learn the best features of both natural and planned the more effective they can be in directing future learning in the ways socialization and weave them into their lives. that will help them the most. Positive socialization is social learning based on pleasurable and Because people cannot select their parents, they are not able to control exciting experiences. People tend to like those who fill their social much of the first 10 to 20 years of socialization in life. However, learning processes with positive motivation, loving care, and

Psychology.EliteCME.com Page 11 most people learn to influence their own socialization as they gain as they go through life. Having a course on socialization can help experience in life. It takes special skills to steer and direct personal people to understand which skills are most effective in guiding socialization, and many people pick up some of those skills naturally socialization toward the goals they most value.

Role of socialization What makes people who they are? Is it the genes people are born with in new, unfamiliar environments. The socialization process aids in or the environment in which they grow up? indoctrinating new members to the rules and norms for behavior and Researchers have traditionally clashed over the relative importance conduct within an organization. of biological inheritance and environmental factors in human Chao et al. (1994) noted that the socialization process takes place development; a conflict called the nature versus nurture (or heredity throughout the entire life cycle of an organizational member. It is versus environment) debate. Today, most social scientists have moved not solely the purview of new organizational members, although the beyond this debate, acknowledging instead the interaction of these research heavily favors this population (Gallagher & Sias, 2009). variables in shaping human development. New organizational members face a variety of challenges as they Organizational socialization is defined by Van Mane and Schein begin the socialization process, intended to make them knowledgeable, (1979) as the process by which an individual acquires the social productive, and involved members of an organization. The knowledge and skills necessary to assume an organizational role and is socialization process is an integral part of any organization from a experienced as a highly anxiety-inducing and stressful process for new small community group to a large multinational company. A part of the organizational members (Spector, Dwyer, & Jex, 1988). organizational entry process for any individual involves engaging in Chao, O‘Leary-Kelly, Wolf, Klein, and Gardner (1994) defined activities to reduce uncertainty and seek information (Forward, 1999). socialization as the primary process by which people adapt to new jobs Van Maanen (1978) observed that when faced with a transition, people and organizational roles. experienced anxiety. They sought to quell this anxiety by learning the Scott and Myers (2005) found that new organizational members must social and functional necessities of their new role. learn about organizational expectations and how to communicate

Uncertainty reduction According to Uncertainty Reduction Theory (Berger & Calabrese, Anticipatory phase 1975), people seek information to reduce uncertainty about social From childhood, people develop certain ideas about what the concept of worlds. Sunnafrank (1986) summarized work done by Berger (1979) work entails and what is involved in different vocations. This, in turn, and Berger and Bradac (1982) and found several ways individuals shapes the expectations people develop about work in the future. Some seek information in order to reduce their uncertainty. The first method of the influences on work and vocational ideas people develop are: involved using passive strategies to acquire information by simply ●● Family. observing others’ behavior and actions. The second strategy was the ●● School. active strategy which included asking others for information. Lastly, ●● Work experiences. the interactive strategy included communicating directly with a person ●● Peers. to reduce uncertainty. Berger and Calabrese found that high levels ●● The media (Jablin, 1985; Hylmo, 2006; Hoffner, Levine, & of uncertainty cause increases in information-seeking behavior. As Toohey, 2008). uncertainty levels decline, information-seeking behavior decreases. People also develop certain ideas and expectations about specific Kramer (1993) found employees experiencing a transfer within an organizations. They acquire this knowledge by information seeking organization had increased levels of feedback requests from their peers about a particular organization and through network interactions as their uncertainty levels about the new organization increased. These (Jablin, 2001). Findings frequently indicate that organizational new workers were able to reduce their uncertainty by determining appropriate members have high positive expectations about an organization and and necessary work relationships, differentiating responsibilities, and these expectations are unrealistic. Throughout the recruitment and gaining a sense of the general work cultural and environment. interview process, organizations tend to stress the positive aspects of Additionally, Douglas (1990) found that uncertainty declined across the organization and the job (Jablin, 2001). Once new members enter conversational segments, and this led to a decrease in question asking. an organization in the encounter phase, they often face the reality Findings by Mignery, Rubin, and Gorden (1995) and Teboul (1995) shock of discovering that their expectations and the reality they face indicated that new organizational members attempted to create differ vastly (Louis, 1980). stability and deal with uncertainty through the process of proactively Encounter phase seeking out communication encounters that helped them uncover both Researchers identified the encounter phase as beginning the moment a emotional support and information related to their specific job within newcomer enters an organization. This entrance may be accompanied the organization. Kramer (1993) noted that communication was an by the realization that expectations do not matching up to reality important part of the sense-making process and that communicating (Nicholson & Arnold, 1991). with peers and supervisors had a positive impact on adjustment. It also Barge and Schlueter (2004) found that organizational discourse helped to reduce uncertainty. associated with socialization emphasized the need for newcomers to fit Forward (1999) suggested that communication plays a central role for into the existing organizational method and focused on developing an new organizational members in managing expectations, generating individual’s specific abilities. Their findings also indicated that during support, reducing uncertainty, and reproducing organizational norms. organizational entry, richer forms of communication, such as face-to- As previously mentioned, the organizational socialization process face interactions, helped with message exchange. Chao et al. (1994) involves three distinct phases: noted that job proficiency, relationship development, politics, history, ●● Anticipatory. and organizational goals and values were all important organizational ●● Encounter. socialization domains. ●● Metamorphosis.

Page 12 Psychology.EliteCME.com These elements may be communicated to new organizational members An additional key aspect in the encounter phase is the development of through official company messages, from other organizational relationships within the workplace. Feeley, Hwang, and Barnett (2008) members, customers, individuals outside the organization, and/or the found that one important predictor of employee turnover was the task itself (Eisenberg & Goodall, 2001). Clearly, new members must social network. Those employees who were more active in their social be attuned to a lot of new information as they navigate their way networks within the organization were less likely to leave, as friends through the encounter phase. in the workplace provide coping resources that serve to reduce the In studying pre-service teachers, Staton-Spicer and Darling (1986) found amount of strain felt by an employee. that reality shock was experienced in terms of the time consumed, work New organizational members usually have greater opportunities to required, and emotional stress involved in the teaching experience. spend time with, share information, and develop relationships with Looking specifically at academic jobs, McInnes (1992) found that job their peers than their superiors (Teboul, 1994). for those that are descriptions for academics were often vague and did not give a new formally and collectively oriented to an organization (institutionalized organizational member a clear idea of what to expect in terms of day-to- socialization), relationships typically developed between new members day work activities. New organizational members face many challenges and, often, assistance and support was provided (Jablin, 2001). when encountering their new roles, including finding ways to access Within institutionalized socialization, collective tactics are used when organizational information, deal with emotions, and seek social support organizations put an entire group through a collective orientation (Simpson, Cockburn-Wootten, & Spiller, 2007). process. New members experience common training to ensure the During the encounter phase, most new organizational members new employees display homogenous future responses (Van Maanen experienced some sort of institutionalized socialization through an & Schein, 1979). Using formal socialization tactics means that new orientation program. Jablin (2001) found that these formal orientations members will be separated from other organizational members while may be very short in nature; lasting only a few days at most. they learn information about their specific roles. This increases the Additionally, they covered vast amounts of information including chance that new members will share the same values, attitudes, and information related to organizational policies and procedures. norms (Van Maanen & Schein, 1979). Employee handbooks may be distributed and benefits paperwork may Using sequential tactics means that new members will receive information need to be completed. He found that the purpose of these orientation concerning exactly how they will move through the socialization process, programs was to welcome new organizational members, give them what the steps involved will be, and the lengths of time associated with information pertinent to the organization, introduce them to existing each. This fixed process offers new members more certainty about their members, and perhaps offer them support through a mentor. organizational futures (Van Maanen & Schein, 1979). Utilizing serial However, the individuals themselves are also agents of socialization. tactics means that established organizational members act as role models Van Maanen (1978) found that new organizational members must for new members (Van Maanen & Schein, 1979). build guidelines and assign meaning to the activities that they have Lastly, investiture relates to the amount of positive social support observed within the organization. provided by established organizational members (Jones, 1986). In testing Information seeking on the part of the new organizational member is these institutionalized socialization tactics, Jones (1986) found that they one crucial aspect of the encounter phase. Gallagher and Sias (2009) helped to reduce anxiety and uncertainty and they positively related to conceptualized information seeking as an individual’s conscious organizational commitment and job satisfaction. Baker and Feldman choice to gain information via specific strategies. (1990) also found that institutionalized tactics can lead to organizational commitment and job satisfaction and, additionally, found that these Members used information seeking during the socialization process tactics were positively associated with trust in peers and management. to deal with problems they faced, such as insufficient, discrepant, or Moreover, satisfaction with communication and confidence in one’s ambiguous role prescriptive statements (Darling & Staton, 1989). These supervisor were also positively associated with these tactics (Mignerey, strategies involved using both direct and indirect tactics and included Rubin, & Gorden, 1995). Using these tactics also reduced the amount asking overt questions, asking indirect questions, testing limits, disguising of role conflict experienced by new members and led to more cohesion conversations, observing, and surveillance (Jablin, 1991). The type of with the organization for new members (Zahrly & Tosi, 1989). information new members gained depends on who they choose to consult. However, not everything associated with institutionalized socialization In many Ph.D. programs, advisors are chosen from among the tactics is positive. Ashforth and Saks (1996) found that these tactics faculty by the student. Consequently, this choice may affect the cause new members to conform to the ways things are already student’s socialization process, depending upon the level of mutual done in the organization; they are simply maintaining the status regard developed between them. (Van Maanen, 1978). For many quo. Interestingly, the welcoming security that institutionalized doctoral students, a one-on-one mentor relationship serves as a main socialization initially represented to a new employee may come to socialization agent; however, due to individual differences in the represent smothering paternalism. mentors themselves, students may experience their particular program in vastly different ways (Hall & Burns, 2009). In looking at individualized socialization, individual tactics are used. Individual tactics allow new members to have their own unique learning Findings by Cawyer and Friedrich (1998) indicated that the encounter experiences so that in the future, responses from new members will be phase was less satisfying than the anticipatory phase and was marked by heterogeneous. When informal tactics are used, new members are not less interaction than expected and ambiguous information. Respondents separated from established organizational members. They are placed in indicated that more opportunities for both socialization and mentorship work groups so that they are able to learn role requirements while they should be provided and encouraged. The encounter process can be broken actually do the work (Van Maanen & Schein, 1979). down into two distinct components: institutionalized socialization and individualized socialization (Jablin, 1987; Jones, 1983). Using random and variable tactics means that the stages associated with the socialization process are unknown to new members, and they This interaction is a reciprocal one as the newcomer negotiates her will not follow any certain pattern. This can lead to new members role within the institutionalized or individualized socialization process feeling uncertain about their organizational futures. Disjunctive offered by the organization. Jablin (2001) noted that this phase is so tactics are utilized when new members do not have experienced important for organizational new members, and the organization itself, organizational role models. They must then develop their own ideas due to the fact that the orientation program utilized can affect employee and definitions of their roles (Van Maanen & Schein, 1979). turnover and attitudes about the job and the organization itself.

Psychology.EliteCME.com Page 13 Lastly, divestiture relates to the amount of negative social support performance (Baker, 1989; Ashforth and Saks 1996). Ashforth and provided by established organizational members (Jones, 1986). Due Saks (1996) also found that using individualized socialization tactics to the fact that individualized socialization gives new members more encouraged new members to innovate within their particular role and latitude in organizational development, findings indicated that these this led to exceptional performance. tactics were positively associated with internal work motivation and

Benefits of socialization In examining the content and consequences of organizational into the organization by receiving social support and understanding socialization, Chao et al. (1994) found that, in general, there were their future within the organization (Gomez, 2009). several beneficial outcomes to well-socialized organizational The socialization process is important to organizations because it new members. These included a higher level of satisfaction and enables an organization to maintain their mission, performance, adaptability, a higher level of career involvement, higher pay, and a and survival (Van Maanen, 1978). Ultimately, the idea behind the better sense of their personal identity within the organization. socialization process is to make certain that organizational new In terms of information seeking, Miller and Jablin (1991) found members can complete their duties effectively (Ashforth & Saks, that the outcomes included less role ambiguity and lower levels 1996). Understandably, communication is highlighted as a central of role conflict for organizational new members. Allen and Meyer aspect of the socialization process. Interns typically learn about their (1990) found that organizations can accomplish both the inspiration new role through talk with others. This also helps them to begin to of strong organizational commitment and innovation within new feel a part of the culture and relieve some of their frustrations and members. Utilizing a focus on the future may help promote effective uncertainties in order to survive (Staton-Spicer & Darling, 1986). socialization tactics through structures that help newcomers assimilate

GROUP DYNAMICS The study of groups and their structure have frequently been termed can be discussed. Notably, on this very broad level, the study of group group dynamics, small groups, and group processes. The sociological dynamics is similar to the study of culture. and psychological interests in groups coincided in the early Groups, their organizations, and their processes were important focus development of sociology and psychology and still coincide. The close of many of the early sociologists. In an influential book,Small Groups, relationship between the psychological and sociological investigations edited by A. P. Paul Hare, Edgar F. Borgatta, and Robert F. Bales (1965), of groups is one of the important characteristics of this area of study. the editors pay allegiance to the early theorists Émile Durkheim, Georg In fact, this inter-disciplinarity, which existed at the beginning of its Simmel, Charles B. Cooley, and George H. Mead. In particular, the development, is still one of its most distinctive characteristics, and has editors emphasize Durkheim’s generic interest in group organization and further developed to include economics and political science. his theoretical ideas of division of labor, which can be translated easily Group dynamics are the underlying processes that give rise to a set into role differentiation and stratification within groups. of norms, roles, relations, and common goals that characterize a Both Cooley and Mead are important ancestors for the specific particular social group. Examples of groups include religious, political, framework of symbolic interaction and frequently addressed the military, and environmental groups, sports teams, work groups, and central importance of groups, especially small groups. Cooley, for therapy groups. Amongst the members of a group, there is a state of example, developed and elaborated the idea of primary groups. Mead’s interdependence, through which the behaviors, attitudes, opinions, (1934) theoretical conceptualizations in Mind, Self, and Society helped and experiences of each member are collectively influenced by the to develop concepts central to the development of group dynamics. other group members. In many fields of research, there is an interest in understanding how group dynamics influence individual behavior, Such concepts involved the centrality of groups and the importance attitudes, and opinions. of role-taking. Within these discussions, Mead used the example of a ball game in which the attitudes of a set of individuals are involved in The dynamics of a particular group depend on how one defines the a cooperative response in which the different roles involve each other. boundaries of the group. Often, there are distinct subgroups within In so far as a man takes the attitude of one individual in the group, he a more broadly defined group. For example, one could define U.S. must take it in its relationship to the action of the other members of the residents as a group, but could also define a more specific set of U.S. groups; and if he is fully to adjust himself, he would have to take the residents. For each of these groups, there are distinct dynamics that attitudes of all involved in the process.

Status and status effects Status is one of the most important concepts in the discipline of social all the leaders were adults. On the basis of their experiment, the psychology. In fact, much of the discipline can be conceptualized as researchers found evidence that the democratic group resulted in more questioning what constitutes status and the effect of status. Status is “we-ness” and group goals and less scapegoating compared with the usually defined as a position in a social network. Importantly, these autocratic group. Interestingly, autocratic groups spent more of their statuses involve status beliefs, beliefs about the social worth of the time working than did the democratic groups, who in turn spent more individuals who occupy these statuses, such as the belief that a person time working than did the laissez-faire groups. However, when the who occupies one position is “better than” a person who occupies autocratic leader left the room, the boys stopped working, while the another position (Sewell, 1992). boys in the other groups continued working. Early studies in status tended to examine leadership. While these Bales (1950) and researchers at Harvard developed different kinds studies sometimes examined individual styles of leadership, most of analyses to map behaviors within the group. Interaction process studies focused on general types of leadership approaches. A well- analysis (IPA), described in 1950, was then an innovative technique known study by Kurt Lewin, Ronald Lippitt, and Ralph White (1939) and still shapes many group investigations. In its original form, it involved an experimental investigation of three different kinds of consisted of 12 categorizations of behavior. leadership: autocratic, democratic, and laissez-faire. The groups consisted of 10- and 11-year-old boys in after-school groups, and

Page 14 Psychology.EliteCME.com These categorizations separated out behaviors into positive and proceeds in several steps; importantly, while the process might be negative social-emotional behavior and neutral task behaviors. So, conscious, it can be unconscious as well. for example, asking for opinions, disagreeing, and giving suggestions Much of the recent expectation states theory, in general, and status were coded, depending on their specific context. In particular, Bales characteristics theory, in particular, has been explicated and elaborated and his colleagues were interested in the kind of interaction that through graph-theoretic models (Berger et al. 1977, 1998; Webster occurred and how the particular behaviors of one group member & Hysom 1998). These models serve to depict how different conditioned the behaviors of another. These studies provided important characteristics within the group and outside the group structure evidence that status was relative to the group (Borgatta & Bales, expectations and subsequent behavior. 1953), a central insight for group dynamics. Because of the burden-of-proof process, status can serve to organize This insight was critical to social psychology because it was the the interactions within a group and help legitimate power use (or the beginning of the powerful idea that while people might possess the lack of power use). The acceptable use of power can make a group same characteristics from one setting to another, these characteristics function relatively smoothly and can generate an acceptance of did not have the same salience in different settings. Such an idea inequality. Additionally, however, power use can generate negative took many years to develop but took root in new thinking about sentiment and interrupt the process through which power use translates characteristics such as gender and ethnicity. to status (Lovaglia & Houser, 1996; Lovaglia et al,. 2005; Walker et Many sociologists have suggested that status significance is acquired al., 2000; Willer, Troyer, & Lovaglia, 2001). through resources. In an analysis of one process through which Dissolving status hierarchies involves more than just a reversal of the nominal characteristics, such as race and sex categories, might acquire burden-of-proof process. Once a status hierarchy is created at an initial status-value and status beliefs, Cecilia Ridgeway (1991) developed point in time, the deference granted serves to reinforce subsequent and then tested aspects of status construction theory (Ridgeway power differentials. Because of this, initial differences become more and Erickson, 2000; Ridgeway et al., 1998). This theory posits one and more entrenched. mechanism through which a characteristic previously not status- valued might acquire such value. According to the theory, members Consequently, it seems that interventions must either occur early in differ in the level of material resources they possess, they differ on an the group interaction or serve to severely contradict the expectations unordered nominal characteristic, and resources are correlated with the generated by other characteristics. Most researchers who have investigated “state” or category of the characteristic (Ridgeway, 1997). this have considered how the addition of certain kinds of characteristics can serve to “dampen” or even eliminate the effects. Some research Status has been examined from a number of different perspectives. has investigated decreasing the effects of diffuse status through adding One of the most developed research programs, in many ways a direct performance information (or specific status characteristics) that contradicts descendant from Bales’ research in group processes, is expectation the evaluation associated with the diffuse status characteristics. states theory. The theory has several subsets. One portion of the theory, status characteristics theory, focuses on how status characteristics Such investigations include those of Pugh and Wahrman (1983) and generate and then sustain inequalities of power and prestige within Wagner, Ford, and Ford (1986) for sex and Freese and Cohen (1973) for groups (Correll & Ridgeway, 2003). age. One important caveat to this research (and an implication from the graph theory) is that characteristics that equate actors do not contribute The two types of status characteristics have different properties. to the formation of expectations and to the subsequent observable power Specific status characteristics are those associated with a specific and prestige (Martin and Sell 1985; Webster 1977). Consequently, if ability, such as the ability to score soccer goals or the ability to do both actors have equally high (or low) specific status characteristics and accounting. These characteristics consist of two or more “states” that they are differentiated by a diffuse status characteristic, only the diffuse correspond to an expectation or assessment of how the individual will status characteristic organizes their interaction. perform in the completion of a task. A diffuse status characteristic is a characteristic that also possesses at least two states of differential Another approach was suggested by Fisek in 1991 and then expanded and evaluation. However, associated with each state, not only are there tested by Goar and Sell (2005). This approach emphasizes how changing associated specific performance expectations, but there are also the nature of the task might change the inequalities generated in the associated general performance expectations “without limit as to group: specifically, if the group task involves different abilities that are scope” (Webster & Foschi, 1988). inconsistent with each other, group participation tends to equalize. If individuals within a task group all are motivated to succeed on The investigation of inequality within groups and how it relates to that task, status characteristics that differentiate among the group status remains an important area within group dynamics. Early studies members are activated in the first step of a status organizing process, stressed descriptions of groups, while later studies investigated possible the burden-of-proof process. Unless some other characteristic or event ways in which status hierarchies might be modified or disrupted. One intervenes, the status characteristics organize interactions such that of the most exciting and promising areas of investigations is that of those who are higher in social status receive higher amounts of power studies that examine different groups, how these groups nest, and how and prestige than those lower in status. The burden of proof rests on status differences translate from one group to others. For example, a demonstration that the status should NOT be used. The process Lovaglia et al. (1998) developed a formulation that assesses how status differences created in a group translate to individual-level performances on standardized tests.

Legitimation Closely related to the issues of status are issues of legitimation. subsequently exchange) and types of authority. He conceptualized three Legitimation is the process through which a principle or set of rules is types of authority: charismatic, traditional, and legal rational (Weber, adhered to, deferred to, or supported, even in the absence of obvious 1978). Traditional authority is based on time-honored traditions, and incentives to do so. These principles may or may not be written down, and charismatic authority is legitimated based on personal qualities of they can refer to persons, positions, and acts. This process is often taken the leader. Legal rational authority, a characteristic of the modern for granted in the establishment and maintenance of social structure. bureaucracy, stresses universal rules, calculability, and efficiency. Max Weber, although not often discussed in terms of small-groups Early studies on leadership (mentioned above) can be considered part analysis, contributed to initial conceptualizations of power (and of legitimation studies (Burke, 2003). In the context of leadership, an

Psychology.EliteCME.com Page 15 important study by Evan and Zelditch (1961) specifically tested some (Lawler & Thompson, 1978). And in further demonstration of the aspects of Weber’s formulation and was one of the first experimental importance of endorsement, Sell and Martin (1983) and Martin studies that created a bureaucracy in the laboratory. They investigated and Sell (1986) found that such a revolution could occur even if a authorization as a source of legitimation and tried to separate the legal legitimate authority had specifically prohibited the act. and rational components of Weber’s theory of bureaucratic authority, In face-to-face group situations, influence and legitimacy are finding that the source of legitimation was more important than the often intertwined. Berger (1998) considered the emergence and competency of the authority when it came to eliciting compliance. consequences of the legitimation and delegitimation of power and Dornbusch and Scott (1975) elaborated on the theory of authority, prestige orders. He described legitimation as a social process that based on Weberian concepts of power, authority, and legitimacy. mediates the relationship between social actors and social structures. Different dimensions defined authority. One dimension refers to the It is also a multilevel process. “Referential belief structures” or norms that underlie the power relationship. Dornbusch and Scott commonly held socially validated beliefs exist on a cultural level and (1975) refer to this dimension as either validity, collective support can then be imported into a local setting, such as a task setting. The for a normative order, or propriety, individual belief in the fairness of theory of reward expectations connects to this process by describing norms. A second dimension refers to the sources of legitimacy. The the relationship between performance and reward expectations based power structure becomes legitimated (p. I-174) through authorization, on the valued status characteristics. Rewards are then allocated to endorsement, or both. The third dimension of authority refers to its valued status positions in line with referential belief structures. formal or informal character. Another theory that addresses how legitimation can be transported Expanding, modifying, and further developing these formulations, from one arena to another is the theory of structural ritualization Bell, Walker, and Willer (2000); Zelditch and Walker (1984); Walker, (Knottnerus, 1997). The theory details how ritualized social practices Rogers, and Zelditch (2002); and Zelditch (2001) argued that theories can be reproduced, even in the absence of incentives and even when concerned with the emergence of legitimacy must deal not only their reproduction may not benefit the group (Knottnerus 1997; with types (validity and propriety) and sources (authorization and Knottnerus & Van de Poel-Knottnerus, 1999; Sell et al., 2000). Such endorsement) but also with multiple objects such as acts, persons, and a theory helps explain paradoxical behaviors, such as how those positions. For example, Thomas, Walker, and Zelditch (1986) found subjected to coercive practices eventually come to adopt and then that collective approval can override personal approval. support these same practices. Read (1974) created leaders with different sources of support: election, Legitimation concerns began with studies of individuals, specifically appointment by expert external authority; appointment by non-expert leaders, and their support from other group members. A particularly external authority; and usurpation by a self-appointed leader. The study critical development within this area is the recognition and then pointed out an important aspect of legitimation: What is given, or the elaboration of how different groups and organization can be “nested” “status quo,” is usually not questioned until something unusual occurs and, consequently, how legitimation in one area can be imported into that calls into question the existing arrangements. Read concludes, other areas. “The leader selection process may establish a relationship between A particularly promising area for further investigation is how the group members and the agent of selection which remains unexpressed sources and origins of legitimation can determine the stability of a until the leader places unusual demands upon group members” (p. group or organization, the potential development and dissolution of 202). Subjects chose to retain the elected leader more than they did routines (Johansson & Sell, 2004), and the sudden development of the expert appointed leader, even though the expert leader had more crisis. In this regard, however, there must be further investigation of task influence. This suggests a complex relationship between source of time. Even though the term group dynamics refers to change and time, authority and influence, even in small informal groups. strangely, “most research on groups neglects the role of time” (Arrow Questioning the status quo was also a focus for research on et al., 2005). revolutionary coalitions. Such coalitions were called revolutionary Much of what legitimation addresses relates to ideas of justice and because they existed to “overthrow” some given arrangement fairness. Historically, the areas seem to have developed somewhat within the group or organization (Lawler, 1975; Webster & Smith, independently, with legitimation issues more often studied and applied 1978). Research in this area also suggested that endorsement was in more “macro-sociological” contexts, while justice and equity was a particularly powerful source of authority. When the leader was more often studied in dyads or micro-sociological contexts. Recently, responsible for a payment scheme that vastly underpaid some however, the two areas seem to be integrating. members, the disadvantaged were likely to revolt against the leader

MEDIA AND SOCIOLOGY New technologies have made new forms of mass media available to U.S. The next section examines the impact of the mass media and changes households. These new technologies have changed people’s viewing and in usage patterns from the three major sociological perspectives, listening habits. Americans now spend less time listening to music than functionalist view, feminist view, and interactionist view. they did just a few years ago; they spend more time surfing the Internet or utilizing applications on their mobile phone device.

Functionalist view One obvious function of the mass media is to entertain. Except for important functions. They also socialize people, enforce social norms, clearly stated news or educational programming, many often think confer status, promote consumption, and keep people informed about the explicit purpose of the mass media is to occupy people’s leisure the social environment. An important dysfunction of the mass media time; from newspaper comics and crossword puzzles to the latest is that they may act as a narcotic, desensitizing people to distressing music releases on the Internet. While that is true, the media have other events (Lazarsfeld and Merton 1948; C. Wright 1986).

Page 16 Psychology.EliteCME.com Feminist view Feminists share the view of conflict theorists that the mass media 1. Women are underrepresented, which suggests that men are the stereotype and misrepresent social reality. According to this view, cultural standard and women are insignificant. the media powerfully influence how we look at men and women, and 2. Men and women are portrayed in ways that reflect and perpetuate their images of the sexes communicate unrealistic, stereotypical, and stereotypical views of gender. Women, for example, are often shown limiting perceptions. Three problems that feminists believe arise from in peril, needing to be rescued by a male. This is rarely the reverse. media coverage include the following (Wood, 1994): 3. Depictions of male–female relationships emphasize traditional sex roles and normalize violence against women.

Interactionist view Interactionists are especially interested in shared understandings of group for many individuals who share TV viewing. Other mass-media everyday behavior. These scholars examine the media on the micro participation is not necessarily face to face. For example, people usually level to see how they shape day-to-day social behavior. Researchers listen to the radio or read the newspaper as a solitary activity, although it increasingly point to the mass media as the source of major daily is possible to share it with others (Cerulo et al. 1992; Waite 2000). activity; some argue that television serves virtually as a primary

SOCIAL CONTROL AND DEVIANCE Social control Social control refers generally to societal and political mechanisms or systems. One way this is done is through coercion, from imprisoning processes that regulate individual and group behavior in an attempt to those who commit a crime to physicians administering drugs that make gain conformity and compliance to the rules of a given society, state, difficult patients more manageable. Social control, however, is mainly or social group. achieved through socialization, in which people come to identify with Social control is a concept that refers to the ways in which people’s a social system and its values and norms, thereby acquiring a stake in thoughts, feelings, appearance, and behavior are regulated in social maintaining those values and norms.

Norms Social norms are group-held beliefs about how members should Norms running counter to the behaviors of the overarching society or behave in a given context. Sociologists describe norms as informal culture may be transmitted and maintained within small subgroups of understandings that govern society’s behaviors, while psychologists society. For example, Crandall (1988) noted that certain groups (i.e. have adopted a more general definition, recognizing smaller group cheerleading squads, dance troupes, sports teams, and sororities) have units, like a team or an office, may also endorse norms separate or a rate of bulimia, a publicly recognized life-threatening disease, that in addition to cultural or societal expectations. The psychological is much higher than society as a whole. Social norms have a way of definition emphasizes social norms’ behavioral component, stating maintaining order and organizing groups. norms have two dimensions: how much behavior is exhibited and how much the group approves of that behavior.

Conformity and obedience From the beginning, social psychology has concerned itself, from It is important to note that the two phenomena are connected. Often, different perspectives, with processes of social influence, producing conformism is a mental direction more easily inclined towards an imposing amount of research. Social influence can be assessed in obedience, and both imply the themes of independence and submission. all situations where there are two “social entities” (two people, two People can sometimes reach an authentic shared consensus, though groups, a person and a group), where one is the source of influence and in some situations, people cannot freely express their ideas. This the other the target; both interact through an “object” which can be an activates people’s resources in order to affirm themselves and their opinion or a behavior. values. Instead others can resign themselves and become submissive, Conformism can be defined as the change in thinking, feeling, or even coming to the point of aligning themselves with their oppressor. acting following pressure, real or imaginary, exercised by a group Analyzing similar situations enables people to distinguish the presence (Moghaddam, 1998). or the forming of binding forces in the social environment, just like the Obedience is the modification that is manifested carrying out the forces that individual people put into action to resist coercion. instructions issued by figures given authority. Conformism and obedience are not necessarily negative phenomena. The list of their positive aspects is decidedly long. In fact, without conformism and obedience, chaos would govern social life. People could not circulate in the streets nor even hold a civil conversation.

Conformism A social norm is generally an accepted way of thinking, feeling, or acting, influence on people in terms of how to perceive social reality (the function emphasized and expected by members of a particular community or social of understanding) and how to behave inside social reality. group, since it is considered the “right” thing (Turner, 1991). A norm is Research on interaction in small groups has demonstrated that the standard of reference for judging what is correct and appropriate to when called to express judgment, people tend to develop a certain do in specific situations, providing people with criteria of validity and agreement. According to Sherif (1936), this agreement is the reducing their sense of uncertainty. Therefore, norms exercise their own equivalent of the formation of social norms. In one of his classic

Psychology.EliteCME.com Page 17 studies, he used an optical illusion called “auto kinetic effect.” In The experiments have been repeated many times in the following years a completely dark room, fixing on a luminous point the sensation with consistent results within differing societies, although not with the is created, though immobile, that it begins to move irregularly. The same percentages across the globe (Blass, 1991). The experiments were participants in Sherif’s experiment, placed in this ambiguous situation also controversial, and considered by some scientists to be unethical and and assigned with the task of estimating the width of movement of the physically or psychologically abusive. Psychologist Diana Baumrind luminous stimulant, manifested a progressive tendency to establish a considered the experiment “harmful because it may cause permanent common rule, producing a convergence in their judgment. psychological damage and cause people to be less trusting in the future” Something analogous is present in the work of Leon Festinger (1950), (Baumrind, 1964). Such criticism motivated more thorough review from where conformity is seen as pressure towards the uniformity that the boards and committees for working with human subjects. group exercises on its members. A uniformity that, excluding deviants, Those who had responded to the newspaper announcement were invited favors the cohesion of the group. But probably the most brilliant to a laboratory to carry out actions that became increasingly in contrast demonstration of pressure towards conformism is retraced in the with their moral conscience. What interested the researchers was to pioneer studies of Solomon Asch (1951). understand to what point the participants would obey orders and when To understand the phenomenon of conformism, a distinction was or how they would rebel. To make the prearranged situation credible, advanced between “informational influence” and “normative a particular strategy was used: staging an experiment which had as its influence” (Deutsch & Gerard, 1955). The first, consisting in taking fictitious objective the study of processes of memory and learning; two positions expressed by others to resolve doubts deriving from participants were assigned the roles of teacher and learner. ambiguous situations, is utilized to integrate sketchy skills and so gain The experimenter informed both participants that it was a study aimed greater security in facing up to life’s chores. In such a case, the group at investigating the effects of punishment on learning. The learner was offers its members’ informational influence. taken into a room, made to sit with hands tied in such a way as to make The second form of influence, pertaining to affiliation (the assumption it evident that freedom of movement would be removed, while an of the norms of the group as an expression of the link between electrode was applied on one pulse. The task of the learner consisted individuals), manifests itself in situations where a person intends to in learning a series of word associations, but for each error of memory, communicate to others a positive image of himself, or wants to avoid the learner would receive an apparent electric shock that increased in embarrassment and sanctions, like exclusion from the group. intensity each time. Both of these processes of sharing norms and knowledge assume In reality, the real “experimental subject” was not the learner but importance for the people, and the prevalence in exercising one rather the teacher who, after helping to accommodate the former, was or the other varies according to the situation. In fact, they produce placed in another room before a false electricity generator contrived their psychological effects at different levels. In this way, two with a series of modulators of intensity ranging from 15 to 450 volts, essential forms of conformism originate: acquiescence, when the rising on a scale by 15 volts with 30 lever switches. The instrument person externally agrees with the group to avoid argument, although indicated, with special labels, the sequence from “light shock” to disagreeing; and internalization, when the person conforms because he “dangerous shock”. The teacher had the task of subjecting the learner is trustful of the responses given by the others and so is convinced of to the word memory test: when the latter responded correctly, the rule their goodwill (Kelman, 1958). was that the test passed to the subsequent series of words, while when a mistake was made, an electric shock was administered starting from If, for the studies of Asch, conformism can be described in words about the lowest level and proceeding upwards as required. As an accomplice obedience from the research conducted by Stanley Milgram (1974), of the experimenter, the false guinea pig did not receive any torture, instead of how conformity comes to involve conduct. Obedience is a but the teacher was convinced that real damage was being inflicted. particular form of conformity: it manifests itself when the “majority” is not a quantitative dimension but qualitative. At the bottom of this, The objective of the experimenter was to observe to what point the there is a difference of status: the one who exercises a power superior to teacher would agree to inflict violence on a person who manifested others operates a direct, explicit pressure on them, who adapt to his will. the will to defend himself, interrupting the test, and unable to do it as he was tied up. The contrast between moral conscience and received The next section examines an example of Milgram’s research on orders was primed so that when the learner, pretending, manifested his immoral orders and dilemmas of conscience. discomfort: around 75 volts the first groans could be heard clearly, at “We will pay you $4.00 for one hour of your time. People needed for a 120 volts there was strong invective, at 150 volts the request that the study of memory.” With this announcement published in a local newspaper, experiment be suspended, finally, when the shocks were now reaching participants were recruited to the first of a series of experiments, which 285 volts excruciating gasps. signaled the story of social psychology (Milgram, 1974). How did the teachers behave? The Milgram experiment on obedience to authority figures was a The results were surprising. Although manifesting tension and series of social psychology experiments conducted by Yale University protesting energetically, 65 percent of the participants continued to psychologist Stanley Milgram, which measured the willingness of punish the learner to the last beat. The groans and imploring of the study participants to obey an authority figure who instructed them to victim were insufficient to make them desist from carrying out the perform acts that conflicted with their personal conscience. Milgram orders of the experimenter. first described his research in 1963 in an article published in the What has just been described illustrates the standard condition of the Journal of Abnormal and Social Psychology, and later discussed his experiment and the general results obtained. But, to understand the findings in greater depth in his 1974 book,Obedience to Authority: An problems faced better, it is opportune to analyze the different experimental Experimental View. modifications introduced to identify which conditions influence the The experiments began in July 1961, three months after the start of behavior of obedience. Milgram conducted several variations on his the trial of German Nazi war criminal Adolf Eichmann in Jerusalem. baseline study and found that obedience was maximized when participants Milgram devised his psychological study to answer the popular merely assisted someone else giving the electric shocks (92.5 percent) and question at that particular time: “Could it be that Eichmann and his when they first observed a peer complying with the experimenter until the million accomplices in the Holocaust were just following orders? end (68.75 percent) (Milgram, 1974). Could we call them all accomplices?” Milgram’s testing was meant to From these variations of situational stimuli, an important element answer that question in a laboratory setting. regards the closeness of teacher and learner: the data show that there

Page 18 Psychology.EliteCME.com is an inversely proportional rapport between the tendency to inflict raising personal responsibility for the suffering inflicted. The principal electric shocks and the proximity of the victim. Milgram arranged morals that guide the action, thus, seem to be subject to the laws four different experimental conditions; if he observed how many of proximity and distance. To act with ferocity towards a nearby or participants arrived at the extreme point, corresponding to the most faraway victim certainly does not change the moral quality of the dangerous shocks, he noted that the percentage of obedient participants action; in spite of this intervention in the spatial rapport profoundly follow the course of the levels of proximity. affects the disposition towards obedience. In fact, the closer the teacher gets to the learner, until they touch, the Therefore, every element that reduces the proximity between action less the phenomenon of obedience to the orders of the experimenter and victim inhibits the voice of conscience and makes the execution of is registered. It can be affirmed that closeness of the victim, on the the violent task easier. perceptive plane, increases the link between action and consequence,

Formal and informal social control Formal social control capacity. Traditional societies mostly embed informal social control Formal social control is implemented by authorized agents, including culture to establish social order. police officers, employers, military officers, and others. It is carried Shame, sarcasm, criticism, ridicule, and disapproval are some of the out as a last option in environments when the desired behavior is not informal sanctions. Social discrimination and exclusion are included possible through informal social control. The situations and severity in informal control at extreme deviant cases. Self-identity, self-worth, where formal control is practiced varies with countries. and self-esteem are affected in informal control through loss of group This is practiced through law as statutes, rules, and regulations against approval or membership. The severity and nature of informal control deviant social behavior. For example, certain laws like prohibition mechanisms differs from varied individuals, groups, and societies. of murder can be directed at all members of a society. Fishing and Informal control is effective in small group settings, including friends, hunting regulations are made for certain groups. Corporate laws are family, neighborhood, work groups, and others. However, in some large laid for governing the behavior of social institutions. Formal control is and complex societies, informal social control and disapproval is ignored conducted by government and organizations through law enforcement easily. In such situations, it is necessary to exercise formal control. mechanisms. It can also be conducted through some formal sanctions, including fines and imprisonment. Processes of formal control in Some of the differences of formal and informal social control include: democratic societies are determined and designed through legislation ●● Formal social control includes written, formalized and codified by elected representatives. statements in laws, rules, and regulations. Whereas informal control does not contain any written rules. Courts or judges, military officers, police officers, school systems or ●● Formal control agencies are authorized ones created by teachers, and government agencies or bureaucrats, enforce formal government, and informal control agencies are created by social social control. networks and organizations but not by government. Informal social control ●● Formal control is much more effective and stronger than informal Informal social control is exercised by a society without stating any social control. Any situations that cannot be handled by informal rules or laws. It is expressed through norms and customs. Social control are subjected to formal ones. control is performed by informal agents on their own in an unofficial ●● Formal control is effective for even large groups of population, but informal control is effective only for a small group of people.

Control theory Control theory in sociology can be classified as centralized, systems result in deviant behavior. Deviant behavior occurs when decentralized, or neither. Decentralized control is considered market external controls on behavior are weak. According to control theory; control. Centralized control is considered bureaucratic control. Some people act rationally, but if someone had the chance to act deviant, types of control, such as clan control, are considered to be a mixture of they would. So, basically, if people have strong social bonds to both decentralized and centralized control. positive influences, they are less likely to engage in deviant behavior Decentralized control or market control is typically maintained through than someone who has no family or friends. factors such as price, competition, or market share. Centralized Control theory stresses how weak bonds between the individuals and control, such as bureaucratic control, is typically maintained through society free people to deviate or go against the norms, or the people administrative or hierarchical techniques, such as creating standards who have weak ties would engage in crimes so they could benefit, or policies. Clan control has characteristics of both centralized and or gain something that is to their own interest. This is where strong decentralized control. Mixed control or clan control is typically bonds make deviance more costly. Deviant acts appear attractive maintained by keeping a set of values and beliefs or norms and traditions. to individuals, but social bonds stop most people from committing Control theory, as developed by Walter Reckless in 1973, states that the acts. Deviance results from extensive exposure to certain social behavior is caused not by outside stimuli, but by what a person wants situations where individuals develop behaviors that encourage them most at any given time. According to the control theory, weak social to avoid conforming to social norms. Social bonds are used in control theory to help individuals from going after these attractive deviations.

Deviance Sociologists use the term deviance to refer to any violation of rules to the act that make something deviant. In some cases, individuals need and norms. From a sociological perspective, deviance is relative. not do anything to be labeled a deviant. They may be falsely accused Definitions of “what is deviant” vary across societies and from one or discredited because of a birth defect, race, or disease. Even crime is group to another within the same society. Howard S. Becker described relative when interpreting the deviance of the actor. the interpretation of deviance as, “It is not the act itself, but the reaction Deviance is based on adherence and violation of norms. Human to the act that makes something deviant.” This coincides with the groups need norms to exist. By making behavior predictable, norms symbolic interactionist point out that is not the act itself but the reactions

Psychology.EliteCME.com Page 19 make social life possible. Consequently, all human groups develop a Conflict theorists note that power plays a central role in defining system of social control, which involves formal and informal means of and punishing deviance. The group in power imposes its definitions enforcing norms. of deviance on other groups, then uses the law and criminal justice Those who violate these norms face the danger of being labeled system to maintain its power and privilege over those other groups. deviant. Violators can expect to experience negative sanctions for Reactions to deviance in the United States include everything from the violation of norms. Members of society who conform to societal mild sanctions to capital punishment. Since the 1980s, the United norms, especially those who go above and beyond what is commonly States has adopted a “get tough” policy on crime that has imprisoned expected, receive positive sanctions. In some societies, such as the millions of people. Amish, shaming is a common negative sanction. Since crime statistics are produced within a specific social and political Biologists, psychologists, and sociologists have different perspectives context for particular purposes, they must be interpreted with caution. on why people violate norms. Biological explanations focus on Power plays a central role in which behaviors are defined as crime, genetic predispositions; psychologists concentrate on abnormalities and how actively “criminal behaviors” are prosecuted or punished. within the individual (commonly known as personality disorders); and For example, although street crime receives the greatest attention from sociologists look at social factors outside the individual. the media, white collar crime actually costs the American taxpayers Symbolic interactionists interpret deviance through the following more. Even cases of gross negligence that cause death are funneled social theories: into administrative hearings that result in little more than a fine for the ●● Differential association theory—people learn deviance from the corporation. The definition of crime is subject to change, however, and groups with whom they associate. how various acts are treated by society changes with shifts in power ●● Control theory—people generally avoid deviance because of an and public priority. effective system of inner and outer controls. Ever since the early 20th century, there has been a growing tendency ●● Labeling theory—people are directed toward or away from toward the medicalization of deviance, viewing deviance, including deviance by the labels others pin on them. crime, as mental illnesses. Thomas Szasz offers another perspective, Functionalists contend that deviance is functional for society; it claiming that mental illnesses are neither mental nor illness. Rather, they contributes to the social order by clarifying moral boundaries, are problem behaviors related to people’s particular experiences in life. promoting social unity, and initiating social change. Furthermore, As deviance is believed to be inevitable, the bigger issues include according to “strain theory,” people who are unable to achieve cultural finding ways to protect people from those forms of deviance that harm goals (such as wealth or high status) through legitimate means are themselves and/or others, tolerating deviant behaviors that are not likely to experience strain, which, in turn, can lead to deviant and/ harmful, and developing systems of fairer treatment for deviants. or criminal behavior. In addition to strain theory, functionalists stress theories addressing illegitimate opportunity structure in society.

Functionalist perspective According to functionalists, deviance is a common part of human Durkheim introduced the term anomie into sociological literature to existence, with positive as well as negative consequences for social describe the loss of direction felt in a society when social control of stability. Deviance helps to define the limits of proper behavior. individual behavior becomes ineffective. Émile Durkheim (1964) focused his sociological investigations mainly Anomie is a state of normlessness that typically occurs during a period on criminal acts; yet his conclusions have implications for all types of profound social change and disorder, such as a time of economic of deviant behavior. In Durkheim’s view, the punishments established collapse. People become more aggressive or depressed, which results within a culture (including both formal and informal mechanisms of in higher rates of violent crime and suicide. Since there is much social control) help to define acceptable behavior and, thus, contribute less agreement on what constitutes proper behavior during times of to stability. revolution, sudden prosperity, or economic depression, conformity and obedience become less significant as social forces. It also becomes much more difficult to state exactly what constitutes deviance.

Interactionist perspective The emphasis on everyday behavior that is the focus of the Routine activities theory interactionist perspective offers two explanations of crime: cultural Routine activity theory, developed by Marcus Felson and Lawrence transmission and routine activities theory. Cohen, draws upon control theories and explains crime in terms of Cultural transmission crime opportunities that occur in everyday life (Lynch, 1987). A Humans learn how to behave in social situations, whether properly crime opportunity requires that elements converge in time and place or improperly. There is no natural, innate manner in which people including: interact with one another. These concepts are not disputed today, but ●● A motivated offender. this was not the case when sociologist Edwin Sutherland (1883–1950) ●● Suitable target or victim. first presented the idea that an individual undergoes the same basic ●● Lack of a capable guardian. socialization process in learning conforming and deviant acts. A guardian at a place, such as a street, could include security guards Sutherland’s ideas have been the dominating force in criminology. or even ordinary pedestrians who would witness the criminal act He drew on the cultural transmission school, which emphasizes that and possibly intervene or report it to police. Routine activity theory one learns criminal behavior by interacting with others. Such learning was expanded by John Eck, who added a fourth element of “place includes not only the techniques of violating the law (for example, manager,” such as rental property managers who can take nuisance how to break into a car quickly and quietly) but also the motives, abatement measures. drives, and rationalizations of the criminal. The cultural transmission approach can also be used to explain the behavior of those who habitually abuse alcohol or drugs. Page 20 Psychology.EliteCME.com Racial and ethnic inequality Social psychologists have long been interested in stereotypes and behavior toward members of the ethnic and racial groups. Previous prejudice, concepts that are typically viewed as being very interrelated. theorists have not adequately captured this distinction and explored its For example, those who subscribe to the tripartite model of attitudes implications for responding to stereotyped group members. hold that a stereotype is the cognitive component of prejudiced Automatic processes involve the unintentional or spontaneous attitudes (Harding, Proshansky, Kutner, & Chein, 1969; Secord activation of some well-learned set of associations or responses that & Backman, 1974). Other theorists suggest that stereotypes are have been developed through repeated activation in memory. They do functional for individuals, allowing rationalization of their prejudice not require conscious effort and appear to be initiated by the presence against a group (Allport, 1954; LaViolette & Silvert, 1951; Saenger, of stimulus cues in the environment (Shiffrin & Dumais, 1981). A 1953; Simpson & Yinger, 1965). crucial component of automatic processes is their inescapability; they In fact, many classic and contemporary theorists have suggested that occur despite deliberate attempts to bypass or ignore them (Neety, prejudice is an inevitable consequence of ordinary categorization 1977; Shiffrin & Dumais, 1981). In contrast, controlled processes are (stereotyping) processes (Allport, 1954; Billig, 1985; Ehrlich, 1973; intentional and require the active attention of the individual. Hamilton, 1981; Tajfel, 1981). The basic argument of the inevitability of Controlled processes, although limited by capacity, are more flexible prejudice perspective is that as long as stereotypes exist, prejudice will than automatic processes. Their intentionality and flexibility makes follow. This approach suggests that stereotypes are automatically (or them particularly useful for decision making, problem solving, and the heuristically) applied to members of the stereotyped group. In essence, initiation of new behaviors. Previous theoretical and empirical work knowledge of a stereotype is equated with prejudice toward the group. on automatic and controlled processes suggests that they can operate This perspective has serious implications, because, as Ehdich (1973) independently of each other (Logan, 1980; Logan & Cowan, 1984; argued, ethnic attitudes and stereotypes are part of the social heritage Neely, 1977; Posner & Snyder, 1975). of a society and no one can escape learning the prevailing attitudes and These concepts suggest that whereas stereotypes are automatically stereotypes assigned to major ethnic groups. activated, activation of personal beliefs require conscious attention. The inevitability of prejudice approach, however, overlooks an In addition, non-prejudiced responses require both the inhibition of important distinction between knowledge of a cultural stereotype the automatically activated stereotype and the intentional activation and acceptance or endorsement of the stereotype (Ashmore & Dcl of non-prejudiced beliefs (Higgins & King, 1981). This should not Boca, 1981; Billig, 1985). Although people may have knowledge of a be surprising because an individual must overcome a lifetime of stereotype, their personal beliefs may or may not be congruent with the socialization experiences. The present model, which suggests that stereotype. Moreover, there is no supportive evidence that knowledge automatic and controlled processes involved in stereotypes and of a stereotype of a group implies prejudice toward that group. For prejudice can be dissociated, posits that the inevitability of prejudice example, in an in-depth interview study of prejudice in war veterans, arguments follow from tasks that are likely to engage automatic Bettleheim and Janowitz (1964) found no significant relation between processes on which those high and low in prejudice are presumed not stereotypes reported about African-Americans and Jews and the degree to differ (i.e., activation of a negative stereotype in the absence of of prejudice the veterans displayed toward these groups. controlled stereotype-inhibiting processes). Although they may have some overlapping features, it is argued that Interestingly, the model implies that if a stereotype is automatically stereotypes and personal beliefs are conceptually distinct cognitive activated in the presence of a member of the target group and those structures. Each structure represents part of one’s entire knowledge who reject the cultural stereotype do not (or perhaps cannot) monitor base of a particular group. consciously this activation, information activated in the stereotype Beliefs are propositions that people endorse and accept as being true. could influence subsequent information processing. Beliefs can differ from one’s knowledge about an object or group One strength of the model in particular is that it suggests how or one’s affective reaction toward the object or group. To the extent knowledge of a stereotype can influence responses even for those who that stereotypes and personal beliefs represent different and only do not endorse the stereotype or have changed their beliefs about the potentially overlapping subsets of information about ethnic or racial stereotyped group. groups, they may have different implications for evaluation of and

GENDER AND AGE Gender The application of traditional gender roles leads to many forms of receptionist and from other patients. “Isn’t he a wonderful father?” runs differentiation between women and men. Both sexes are physically through their minds. But if the boy’s mother leaves her job and sits with capable of learning to cook and sew, yet most Western societies the son in the doctor’s office, she will not receive such silent applause. determine that women should perform these tasks. Both men and People construct their behavior socially so as to create or exaggerate women are capable of learning to weld and fly airplanes, but those male–female differences. For example, men and women come in a functions are generally assigned to men. variety of heights, sizes, and ages. Yet traditional norms regarding Gender roles are evident not only in work and behavior but also in how marriage and even casual dating tell people that in heterosexual couples, people react to others. People are constantly “doing gender” without the man should be older, taller, and wiser than the woman. Such social realizing it. If a father sits in the doctor’s office with his son in the middle norms help to reinforce and legitimize patterns of male dominance. of a workday, he will probably receive approving glances from the

Gender-role socialization Male babies often get blue blankets; females get pink ones. Boys are tough, daring, and dominant. Girls however are expected to be expected to play with trucks, blocks, and toy soldiers; girls receive feminine, soft, emotional, sweet, and submissive. These traditional dolls and kitchen goods. Boys must be masculine, active, aggressive,

Psychology.EliteCME.com Page 21 gender-role patterns have been influential in the socialization of Adults play a critical role in guiding children into those gender roles children in the United States. deemed appropriate in a particular society. Parents are normally the An important element in traditional views of proper “masculine” and first and most crucial agents of socialization. But other adults, older “feminine” behavior is homophobia, fear of and prejudice against siblings, the mass media, and religious and educational institutions homosexuality. Homophobia contributes significantly to rigid gender- also exert an important influence on gender-role socialization, in the role socialization, since many people stereotypically associate male United States and elsewhere. homosexuality with femininity and lesbianism with masculinity. Disobeying a gender norm reveals just how rigid gender-role Consequently, men and women who deviate from traditional socialization can be. For example: a female smoking a cigar in public expectations about gender roles are often presumed to be gay. Despite or a male carrying a purse. That was exactly an assignment given to the advances made by the gay liberation movement, the continuing sociology students at the University of Colorado and Luther College stigma attached to homosexuality in society places pressure on all in Iowa. Professors asked students to behave in ways that they thought males (whether gay or not) to exhibit only narrow “masculine” violated norms of how a man or woman should act. The students behavior and on all females (whether lesbian or not) to exhibit only had no trouble coming up with gender-norm transgressions and they narrow “feminine” behavior (Seidman 1994; Lehne 1995). kept careful notes on others’ reactions to their behavior, ranging from amusement to disgust (Nielsen et al., 2000).

Women’s gender roles Q: How does a girl develop a feminine self-image, while a boy strong male caretaker. Studies of picture books published from the develops one that is masculine? 1970s through the 1990s found some improvement, but males still Typically they do so by identifying with females and males in dominated the central roles. While males were portrayed as a variety their families, their neighborhoods, and in the media. If a young of characters, females tended to be shown mostly in traditional roles, girl regularly sees female television characters working as defense such as mother, grandmother, or volunteer, even if they also held attorneys and judges, she may believe that she herself can become a nontraditional roles, such as working professional (Etaugh, 2003). lawyer. And it will not hurt if women that she knows work as lawyers. Social research on gender roles reveals some persistent differences In contrast, if this young girl sees women portrayed on television only between men and women in North America and Europe. Women tend as models, nurses, and secretaries, her identification and self-image to feel pressure both to marry and to become a mother. Often, marriage will be quite different. Even if she does become a professional, she is viewed as their true entry into adulthood. And women are expected may secretly regret falling short of the media stereotype which is often not only to become mothers but to want to be mothers. a shapely, sexy young woman in a bathing suit. Obviously, men play a role in marriage and parenthood, but also Television is not the only outlet stereotyping women. Studies of these events do not appear to be as critical in the life course of a man. children’s books published in the United States in the 1940s, 1950s, Society defines men’s identities by their economic success. And even and 1960s found that females were significantly underrepresented though many women today fully expect to have careers and achieve in central roles and illustrations. Virtually all female characters recognition in the labor force, success at work is not as important to were portrayed as helpless, passive, incompetent, and in need of a their identity as it is for men (Doyle and Paludi, 1998; Russo, 1976).

Men’s gender roles Until recent decades, the idea of “stay-at-home fathers” was constructed gender role face constant criticism and even humiliation, unthinkable. Yet in a nationwide survey done in 2002, 69 percent of both from children when they are boys and from adults as men. respondents said that if one parent stays home with the children, it A small but growing body of scholarship suggests that for men as makes no difference whether that parent is the mother or the father. well as women, traditional gender roles may be disadvantageous. In Only 30 percent thought that the mother should be the one to stay many communities across the nation, girls seem to outdo boys in high home. But while people’s conceptions of gender roles are obviously school, grabbing a disproportionate share of the leadership positions, changing, the fact is that men who stay home to care for their children from valedictorian to class president to yearbook editor, except being are still an unusual phenomenon. In 2001, for every stay-at-home dad captain of the boys’ athletic teams. Their advantage continues after high there were about seven married stay-at-home moms (Bureau of the school. In the 1980s, girls in the United States became more likely than Census, 2002; Robison, 2002). boys to go to college. By 2001, women accounted for over 57 percent Although attitudes toward parenting may be changing, studies indicate of college students nationwide. And in 2002, for the first time, more little change in the traditional male gender role. Men’s roles are socially women than men in the United States earned doctoral degrees (Faludi, constructed in much the same way as women’s roles are. Family, peers, 1999; McCreary, 1994; Sheehy, 1999; Smallwood, 2003). and the media all influence how a boy or a man comes to view his Some of the difference in achievement can be explained by noting that appropriate role in society. Robert Brannon (1976) and James Doyle men can earn decent hourly wages with less formal schooling than (1995) have identified five aspects of the male gender role: women. Yet by a number of measures, girls appear to take schooling ●● Anti-feminine element: show no “sissy stuff,” including any more seriously than boys. In 2002, for example, female students taking expression of openness or vulnerability. the Advanced Placement (AP) tests outnumbered male students in 19 ●● Success element: prove one’s masculinity at work and in sports. out of 33 subjects. Overall, they accounted for 54 percent of students ●● Aggressive element: use force in dealing with others. who took the AP tests. Educational professionals need to look more ●● Sexual element: initiate and control all sexual relations. closely at men’s underperformance in school, not to mention their ●● Self-reliant element: keep cool and unflappable. over-representation in reported crime and illegal drug use (Bureau No systematic research has established all these elements as of the Census, 2003; Conlin, 2003; Rollins, 2003; Smallwood, 2003; necessarily common to all males, but specific studies have confirmed Sommers, 2000). individual elements. Males who do not conform to the socially

Page 22 Psychology.EliteCME.com Cross-cultural perspective In any society, gender stratification requires not only individual maintenance of traditional gender roles requires constant social socialization into traditional gender roles within the family, but the controls; and those controls are not always effective. promotion and support of those traditional roles by other social Cross-cultural studies indicate that societies dominated by men are institutions, such as religion and education. Even with all major much more common than those in which women play the decisive role. institutions socializing the young into conventional gender roles, Sociologists have turned to all of the major theoretical perspectives every society has women and men who resist and successfully oppose to understand how and why these social distinctions are established. the stereotypes: strong women who become leaders or professionals, Each approach focuses on culture rather than biology as the primary gentle men who care for children, and so forth. It seems clear that determinant of gender differences. Yet in other respects, advocates of differences between the sexes are not dictated by biology. The these sociological perspectives disagree widely. The functionalist view Functionalists maintain that gender differentiation has contributed to the occupational world outside the home. Of course, Parsons and overall social stability. Sociologists Talcott Parsons and Robert Bales Bales offered this framework in the 1950s, when many more women (1955) argued that to function most effectively, the family requires were full-time home-makers than is true today. These theorists did adults who specialize in particular roles. They viewed the traditional not explicitly endorse traditional gender roles, but they implied that gender roles as arising out of the need to establish a division of labor dividing tasks between spouses was functional for the family as a unit. between marital partners. Parsons and Bales contended that women Given the typical socialization of women and men in the United States, take the expressive, emotionally supportive role and men take the the functionalist view is initially persuasive. However, it would lead instrumental, practical role, with the two complementing each other. people to expect girls and women who have no interest in children to Instrumentality refers to an emphasis on tasks, a focus on more distant become baby-sitters and mothers. goals, and a concern for the external relationship between one’s family Similarly, males who love spending time with children might be and other social institutions. programmed into careers in the business world. Such differentiation Expressiveness denotes concern for the maintenance of harmony and might harm the individual who does not fit into prescribed roles, as well the internal emotional affairs of the family. According to this theory, as deprive society of the contributions of many talented people who feel women’s interest in expressive goals frees men for instrumental confined by gender stereotyping. Overall, the functionalist approach tasks, and vice versa. Women become anchored in the family as does not convincingly explain why men should be assigned categorically wives, mothers, and household managers; men become anchored in to the instrumental role, and women to the expressive role.

The conflict response Viewed from a conflict perspective, the functionalist approach masks the dominant position over women. Men may originally have become underlying power relations between men and women. Parsons and Bales powerful in preindustrial times because their size, physical strength, never explicitly presented the expressive and instrumental roles as being and freedom from childbearing duties allowed them to dominate of unequal value to society, yet their inequality is quite evident. women physically. In contemporary societies, such considerations Although social institutions may pay lip service to women’s expressive are not so important, yet cultural beliefs about the sexes have been skills, men’s instrumental skills are more highly rewarded, whether in long established,, as anthropologist Margaret Mead and feminist terms of money or prestige. Consequently, according to feminists and sociologist Helen Mayer Hacker (1974) both stressed. Such beliefs conflict theorists, any division of labor by gender into instrumental and support a social structure that places males in controlling positions. expressive tasks is far from neutral in its impact on women. Conflict theorists tend to see gender differences as a reflection of the subjugation of one group (women) by another group (men). Conflict theorists contend that the relationship between females and males has traditionally been one of unequal power, with men in a

The feminist perspective A significant component of the conflict approach to gender as inevitable in all male-dominated societies, whether they are labeled stratification draws on feminist theory. Although use of that term is capitalist, socialist, or communist (Feuer, 1989; Tuchman, 1992). comparatively recent, the critique of women’s position in society and Feminist sociologists would find little to disagree with in the conflict culture goes back to some of the earliest works that have influenced theorists’ perspective but are more likely to embrace a political agenda. sociology. Among the most important are Mary Wollstonecraft’s A Feminists would also argue that until recently, the very discussion Vindication of the Rights of Women (1792), John Stuart Mill’s The of women and society, however well meant, was distorted by the Subjection of Women (1869), and Friedrich Engels’s The Origin of the exclusion of women from academic thought, including sociology. Family, Private Property, and the State (1884). Functionalist, conflict, and feminist theorists acknowledge that it is not Engels, a close associate of Karl Marx, argued that women’s subjugation possible to change gender roles drastically without making dramatic coincided with the rise of private property during industrialization. Only revisions in a culture’s social structure. Functionalists perceive the when people moved beyond an agrarian economy could males enjoy potential for social disorder, or at least unknown social consequences, the luxury of leisure and withhold rewards and privileges from women. if all aspects of traditional gender stratification are disturbed.Yet for Drawing on the work of Marx and Engels, contemporary feminist conflict and feminist theorists, no social structure is ultimately desirable theorists often view women’s subordination as part of the overall if it is maintained by oppressing a majority of citizens. These theorists exploitation and injustice that they see as inherent in capitalist societies. argue that gender stratification may be functional for men, who hold the Some radical feminist theorists, however, view the oppression of women power and privilege, but it is hardly in the interests of women.

Psychology.EliteCME.com Page 23 The interactionist approach While functionalists and conflict theorists who study gender stratification to minimize the contributions and ideas of members of the opposite typically focus on macro-level social forces and institutions, interactionist sex, and to validate their own contributions. These patterns reflect researchers tend to examine gender stratification on the micro level the conversational (and in a sense, political) dominance of males. of everyday behavior. As an example, studies have shown that men Moreover, even when women occupy a prestigious position, such as initiate up to 96 percent of all interruptions in cross-sex (male–female) that of physician, they are more likely to be interrupted than their male conversations. Men are more likely than women to change the topic of counterparts (Ridgeway & Smith-Lovin, 1999; Tannen, 1990; West & conversation, to ignore topics chosen by members of the opposite sex, Zimmerman, 1983).

Sexism and sex discrimination Just as African-Americans are victimized by racism, women suffer Sexual harassment is behavior that occurs when work benefits are from sexism in society. Sexism is the ideology that one sex is superior made contingent on sexual favors (as a quid pro quo), or when to the other. The term is generally used to refer to male prejudice and touching, lewd comments, or the exhibition of pornographic material discrimination against women. creates a “hostile environment” in the workplace. In 1998, the Institutional discrimination was defined as the denial of opportunities Supreme Court ruled that harassment applies to people of the same sex and equal rights to individuals and groups that results from the normal as well as the opposite. operations of a society. In the same sense, women suffer from both Sexual harassment must be understood in the context of continuing individual acts of sexism (such as sexist remarks and acts of violence) prejudice and discrimination against women. Whether it occurs in the and institutional sexism. federal bureaucracy, in the corporate world, or in universities, sexual American society is run primarily by male-dominated institutions (i.e., harassment generally takes place in organizations in which Caucasian government and armed forces), yet with the power that flows to men males are at the top of the hierarchy of authority, and women’s work comes responsibility and stress. Men have higher reported rates of is valued less than men’s. One survey of the private sector found that certain types of mental illness than women, and a greater likelihood of African-American women were three times more likely than Caucasian death due to heart attack or stroke. The pressure on men to succeed, women to experience sexual harassment. From a conflict perspective, and then to remain on top in the competitive world of work, can be it is not surprising that women are most likely to become victims of especially intense. That is not to suggest that gender stratification is as sexual harassment. In terms of job security, these groups are typically damaging to men as it is to women. But it is clear that the power and an organization’s most vulnerable employees (J. Jones, 1988). privilege men enjoy are no guarantee of personal well-being.

Age Understandably, all societies have some system of age stratification The aging process that associates certain social roles with distinct periods in life. Some Aging is one important aspect of socialization. It can be defined as the of this age differentiation seems inevitable; it would make little sense lifelong process through which an individual learns the cultural norms to send young children off to war, or to expect most older citizens and values of a particular society. There are no clear-cut definitions for to handle physically demanding tasks, such as loading freight at different periods of the aging cycle in the United States. shipyards. However, as is the case with stratification by gender, in Old age has typically been regarded as beginning at 65, which the United States, age stratification goes far beyond the physical corresponds to the retirement age for many workers, but not everyone constraints of human beings at different ages. in the United States accepts that definition. With the increase in life The model of five basic properties of a minority or subordinate group expectancy, writers are beginning to refer to people in their 60s as the can be applied to older people in the United States to clarify their “young old,” to distinguish them from those in their 80s and beyond (the subordinate status: “old old”). The particular problems of the elderly have become the focus 1. The elderly experience unequal treatment in employment, and may of a specialized field of research and inquiry known as gerontology. face prejudice and discrimination. Gerontology is the scientific study of the sociological and 2. The elderly share physical characteristics that distinguish them psychological aspects of aging and the problems of the aged. It from younger people. In addition, their cultural preferences and originated in the 1930s, as an increasing number of social scientists leisure-time activities often differ from those of the rest of society. became aware of the plight of the elderly. Gerontologists rely heavily 3. Membership in this disadvantaged group is involuntary. on sociological principles and theories to explain the impact of 4. Older people have a strong sense of group solidarity, as is reflected aging on the individual and society. They also draw on psychology, in the growth of senior citizens’ centers, retirement communities, anthropology, physical education, counseling, and medicine in their and advocacy organizations. study of the aging process. 5. Older people generally are married to others of comparable age. Two influential views of aging can best be understood in terms of There is one crucial difference between older people and other subordinate the sociological perspectives of functionalism and interactionism, groups, such as racial and ethnic minorities or women: People who respectively: live long enough will eventually assume the ascribed status of an older ●● Disengagement theory. person (Barron, 1953; Levin & Levin, 1980; Wagley & Harris, 1958). ●● Activity theory.

Disengagement theory After studying elderly people in good health and relatively comfortable their relationships. In keeping with the functionalist perspective, economic circumstances, Elaine Cumming and William Henry disengagement theory emphasizes that passing social roles on from (1961) introduced their disengagement theory, which implicitly one generation to another ensures social stability. suggests that society and aging individuals mutually sever many of

Page 24 Psychology.EliteCME.com According to this theory, the approach of death forces people to drop At the same time, society withdraws from the elderly by segregating most of their social roles, including those of worker, volunteer, spouse, them residentially (in retirement homes and communities), hobby enthusiast, and even reader. Younger members of society then educationally (in programs designed solely for senior citizens), and take on these functions. The aging person, it is held, withdraws into an recreationally (in senior citizens’ centers). increasing state of inactivity while preparing for death.

Activity theory Often seen as an opposing approach to disengagement theory, desire to perform various social roles that he or she had at age 40. Yet activity theory suggests that elderly people who remain active and they contend that old people have essentially the same need for social socially involved will be best adjusted. Proponents of this perspective interaction as any other group. acknowledge that a 70-year-old person may not have the ability or

FAMILY AND RELATIONSHIPS If people were to take information on what a family is from what they see Some cultures allow an individual to have several husbands or wives on television, they might come up with some very strange scenarios. The simultaneously. This form of marriage is known as polygamy. In fact, media doesn’t always present a realistic view of the family. Moreover, most societies throughout the world, past and present, have preferred many people still think of the family in very narrow terms: as a married polygamy to monogamy. Anthropologist George Murdock (1957) couple and their unmarried children living together, like the family in the sampled 565 societies and found that in more than 80 percent, some Cosby Show or Family Ties or even Dawson’s Creek. However, this is type of polygamy was the preferred form. While polygamy declined but one type of family, what sociologists refer to as a nuclear family. The steadily through most of the 20th century, in at least five countries in term nuclear family is well chosen, since this type of family serves as the Africa 20 percent of men still have polygamous marriages (Population nucleus, or core, on which larger family groups are built. Reference Bureau, 1996). Most people in the United States see the nuclear family as the There are two basic types of polygamy. preferred family arrangement. Yet by 2000, only about a third of Polygamy refers to the marriage of a man to more than one woman at the nation’s family households fit this model. The proportion of the same time. The wives are often sisters, who are expected to hold households in the United States composed of married couples with similar values and have already had experience sharing a household. children at home has decreased steadily over the last 40 years, and In polygynous societies, relatively few men actually have multiple is expected to continue shrinking. At the same time, the number of spouses. Most individuals live in monogamous families; having single-parent households has increased. multiple wives is viewed as a mark of status. A family in which relatives such as grandparents, aunts, or uncles reside The other principal variation of polygamy is polyandry, in which in the same home as parents and their children is known as an extended a woman can have more than one husband at the same time. Many family. Some utilize the term regardless of whether or not these people can trace their roots by looking at a family tree or by listening individuals all live under the same roof, but rather as a representation to elderly family members talk about their lives and about the lives of of the family members who play an active role in one another’s lives. ancestors who died long before they were born. Yet a person’s lineage The structure of the extended family offers certain advantages over that is more than simply a personal history; it also reflects societal patterns of the nuclear family. Crises such as death, divorce, and illness put less that govern descent. In every culture, children encounter relatives to strain on family members, since more people can provide assistance and whom they are expected to show an emotional attachment. emotional support. In addition, the extended family constitutes a larger economic unit than the nuclear family. The state of being related to others is called kinship. Kinship is culturally learned, however, and is not totally determined by biological If the family is engaged in a common enterprise, such as a farm or or marital ties. For example, adoption creates a kinship tie that is a small business, the additional family members may represent the legally acknowledged and socially accepted. difference between prosperity and failure. The family and the kin group are not necessarily one and the same. In considering these differing family types, people have limited Whereas the family is a household unit, kin do not always live together themselves to the form of marriage that is characteristic of the United or function as a collective body on a daily basis. Kin groups include States: monogamy. The term monogamy describes a form of marriage aunts, uncles, cousins, in-laws, and so forth. In a society such as the in which one woman and one man are married only to each other. United States, the kinship group may come together only rarely, for a Some observers, noting the high rate of divorce in the United States, wedding or funeral. However, kinship ties frequently create obligations have suggested that “serial monogamy” is a more accurate description and responsibilities. People may feel compelled to assist kin, as well as of the form that marriage takes in the United States. In serial call upon them for many types of aid, including loans and babysitting. monogamy, a person may have several spouses in his or her lifetime, but only one spouse at a time.

Sociology of marriage In the Judeo-Christian belief system, marriage is modeled after indentured servants to support themselves economically. The modern Adam and Eve’s lifetime commitment between man and woman. The “breadwinner-homemaker model,” argues Coontz, then has little married couple produces children, constituting the nuclear family. historical basis. Only in the 1950s did the myth of the happy, nuclear Some sociologists now dispute the degree to which this idealized family as the correct family structuration arise (Coontz, 1995). arrangement has and does reflect the true structure of families in Yet Coontz argues in Marriage, a History that during the 20th American society. century, marriages have become increasingly unstable in the United In her 1995 article “The American Family and the Nostalgia Trap,” States as individuals have begun to seek unions for the ideals of love sociologist Stephanie Coontz first posited that the American family and affection rather than social or economic expediency (Coontz, has always been defined first and foremost by its economic needs. 2005). This transition has blurred the division of labor within the For instance, in colonial times, families often relied on slaves or breadwinner-homemaker model, such that maintenance of the

Psychology.EliteCME.com Page 25 household and childcare, called the “second shift,” are now topics for economic foundations for marriage, women continue to do the bulk of debate between marital partners. care work to the detriment of the American family. Hochschild illustrates Sociologist Arlie Russell Hochschild argues in The Second Shift that the ways in which an unequal division of the second shift undermines despite changes in perceptions of the purpose of marriage and the family welfare by reducing marital equality and spousal satisfaction.

Divorce Divorce rates in Canada and the United States fluctuated in a similar 3. Women have become more independent: Now that women have pattern, though the United States still has the highest divorce rate equal rights and have proven over time that they have the potential in the world; which is 50 percent higher than Canada’s divorce rate and ability to support themselves, women find it much easier to (Macionis & Gerber, 2011). Many of today’s marriages end up in leave unhappy marriages. They are also more work focused, thus divorce, for many different reasons. The following are some of the giving them less time to cope with their relationship. most common causes: 4. Stress: Stress is a big factor in marriages. Working to support a 1. Individualism: In today’s society, families spend more time apart family while trying to stabilize finances is a big factor of stress. than they do together. Some individuals in a family focus so much Also, with both partners working (in most cases), it leaves less more on personal happiness and earning income to support their “family time” which makes raising children difficult. This often family that it consumes the time actually spent with their family. happens in the stage when couples are raising young children. 2. Feelings are no longer mutual: Many people end marriages 5. Socially acceptable: In today’s generation, divorce is now more because they are no longer satisfied by sexual needs or merely socially acceptable. Now, instead of discouraging a divorce in because they have lost feelings for one another. This often happens an unsatisfying relationship, it is more widely accepted and when one partner finds a more exciting relationship and chooses to sometimes even encouraged. Not only is it now more acceptable, move forward with that new relationship. In some cases, a partner but it is also easier to get a divorce legally than it was in previous may even commit adultery, which also may result in a divorce as a years according to the Divorce Act of 1968. partner discovers their partner being unfaithful to them.

Sociology of motherhood In many cultures, especially in a traditional Western one, a mother not contributing to the family income, but the lack of money that they is usually the wife in a married couple. Her role in the family is contribute is due to the time that is put into raising the children, which celebrated on Mother’s Day. Anna Reeves Jarvis was a woman who allows no time for the mother to go out and work. If the family is originally organized Mother’s Work Day’s protesting the lack of really struggling and the mother does have to go out and seek work, cleanliness and sanitation in the work place. Anna died in 1905 and she is also criticized. If the mother works, many people view her as her daughter created a National Mother’s Day to honor her mother. abandoning her children and not giving them the best life. Mothers frequently have a very important role in raising offspring, However, this limited role has increasingly been called into question. and the title can be given to a non-biological mother that fills this role. Both feminist and masculist authors have decried such predetermined This is common in stepmothers (female married to a biological father). roles as unjust. An emerging fathers’ rights movement seeks to increase In most family structures, the mother is both a biological parent and a the legal standing of fathers in everything from child-custody cases to primary caregiver. the institution of paid paternity leave or family leave. The European In East Asian and Western traditional families, fathers were the Working Time Directive allows parents to take 13 weeks of unpaid leave heads of the families, which meant that his duties included providing at any time in the first five years of a child’s life (Brogan, 2000). financial support and making critical decisions, some of which must Families are often influenced by the media portrayal of the way have been obeyed without question by the rest of the family members. women should run their families. In the book Media and Middle-Class Some Asian-American men are raised under stringent gender-role Moms by Descartes, women are often influenced by the social norms, expectations with a focus on group harmony and filial piety, carrying and it is often the reason as to why they believe staying home or on their family name and conforming to the expectations of the parents working is the right thing to do while having a family. (Liu, 2002). In the United States, 82.5 million women are mothers of all ages, while As with cultural concepts of family, the specifics of a mother’s role the national average age of first child births is 25.1 years. In 2008, 10 vary according to cultural mores. In what some sociologists term percent of births were to teenage girls, and 14 percent were to women the “bourgeois family,” which arose out of typical 16th- and 17th- ages 35 and older (Livingston, 2009). century European households and is often considered the “traditional Western” structure, the father’s role has been somewhat limited. In this In the United States, a study found that the average woman spends family model, the father acts as the economic support and sometimes five years working and building a career before having children, and disciplinarian of the family, while the mother or other female relative mothers working non-salary jobs began having children at age 27, oversees most of the childrearing. This structure is reflected, for compared to mothers with salary positions, who became pregnant at example, in societies that utilize “maternity leave” but do not have age 31. The study shows that the difference in age of child birth relates corresponding “paternity leave.” to education level, since the longer a woman has been in school, the older she will be when she enters the workforce. Other factors that Some often view mothers’ duties as raising and looking after their determine age of first child birth include infertility rates, when women children every minute of every day. Mothers are often criticized for meet their partners, and the age of marriage.

Sociology of fatherhood According to anthropologist Maurice Godelier, a critical novelty In many cultures, especially traditional Western ones, a father is in human society, compared to humans’ closest biological relatives usually the husband in a married couple. Many times, fathers play a (chimpanzees and bonobos), is the parental role assumed by the males, very important role in raising offspring and the title can be given to a which were unaware of their “father” connection (Goody, 2007). non-biological father that fills this role. This is common in stepfathers (males married to biological mothers). In East Asian and Western

Page 26 Psychology.EliteCME.com traditional families, fathers serve as the heads of the families, which critical decisions, some of which must be obeyed without question by means that their duties include providing financial support and making the rest of the family members.

Parenting Described as ‘the science of male parenting,’ the study of ‘father The words “Ma Ma” and “Mom,” usually regarded as terms of craft’ emerged principally in Britain and the USA (but also throughout endearment directed towards a mother figure, are generally one of the Europe) in the 1920s. “Male adjuncts to Maternity and Infant Welfare first words a child speaks. While “Da Da” or “Dad” often precedes it, Centers reacted to the maternal dominance in infant welfare and this does not reflect a stronger bond between the father and child than parenting in interwar Britain by arguing that fathers should play a that of the mother and child, it is merely simpler to pronounce than crucial role in the upbringing of children” Fisher (2009). Were such a “Mummy” or “Mum” which require greater control over the mouth study to be conducted into the science of female parenting, it would be muscles. Children tend to remember daddy more because, according to called mother craft. research, they are more exciting to the child (Golinkoff, 2003).

Leaders of the family Societies vary in the way that power is distributed within the family. A 2. Protection—In all cultures, the family assumes the ultimate society that expects males to dominate in all family decision-making responsibility for the protection and upbringing of children. is termed a patriarchy. In patriarchal societies, such as Iran, the eldest 3. Socialization—Parents and other kin monitor a child’s behavior and male often wields the greatest power, although wives are expected transmit the norms, values, and language of their culture to the child. to be treated with respect and kindness. A woman’s status in Iran is 4. Regulation of sexual behavior—Sexual norms are subject to typically defined by her relationship to a male relative, usually as a change both over time (for instance, in the customs for dating) wife or daughter. In many patriarchal societies, women find it more and across cultures (compare strict Saudi Arabia to the more difficult to obtain a divorce than a man does (Farr, 1999). permissive Denmark). However, whatever the time period or In contrast, in a matriarchy, women have greater authority than men. cultural values of a society, standards of sexual behavior are most Matriarchies, which are very uncommon, emerged among Native clearly defined within the family circle. American tribal societies and in nations in which men were absent for 5. Affection and companionship—Ideally, the family provides long periods because of warfare or food gathering expeditions. members with warm and intimate relationships, helping them to feel satisfied and secure. Of course, a family member may find In a third type of authority pattern, the egalitarian family, spouses are such rewards outside the family from peers, in school, at work, and regarded as equals. That does not mean, however, that all decisions are may even perceive the home as an unpleasant or abusive setting. shared in such families. Wives may hold authority in some spheres, Nevertheless, people expect relatives to understand them, to care husbands in others. Many sociologists believe the egalitarian family for them, and to be there when needed. has begun to replace the patriarchal family as the social norm in the 6. Provision of social status—People inherit a social position United States. because of the family background and reputation of their parents According to a functionalist view, the family performs six paramount and siblings. The family presents the newborn child with an functions which sociologist William F. Ogburn first outlines (Ogburn ascribed status based on race and ethnicity that helps to determine & Tibbits, 1934): his or her place within society’s stratification system. Moreover, 1. Reproduction—For a society to maintain itself, it must replace family resources affect children’s ability to pursue certain dying members. In this sense, the family contributes to human opportunities, such as higher education. survival through its function of reproduction. RELIGION Sociology of religion is the study of the beliefs, practices and religion may also encompass the sociology of irreligion (for instance, organizational forms of religion using the tools and methods of the in the analysis of secular humanist belief systems). discipline of sociology. This objective investigation may include Sociology of religion is distinguished from the philosophy of religion the use of both quantitative methods (surveys, polls, demographic, in that it does not set out to assess the validity of religious beliefs. and census analysis) and qualitative approaches such as participant The process of comparing multiple conflicting dogmas may require observation; interviewing; and analysis of archival, historical, and what Peter L. Berger has described as inherent “methodological documentary materials (Berger, 1967). atheism.” Whereas the sociology of religion broadly differs from Modern academic sociology began with the analysis of religion in Émile theology in assuming indifference to the supernatural, theorists tend to Durkheim’s 1897 study of suicide rates among Catholic and Protestant acknowledge socio-cultural reification of religious practice. populations, a foundational work of social research which served Classical, seminal sociological theorists of the late 19th and early 20th to distinguish sociology from other disciplines, such as psychology. century such as Durkheim, Weber, and Marx were greatly interested The works of Karl Marx and Max Weber emphasized the relationship in religion and its effects on society. Like those of Plato and Aristotle between religion and the economic or social structure of society. from ancient Greece, and Enlightenment philosophers from the 17th Contemporary debates have centered on issues such as secularization, through 19th centuries, the ideas posited by these sociologists continue civil religion, and the cohesiveness of religion in the context of to be examined today. globalization and multiculturalism. The contemporary sociology of

View of religion in classical sociology Durkheim, Marx, and Weber had very complex and developed theories Karl Marx about the nature and effects of religion. Of these, Durkheim and Weber Despite his later influence, Karl Marx did not view his work as an are often more difficult to understand, especially in light of the lack of ethical or ideological response to 19th-century capitalism (as most context and examples in their primary texts. Religion was considered later commentators have). His efforts were, in his mind, based to be an extremely important social variable in the work of all three. solely on what can be called applied science. Marx saw himself as

Psychology.EliteCME.com Page 27 participating in morally neutral sociology and economic theory for the to sacred things, that is to say, things set apart and forbidden beliefs sake of human development. and practices which unite into one single moral community called a As such, the crux of his arguments was that humans are best guided Church, all those who adhere to them.” This is a functional definition by reason. Religion, Marx held, was a significant hindrance to reason, of religion, meaning that it explains what religion does in social life: inherently masking the truth and misguiding followers (McKinnon, essentially, it unites societies. Durkheim defined religion as a clear 2010). As discussed later, Marx viewed social alienation as the heart of distinction between the sacred and the profane, in effect this can be social inequality. The antithesis to this alienation is freedom. Thus, to paralleled with the distinction between God and humans. propagate freedom means to present individuals with the truth and give This definition also does not stipulate what exactly may be considered them a choice to accept or deny it. sacred. Thus, later sociologists of religion (notably Robert Bellah) have Central to Marx’s theories was the oppressive economic situation in extended Durkheimian insights to talk about notions of civil religion, which he dwelt. With the rise of European industrialism, Marx and his or the religion of a state. American civil religion, for example, might colleague Friedrich Engels witnessed and responded to the growth of be said to have its own set of sacred “things”: the Flag of the United what he called “surplus value.” Marx’s view of capitalism saw rich States, Abraham Lincoln, Martin Luther King Jr., etc. Other sociologists capitalists getting richer and their workers getting poorer (the gap, the have taken Durkheim’s concept of what religion is in the direction of the exploitation, was the “surplus value”). Not only were workers getting religion of professional sports, the military, or of rock music. exploited, but in the process they were being further detached from the Max Weber products they helped create. Max Weber published four major texts on religion in a context of By simply selling their work for wages, workers simultaneously lose economic sociology and his rationalization thesis: The Protestant connection with the object of labor and become objects themselves. Ethic and the Spirit of Capitalism (1905), The Religion of China: According to capitalism views, workers are devalued to the level of Confucianism and Taoism (1915), The Religion of India: The Sociology a commodity. From this objectification comes alienation. Common of Hinduism and Buddhism (1915), and Ancient Judaism (1920). workers are led to believe that they are a replaceable tool, and they In his sociology, Weber uses the German term “Verstehen” to describe are alienated to the point of extreme discontent. Here, in Marx’s eyes, his method of interpretation of the intention and context of human religion enters. Capitalism utilizes people’s tendency towards religion action. Weber is not a positivist in the sense that he does not believe as a tool or ideological state apparatus to justify this alienation. people can find out “facts” in sociology that can be causally linked. Christianity teaches that those who gather up riches and power in Although he believes some generalized statements about social life can this life will almost certainly not be rewarded in the next, while those be made, he was not interested in hard positivist claims, but instead in who suffer oppression and poverty in this life, while cultivating linkages and sequences, in historical narratives and particular cases. their spiritual wealth, will be rewarded in the Kingdom of God. This Weber argues for making sense of religious action on its own terms. influenced Marx’s famous line, “religion is the opium of the people,” A religious group or individual is influenced by all kinds of things, as it soothes them and dulls their senses to the pain of oppression. he says, but if they claim to be acting in the name of religion, people Émile Durkheim should attempt to understand their perspective on religious grounds Émile Durkheim placed himself in the positivist tradition, meaning that first. Weber gives religion credit for shaping people’s image of the he thought of his study of society as dispassionate and scientific. He was world, and this image of the world can affect their view of their deeply interested in the problem of what held complex modern societies interests, and ultimately, how they decide to take action. together. Religion, he argued, was an expression of social cohesion. For Weber, religion is best understood as it responds to the human need In the fieldwork that led to his famousElementary Forms of Religious for theodicy and soteriology. Human beings are troubled, he says, with Life, Durkheim, a secular Frenchman, looked at anthropological data the question of theodicy; the question of how the extraordinary power of of Indigenous Australians. His underlying interest was to understand a divine god may be reconciled with the imperfection of the world that he the basic forms of religious life for all societies. In Elementary Forms, has created and rules over. People need to know, for example, why there is Durkheim argues that the totems the Aborigines venerate are actually undeserved good fortune and suffering in the world. Religion offers people expressions of their own conceptions of society itself. This is true not soteriological answers, or answers that provide opportunities for salvation; only for the Aborigines, he argues, but for all societies. relief from suffering, and reassuring meaning. The pursuit of salvation, like the pursuit of wealth, becomes a part of human motivation. Religion, for Durkheim, is not “imaginary,” although he does deprive it of what many believers find essential. Religion is very real; it is an Because religion helps to define motivation, Weber believed that expression of society itself, and indeed, there is no society that does religion (and specifically Calvinism) actually helped to give rise to not have religion. People perceive a force greater than themselves modern capitalism, as he asserted in his most famous and controversial and give that perception a supernatural face. People then express work, The Protestant Ethic and the Spirit of Capitalism. themselves religiously in groups, which for Durkheim makes the In The Protestant Ethic, Weber argued that capitalism arose in Europe symbolic power greater. Religion is an expression of the collective in part because of how the belief in predestination was interpreted consciousness, which is the fusion of individual consciousness, which by everyday English Puritans. Puritan theology was based on the then creates a reality of its own. Calvinist notion that not everyone would be saved; there was only a It follows, then, that less complex societies, such as the Australian specific number of the elect who would avoid damnation, and this was Aborigines, have less complex religious systems, involving totems based solely on God’s predetermined will and not on any action one associated with particular clans. The more complex a particular society, could perform in this life. Official doctrine held that one could not ever the more complex the religious system is. As societies come in contact really know whether one was among the elect. with other societies, there is a tendency for religious systems to emphasize Practically, Weber noted, this was difficult psychologically: people were universalism to a greater and greater extent. However, as the division of anxious to know whether they would be eternally damned or not. Thus, labor makes the individual seem more important (a subject that Durkheim Puritan leaders began assuring members that if they began doing well treats extensively in his famous Division of Labor in Society), religious financially in their businesses, this would be one unofficial sign they systems increasingly focus on individual salvation and conscience. had God’s approval and were among the saved – but only if they used Durkheim’s definition of religion, fromElementary Forms, is as the fruits of their labor well. This, along with the rationalism implied by follows: “A religion is a unified system of beliefs and practices relative monotheism, led to the development of rational bookkeeping and the

Page 28 Psychology.EliteCME.com calculated pursuit of financial success beyond what one needed simply In his magnum opus Economy and Society Weber distinguished three to live, and this is the “spirit” of capitalism (Zaleski, 2010). Over time, ideal types of religious attitudes: the habits associated with the spirit of capitalism lost their religious 1. World-flying mysticism. significance, and rational pursuit of profit became its own aim. 2. World-rejecting asceticism. The Protestant Ethic thesis has been much critiqued, refined, and 3. Inner-worldly asceticism. disputed, but is still a lively source of theoretical debate in sociology He also separated magic as pre-religious activity. of religion. Weber also did considerable work in world religions, including Hinduism and Buddhism.

Typology of religious groups One common typology among sociologists, religious groups are One study also notes that it is the more secular, pro-evolution societies classified as ecclesias, denominations, sects, or cults (now more that come close to “cultures of life.” The authors conclude that the commonly referred to in scholarship as New Religious Movements). reasonable success of non-religious democracies like Japan, France, Note that sociologists give these words precise definitions that differ and Scandinavia has refuted the idea that godless societies suffer from how they are commonly used. In particular, sociologists use the disaster. They added that contradicting these conclusions requires words ‘cult’ and ‘sect’ without negative connotations, even though the demonstrating a positive link between theism and societal conditions popular use of these words is often pejorative. in the first world with a similarly large body of data; a doubtful In prosperous democracies, higher rates of belief in and worship of possibility in view of the observable trends (Law, 2007). a creator correlate with higher rates of homicide, juvenile and early BBC news reported on a study that attempted to use mathematical adult mortality, STD infection rates, teen pregnancy, and abortion. The modeling (nonlinear dynamics) to predict future religious orientations United States is almost always the most dysfunctional of the developed of populations. (BBC News, 2009) The study suggests that religion is democracies, sometimes spectacularly so...The view of the U.S. as a headed towards ‘extinction’ in various nations where it has been on the “shining city on the hill” to the rest of the world is falsified when it decline: Australia, Austria, Canada, the Czech Republic, Finland, Ireland, comes to basic measures of societal health. the Netherlands, New Zealand and Switzerland. The model considers not only the changing number of people with certain beliefs, but also attempts to assign utility values of a belief as per each nation (Davie, 2003).

Secularization and civil religion In relation to the processes of rationalization associated with the Arguments may be presented regarding the concept of civil religion development of modernity, it was predicted in the works of many and new world belief systems. In short, presupposed secularization classical sociologists that religion would decline (Davie, 2003). as a decline in religiosity might seem to be a myth, depending on Despite the claims of many classical theorists and sociologists its definition and the definition of its scope. For instance, some immediately after World War II, many contemporary theorists have sociologists have argued that steady church attendance and personal critiqued secularization thesis, arguing that religion has continued to religious belief may coexist with a decline in the influence of religious play a vital role in the lives of individuals worldwide. authorities on social or political issues. In the United States in particular, church attendance has remained Additionally, the regular attendance or affiliation does not necessarily relatively stable in the past 40 years. In Africa, the emergence of translate into a behavior, according to their doctrinal teachings. In Christianity has occurred at a high rate. While Africa could claim roughly other words, there might be still a growing in numbers of members, 10 million Christians in 1900, recent estimates put that number closer to but it does not mean that all members are faithfully following the rules 200 million. The rise of Islam as a major world religion, especially its of pious behaviors expected. In that sense, religion may be seen as new-found influence in the West, is another significant development. declining because of its waning ability to influence behavior.

Religion as related to globalization The sociology of religion continues to grow throughout the world as back the advancement of religion. The main difference between different cultures take on different types of religion. The two main these theories is whether they view capitalism as a friend or foe. As theories of globalization are modernization development, which is a technology advanced, many different cultures started to look into functionalist derivative, and exploitation which is a Marxist derivative. different religions and incorporate different beliefs into society. Both of these theories came from the idea that prejudices were holding

POLITICAL SOCIOLOGY Contemporary political sociology involves, but is not limited to, the 2. How social inequality between groups (class, race, gender, etc.) study of the relations between state and society. In this field, a typical influences politics. research question in political sociology might have been: “Why do 3. How public personalities, social movements and trends outside of so few American citizens choose to vote?” (Piven, 1988) or “What the formal institutions of political power affect formal politics. difference does it make if women get elected?” Political sociologists 4. Power relationships within and between social groups (e.g. also now ask: “How is the body a site of power?” How are emotions families, workplaces, bureaucracy, media, etc.). relevant to global poverty?”, and “What difference does knowledge In other words, political sociology was traditionally concerned with how make to democracy?” social trends, dynamics, and structures of domination affect formal political The opening up of political sociology does not mean that old topics have processes, as well as exploring how various social forces work together to been discarded. Traditionally, there were four main areas of research: change political policies. From this perspective, professionals can identify 1. The socio-political formation of the modern state. three major theoretical frameworks: pluralism, elite or managerial theory, and class analysis (which overlaps with Marxist analysis).

Psychology.EliteCME.com Page 29 Pluralism sees politics primarily as a contest among competing interest Contemporary political sociology takes these questions seriously, but groups. Elite or managerial theory is sometimes called a state-centered it is concerned with the play of power and politics across societies, approach. It explains what the state does by looking at constraints which includes, but is not restricted to, relations between the state and from organizational structure, semi-autonomous state managers, and society. In part, this is a product of the growing complexity of social interests that arise from the state as a unique, power concentrating relations, the impact of social movement organizing, and the relative organization. A leading representative is Theda Skocpol. Social weakening of the state as a result of globalization. class theory analysis emphasizes the political power of capitalist In large part, however, it is due to the radical rethinking of social theory. elites. It can be split into two parts. One is the “power structure” or This is as much focused now on micro questions (such as the formation “instrumentalist” approach, another is the structuralist approach. The of identity through social interaction, the politics of knowledge, and the power structure approach focuses on “Who Rules?” and its most effects of the contestation of meaning on structures), as it is on macro well-known representative is G. William Domhoff. The structuralist questions (such as how to capture and use state power). Chief influences approach emphasizes on the way a capitalist economy operates; only here include cultural studies (Stuart Hall), post-structuralism (Michel allowing and encouraging the state to do some things but not others. Foucault, Judith Butler), pragmatism (Luc Boltanski), structuration theory (Anthony Giddens), and cultural sociology (Jeffrey C. Alexander).

EDUCATION The sociology of education is the study of how public institutions and A systematic sociology of education began with Émile Durkheim’s individual experiences affect education and its outcomes. It is most work on moral education as a basis for organic solidarity and that concerned with the public schooling systems of modern industrial by Max Weber, on the Chinese literati as an instrument of political societies, including the expansion of higher, further, adult, and control. It was after World War II, however, that the subject received continuing education. renewed interest around the world: from technological functionalism Education has often been seen as a fundamentally optimistic human in the US, egalitarian reform of opportunity in Europe, and human- endeavor characterized by aspirations for progress and betterment. capital theory in economics. It is understood by many to be a means of overcoming handicaps, These all implied that with industrialization, the need for a technologically achieving greater equality and acquiring wealth and social status. skilled labor force undermines class distinctions and other systems of Educational institutions are perceived as a place where children stratification, and that education promotes social mobility. However, can develop according to their unique needs and potential. It is also statistical and field research across numerous societies showed a persistent perceived as one of the best means of achieving greater social equality. link between an individual’s social class and achievement, and suggested Many would say that the purpose of education should be to develop that education could only achieve limited social mobility. every individual to their full potential and give them a chance to Sociological studies showed how schooling patterns reflected, rather achieve as much in life as their natural abilities allow (meritocracy). than challenged, class stratification and racial and sexual discrimination. Few would argue that any education system accomplishes this goal After the general collapse of functionalism from the late 1960s onwards, perfectly. Some take a particularly negative view, arguing that the the idea of education as an unmitigated good was even more profoundly education system is designed with the intention of causing the social challenged. Neo-Marxists argued that school education simply produced reproduction of inequality. a docile labor-force essential to late-capitalist class relations.

Theoretical perspectives The sociology of education contains a number of theories. Some of the The Politics of Education Association at Florida State University and main theories are presented below. the Center for Policy Research at New Delhi are bright examples Political arithmetic where a number of studies carried out on the social policy. India, The Political Arithmetic tradition within the sociology of education though popular being the largest democracy of the world, political began with Hogben (1938) and denotes a tradition of politically critical arithmetic has paralyzed the entire education system. Equity and quantitative research dealing with social inequalities, especially those equality continue to grow in Indian context; educated Indian society is generated by social stratification (Heath, 2000). Important works in more stratified than ever before. this tradition have been Glass, 1954; Floud et al., 1956; and Halsey et It is not the wrong approaches that are being employed to examine al., 1980. All of these works were concerned with the way in which the political arithmetic in sociology of Indian education rather the school structures were implicated in social class inequalities in Britain. diversities within the nation is the major concern. Political parties use More recent work in this tradition has broadened its focus to include public votes as the simplest and cheapest means for their survival. gender, ethnic differentials, and international differences. Political arithmetic in India has never allowed for education to be While researchers in this tradition have engaged with sociological defined the way it ought to be. The ex-prime minister of India and the theories such as Rational Choice Theory and Cultural Reproduction former Union Minister of HRD, Mr. P.V. Narasimharao’s authored Theory, the political arithmetic tradition has remained rather skeptical book, Politics of Education (1967) illustrates the political arithmetic of of ‘grand theory’ and very much concerned with empirical evidence Indian education system. and social policy. The political arithmetic tradition was attacked by the Structural functionalism ‘New Sociology of Education’ of the 1970s which rejected quantitative Structural functionalists believe that society leans towards social research methods. This heralded a period of methodological division equilibrium and social order. They see society like a human body, in within the sociology of education. However, the political arithmetic which institutions such as education are like important organs that tradition, while rooted in quantitative methods, has increasingly keep the society/body healthy and well. engaged with mixed methods approaches. Social health means the same as social order, and it is guaranteed when Political arithmetic is the philosophical insights that govern the nearly everyone accepts the general moral values of their society. pluralistic society like India. Politics of Education has emerged as one Hence, structural functionalists believe the aim of key institutions, of potential human knowledge where politics play significant role in such as education, is to socialize children and teenagers. Socialization social inequalities and stratifications. is the process by which the new generation learns the knowledge,

Page 30 Psychology.EliteCME.com attitudes, and values that they will need to become productive citizens. powerful, indoctrination of the norms and values of the wider society. Although this aim is stated in the formal curriculum, it is mainly Students learn these values because their behavior at school is achieved through the hidden curriculum, a subtler, but nonetheless regulated until they gradually internalize and accept them.

Filling roles in society Education must also perform another function: As various jobs become because the middle class cultural experiences received at school may vacant, they must be filled with the appropriate people. Therefore be contrary to the experiences working-class children receive at home. the other purpose of education is to sort and rank individuals for In other words, working-class children are not adequately prepared placement in the labor market (Munro, 1997). Those with high to cope at school. They are therefore “cooled out” from school with achievement will be trained for the most important jobs and in reward, the least qualifications; hence, they get the least desirable jobs, and receive the highest incomes. Those who achieve the least, will be so remain working class. Sargent confirms this cycle, arguing that given the least demanding (intellectually at any rate, if not physically) schooling supports continuity, which in turn supports social order. jobs, and hence the least income. Talcott Parsons believed that this process, whereby some students were According to Sennet and Cobb however, “to believe that ability identified and labeled educational failures, “was a necessary activity alone decides who is rewarded is to be deceived.” Meighan agrees, which one part of the social system, education, performed for the stating that large numbers of capable students from working-class whole.” Yet the structural functionalist perspective maintains that this backgrounds fail to achieve satisfactory standards in school, and, social order, this continuity, is what most people desire. therefore, fail to obtain the status they deserve. Jacob believes this is

Education and social reproduction Social reproduction according to Doob, “refers to the emphasis on of such domestic labor often make it difficult for them to find time to do the structures and activities that transmit social inequality from one all their homework and thus affects their academic performance. generation to the next.” Four types of capital contribute to social While teachers have softened the formality of regular study and reproduction in society: integrated student’s preferred working methods into the curriculum, ●● Financial. they noted that particular students displayed strengths they had ●● Capital. not been aware of before. However, few teachers deviate from the ●● Cultural capital. traditional curriculum, and the curriculum conveys what constitutes ●● Human capital. knowledge as determined by the state and those in power. ●● Social capital. This knowledge isn’t very meaningful to many of the students, who see it Four types of capital as pointless. Wilson & Wyn state that the students realize there is little or Financial capital refers to the income and wealth of a person. Financial no direct link between the subjects they are studying and their perceived capital will influence the cultural capital one receives. Cultural capital future in the labor market. Anti-school values displayed by these children is the shared outlook, beliefs, knowledge, and skills passed between often derive from their consciousness of their real interests. Sargent generations. Cultural capital influences human capital, which refers to believes that for working-class students, striving to succeed and absorbing the education and job training a person receives. Human capital creates the school’s middle class values is accepting their inferior social position the ability for one to attain social capital, which is essentially the social as much as if they were determined to fail (Wirth, 1938). network to which one belongs. Social capital can largely influence one’s ability to find an internship or job. The federal government subsidies ‘independent’ private schools, enabling the rich to obtain ‘good education’ by paying for it. Children All four forms of capital play a role in social reproduction, because who receive this ‘good education’ perform better, achieve higher, and capital is passed from generation to generation and keeps people in the obtain greater rewards. In this way, the continuation of privilege and same social class as their parents before them. This keeps reproducing wealth for the elite is made possible in continuum. inequality through the system of social stratification (Trepl, 1996). Conflict theorists believe this social reproduction continues to occur The perspective of conflict theory, contrary to the structural because the whole education system is overlain with ideology provided functionalist perspective, believes that society is full of vying social by the dominant group. In effect, they perpetuate the myth that education groups with different aspirations, different access to life chances and is available to all to provide a means of achieving wealth and status. gain different social rewards. The duplicity is so successful that many parents endure appalling jobs Relations in society, in this view, are mainly based on exploitation, for many years, believing that this sacrifice will enable their children oppression, domination, and subordination. Many teachers assume that to have opportunities in life that they did not have themselves. Some students will have particular middle class experiences at home, and for may argue that people who are poor and disadvantaged are victims of some children this assumption isn’t necessarily true. Some children a societal confidence trick, believing that they have been encouraged are expected to help their parents after school and carry considerable to think that a major goal of schooling is to strengthen equality while, domestic responsibilities in their often single-parent home. The demands in reality, schools reflect society’s intention to maintain the previous unequal distribution of status and power.

URBAN AND RURAL SOCIOLOGY Urban sociology Urban sociology is the sociological study of life and human interaction In other words, it is the sociological study of cities and their role in the in metropolitan areas. It is a normative discipline of sociology seeking development of society (Martin, 2009). to study the structures, processes, changes, and problems of an urban Like most areas of sociology, urban sociologists use statistical area, and by doing so, provide inputs for planning and policy making. analysis, observation, social theory, interviews, and other methods to

Psychology.EliteCME.com Page 31 study a range of topics, including migration and demographic trends, transmission of immigrants’ native culture roles and norms into new economics, poverty, race relations, and economic trends. and developing environments. Political participation and the rise in The philosophical foundations of modern urban sociology originate inter-community organizations were also frequently covered in this from the work of sociologists such as Karl Marx, Ferdinand Tönnies, period, with many metropolitan areas adopting census techniques Émile Durkheim, Max Weber, and Georg Simmel who studied and that allowed for information to be stored and easily accessed by theorized the economic, social and cultural processes of urbanization participating institutions such as the University of Chicago. and its effects on social alienation, class formation, and the production Park, Burgess, and McKenzie, professors at the University of Chicago or destruction of collective and individual identities. and three of the earliest proponents of urban sociology, developed the These theoretical foundations were further expanded upon and Subculture Theories, which helped to explain the often-positive role of analyzed by a group of sociologists and researchers who worked at local institutions on the formation of community acceptance and social the University of Chicago in the early 20th century. In what became ties (Wellman, 1979). When race relations break down and expansion known as the Chicago School of Sociology, the work of Robert renders one’s community members anonymous, as was proposed to be Park, Louis Wirth, and Ernest Burgess on the inner city of Chicago occurring in this period, the inner city becomes marked by high levels revolutionized the purpose of urban research in sociology but also of social disorganization that prevent local ties from being established the development of human geography through its use of quantitative and maintained in local political arenas. and ethnographic research methods. The importance of the theories The rise of urban sociology coincided with the expansion of statistical developed by the Chicago School within urban sociology have been inference in the behavioral sciences, which helped ease its transition critically sustained and critiqued but still remain one of the most and acceptance in educational institutions along with other burgeoning significant historical advancements in understanding urbanization and social sciences. Micro-sociology courses at the University of Chicago the city within the social sciences (Flanagan, 1993). were among the earliest and most prominent courses on urban As just discussed, urban sociology rose to prominence within the sociological research in the United States. academy in North America through a group of sociologists and The evolution and transition of sociological theory from the Chicago theorists at the University of Chicago from 1915 to 1940, known School began to emerge in the 1970s with the publication of Claude as Chicago School of Sociology. The Chicago School of Sociology Fischer’s (1975) “Toward a Theory of Subculture Urbanism” which combined sociological and anthropological theory with ethnographic incorporated Bourdieu’s theories on social capital and symbolic fieldwork in order to understand how individuals interact within capital within the invasion and succession framework of the Chicago urban social systems (Wirth, 1938; Trepl, 1996). Unlike the primarily School in explaining how cultural groups form, expand, and solidify a macro-based sociology that had marked earlier subfields, members neighborhood. of the Chicago School placed greater emphasis on micro-scale social The theme of transition by subcultures and groups within the city interactions that sought to provide subjective meaning to how humans was further expanded by Barry Wellman’s article (1979) “The interact under structural, cultural, and social conditions. Community Question: The Intimate Networks of East Yorkers,” which The theory of symbolic interaction, the basis through which many determined the function and position of the individual, institution, methodologically ground-breaking ethnographies were framed in this and community in the urban landscape in relation to their community. period, took primitive shape alongside urban sociology and shaped its Wellman categorized and incorporated community-focused theories early methodological leanings. Symbolic interaction was forged out of as community lost, community saved, and community Liberated. the writings of early micro-sociologists George Mead and Max Weber, These theories centered around the structure of the urban community and sought to frame how individuals interpret symbols in everyday in shaping interactions between individuals and facilitating active interactions. With early urban sociologists framing the city as a ‘super- participation in the local community. organism,’ the concept of symbolic interaction aided in parsing out Community lost how individual communities contribute to the seamless functioning of The earliest of the three theories, this concept was developed in the the city itself (Burgess, 1925). late 19th century to account for the rapid development of industrial Scholars of the Chicago School originally sought to answer a single patterns that seemingly caused rifts between the individual and their question: how did an increase in urbanism during the time of the local community. Urbanites were said to hold networks that were Industrial Revolution contribute to the magnification of contemporary “impersonal, transitory, and segmental,” maintaining ties in multiple social problems? Sociologists centered on Chicago due to its ‘tabula social networks while at the same time lacking the strong ties that rasa’ state, having expanded from a small town of 10,000 in 1860 to an bound them to any specific group. This disorganization in turn caused urban metropolis of over two million in the next half-century. Along members of urban communities to subsist almost solely on secondary with this expansion came many of the era’s emerging social problems, affiliations with others, and rarely allowed them to rely on other ranging from issues with concentrated homelessness and harsh living members of the community for assistance with their needs. conditions to the low wages and long hours that characterized the work Community saved of the many newly-arrived European immigrants. A critical response to the community lost theory that developed Unlike many other metropolitan areas, Chicago did not expand outward during the 1960s, the community saved argument suggests that at the edges as predicted by early expansionist theorists, but instead multi-stranded ties often emerge in sparsely knit communities as time ‘reformatted’ the space available in a concentric ring pattern (Sassen, goes on, and that urban communities often possess these strong ties, 2000). As with many modern cities, the business district occupied the city albeit in different forms. Especially among low-income communities, center and was surrounded by slum and blighted neighborhoods, which individuals have a tendency to adapt to their environment and pool were further surrounded by working men’s’ homes and the early forms of resources in order to protect themselves collectively against structural the modern suburbs. Urban theorists suggested that these spatially distinct changes. Over time, urban communities have tendencies to become regions helped to solidify and isolate class relations within the modern “urban villages,” where individuals possess strong ties with only a few city, moving the middle class away from the urban core and into the individuals that connect them to an intricate web of other urbanities privatized environment of the outer suburbs (Park, 1984). within the same local environment. Due to the high concentration of first-generation immigrant families Community liberated in the inner city of Chicago during the early 20th century, many A cross-section of the community lost and community saved prominent early studies in urban sociology focused upon the arguments, the community liberated theory suggests that the separation

Page 32 Psychology.EliteCME.com of workplace, residence, and familial kinship groups has caused However, as theories surrounding social networks have developed, urbanites to maintain weak ties in multiple community groups that are sociologists such as Alejandro Portes and the Wisconsin model of further weakened by high rates of residential mobility. However, the sociological research began placing increased leverage on the importance concentrated number of environments present in the city for interaction of these weak ties (Oliver, 2001). While strong ties are necessary for increase the likelihood of individuals developing secondary ties, even providing residents with primary services and a sense of community, weak if they simultaneously maintain distance from tightly knit communities. ties bring together elements of different cultural and economic landscapes Primary ties that offer the individual assistance in everyday life form out in solving problems that affect a large number of individuals. As theorist of sparsely knit and spatially dispersed interactions, with the individual’s Eric Oliver notes, neighborhoods with vast social networks are also access to resources dependent on the quality of the ties they maintain those that most commonly rely on heterogeneous support in problem within their community (Granovetter, 1973). solving, and are also the most politically active (Smith, 1996). Along with the development of these theories, urban sociologists have As the suburban landscape developed during the 20th century and the increasingly begun to study the differences between the urban, rural, outer city became a refuge for the wealthy and, later, the burgeoning and suburban environment within the last half-century. Consistent middle class, sociologists and urban geographers such as Harvey with the community liberated argument, researchers have in large part Molotch, David Harvey, and Neil Smith began to study the structure found that urban residents tend to maintain more spatially dispersed and revitalization of the most impoverished areas of the inner city. networks of ties than rural or suburban residents. Among lower-income In their research, impoverished neighborhoods, which often rely on urban residents, the lack of mobility and communal space within tightly knit local ties for economic and social support, were found to the city often disrupts the formation of social ties and lends itself to be targeted by developers for gentrification which displaced residents creating an unintegrated and distant community space. living within these communities (Harvey, 1989). While the high density of networks within the city weakens relations Political experimentation in providing these residents with semi- between individuals, it increases the likelihood that at least one permanent housing and structural support ranging from Section 8 individual within a network can provide the primary support found housing to Community Development Block Grant programs have, in among smaller and more tightly knit networks. Since the 1970s, many cases, eased the transition of low-income residents into stable research into social networks has focused primarily on the types of ties housing and employment. Yet research covering the social impact of developed within residential environments. forced movement among these residents has noted the difficulties that Bonding ties, common of tightly knit neighborhoods, consist of individuals often have with maintaining a level of economic comfort, connections that provide an individual with primary support, such which is spurred by rising land values and inter-urban competition as access to income or upward mobility among a neighborhood between cities as a means to attract capital investment (Molotch, 1976; organization. Bridging ties, in contrast, are the ties that weakly connect Carter, 2001). The interaction between inner-city dwellers and middle- strong networks of individuals together. A group of communities class passersby in such settings has also been a topic of study for urban concerned about the placement of a nearby highway may only be sociologists (Dromi, 2012). connected through a few individuals that represent their views at a community board meeting, for instance (Portes & Sensenbrenner, 1993).

Rural sociology Rural sociology is a field of sociology associated with the study of The Second Morrill Act of 1890 created 17 historically African- social life in rural areas. It is an active field in much of the world, American land-grant colleges, and in 1994, 29 Native-American and in the United States originated in the 1910s with close ties to the tribal colleges were given land-grant status. Today, 105 land-grant national Department of Agriculture and land-grant university colleges institutions award one-third of all U.S. bachelor’s degrees and of agriculture. 60 percent of all doctorates (Jischke, 2004). This mix of public The sociology of food and agriculture is one focus of rural sociology, and infrastructure is important not only in how rural sociology emerged but much of the field is dedicated to the economics of farm production. Other also in how it operates as a field of study and profession today. areas of study include rural migration and other demographic patterns, Rural sociology was born into this era of concern with farm families environmental sociology, amenity-led development, public lands policies, and a federal goal of stemming rural out-migration. Its origins are so-called “boomtown” development, social disruption, the sociology of usually traced to the creation of the County Life Commission in natural resources (including forests, mining, fishing, and other areas), rural 1908 by President Theodore Roosevelt (Bertrand, 1982; Hooks & cultures and identities, rural health care, and educational policies. Many Flinn, 1981). The commission launched a nationwide investigation rural sociologists work in the areas of development studies, community documenting the difficulties faced by farm families. It conducted studies, community development, and in environmental studies. Much of surveys of farm families and compiled other information, leading to a the research involves the Third World. report that formed the basis for subsequent national policy. The roots of rural sociology firmly tie to U.S. historical events and The commission downplayed structural determinants of farmers’ policy interventions. As Bertrand (1982) notes, rural sociology has hardships (Hooks & Flinn, 1981). Instead, it focused on individuals’ the distinction of being a truly American invention. The institutional human capital, cultural values, and weaknesses of rural schools and infrastructure for establishing rural sociology was formed with the churches. Upgrading rural people’s presumed social deficits was thus Morrill Land-Grant Act, signed by President Lincoln in 1862. The act emphasized over addressing fundamental inequalities in power and set aside federal land in each state for building public colleges for the economic resources. study of “agriculture and the mechanical arts,” in order to extend the In the wake of this widespread public attention, sociologists university system beyond elite private or religious-based institutions. became increasingly interested in rural people, taking a social- Related legislation added other components. problems approach that differed from the discipline’s standard Research infrastructure, including access to federal funding pipelines, social-philosophical approach. Bertrand (1982) notes that they was established through the Agricultural Experiment Stations created in called themselves rural sociologists and that they had defined their each state by the Hatch Act of 1887. Public outreach bringing academic professional effort as the development and application of concepts research directly into public use was institutionalized through the and theoretical models for the express purpose of improving the life Cooperative Extension Service, created by the Smith Lever Act of 1914. Psychology.EliteCME.com Page 33 and well-being of rural people. The first course in rural sociology was that prospective interest in rural sociology would dampen since those taught at the University of Chicago in 1894 (Nelson, 1969). having no desire to join the ASA were required to be ASA members. With expanding interest in the field, the Rural Section in ASA decided Furthermore, participation at ASA (p. I-467) meetings was limited to one to publish its own journal, Rural Sociology. The first issue appeared paper, tending to restrict involvement into a single section. in 1936. In December 1937, the Rural Section went further, voting to With a new society, members retained a primary focus on rural establish a separate professional organization, the Rural Sociological sociology but were freer to present papers and join ASA sections. The Society (RSS). The separation occurred because rural sociology had organizational split signaled that rural sociologists saw themselves as grown large and varied and some felt limited by ASA (Nelson, 1969). occupying a separate field, with specialty areas within it, not simply While most members of the Rural Section were college sociologists, as a specialty area within sociology. In 1938, the membership in RSS the field interested agricultural and home economists, as well as staff stood at 206 but rose steadily. In 1966, it reached 840 (Nelson, 1969), members of farm and government organizations. Some were concerned and has hovered at around 1,000 since then.

SOCIAL NETWORKS Social networks have come to take on prominence in sociology, Like the founding sociologist, social interaction was the currency that other academic disciplines, many policy areas, and even in the public set Simmel’s work apart from other social sciences and philosophies. In discourse in recent years. “Networking,” “six degrees of separation,” Durkheim’s (1951) Suicide, for example, two types of social interaction “social support,” and “social capital” have been adopted in the (integration and regulation) were seen as combining to create four distinct business world, among poets and playwrights, and among friends. types of social structures (anomic, fatalistic, altruistic, and egoistic), which Yet the diffusion of the underlying terms and concepts from a social shaped the behavior of individuals who lived within them. To map these network perspective has produced both acceptance and confusion in social structures, Durkheim referred to different kinds of “societies,” academic and community circles. Simply stated, a social network is a social groups, or institutions such as the family, polity, or religions. “structure of relationships linking social actors” (Marsden, 2000) or “the While consistent with a network approach, Durkheim’s approach was set of actors and the ties among them” (Wasserman & Faust, 1994). more implicit than explicit on social ties (Pescosolido, 1994). Relationships or ties are the basic building blocks of human Simmel suggested that it was the nature of ties themselves, rather than experience, mapping the connections that individuals have to one the social group per se, that lay at the center of many human behaviors. another (Pescosolido, 1991). As network theorists claim, the structure In his attempt to (p. 209) understand the transition from agrarian to of these relationships among actors has important consequences for industrial society, Simmel discussed two ideal configurations of social individuals and for whole systems (Knoke, 1990). networks, commonly referred to as the “pre-modern” form of concentric Some sociologists see social networks as the essence of social structure social circles and the “modern” form of the intersection of social circles. (Burt 1980); others see social structure governing these networks (Blau, For each, Simmel described and considered their effect on individuals, 1974); still others see networks as the mechanism that connects micro including the way personality and belief structures are formed. Briefly, and macro levels of social life (Coleman, 1990; Pescosolido, 1992). social networks in pre-modern society were encapsulating and comforting To many, the power of network explanations lies in changing the focus but often intolerant of outsiders (Blau 1993; Giddens 1990). They of social structure from static categories such as age, gender, and race provided a sense of security and solidarity, which minimized psychological to the actual nature of the social contacts that individuals have and “tensions” for the majority of individuals. Yet such a structure, as Simmel their impact on life chances (White, 1992; Wilson, 1996). In any case, noted, limited freedom, individuality, and diversity. These networks were, there is a clear link between networks and sociology’s central concerns as Suchman (1964) was later to call them, “parochial.” with social structures and social interaction. Modern society brought “cosmopolitan” networks characterized Despite the many varieties of “sociology” in contemporary theory, the by intersecting circles. The transition to modern society allowed role of social interactions may be the single commonality (Pescosolido, individuals to increasingly participate in a greater number of networks 1992). Social relationships have always been at the heart of sociological with more numerous, but fewer multi-stranded, ties (Blau, 1977). understandings of the world. Many sociologists trace the introduction of Individuals craft unique personalities that stand at the intersection the structural approach to social interactions to Georg Simmel (1955) in of all the social networks they have inherited and built (Burt, 1976). Conflict and the Web of Group Affiliations (Pescosolido & Rubin, 2000; Individuals are more unique and tolerant. But with greater choices White, Boorman, & Brieger, 1976). In this work, Simmel (1955) began possible, individuals deal with greater uncertainty and less support with the classic statement, “Society arises from the individual and the (Giddens, 1990; Maryanski & Turner, 1992). individual arises out of association” (p. 163).

Main contributions: Principles underlying the social network perspective There is no single network “theory”; in fact, Knoke (1990) sees this as (Elder, 1998; Pescosolido, 1992). They are, however, always seen as unlikely and even inappropriate. The network approach is considered interdependent rather than independent (Wasserman & Faust, 1994). by most who use it as more of a perspective or frame that can be used Some theorists (Coleman 1990) see networks in the purposive to develop specific theories. Yet sociologists share, across studies, basic action, rational actor tradition, but this represents only one view that principles that often underlie much research using a network frame and can be subsumed within a network perspective (Pescosolido, 1992). guide the development of specific investigations and analyses. ●● Important but often daunting and abstract influences such as “society,” ●● Social actors, whether individuals, organizations, or nations, “institution,” “culture,” the “community,” and the “system” can be shape their everyday lives through consultation, information and understood by looking to the set of social interactions that occur resource sharing, suggestion, support, and nagging from others within them (Tilly, 1984). Networks set a context within groups, (White et al., 1976). Network interactions influence beliefs and formal organizations, and institutions for those who work in or are attitudes as well as behavior, action, and outcomes. served by them, which, in turn, affects what people do, how they feel, ●● Individuals are neither puppets of the social structure nor purely and what happens to them (Wright, 1997). rational, calculating individuals. Individuals are “sociosyncratic,” ●● Three characteristics of social networks are distinct—structure, both acting and reacting to the social networks in their environment content, and function. Structure targets the architectural aspect of

Page 34 Psychology.EliteCME.com network ties (i.e., size, density, or types of relationships). Content taps approaches are becoming available to see how social networks look what flows across the network ties. They are “channels for transfers of and trace how they change (Bearman et al., 2004; Freeman, 2004). material or non-material resources” (Wasserman & Faust, 1994). That ●● A network perspective allows for, and even calls for, multi-method is, attitudes and opinions, as well as more tangible experiences and approaches. Jinnett, Coulter, and Koegel (2002) conclude that collective memory, are held within networks (Emirbayer & Goodwin, quantitative research is powerful in documenting the effects of social 1994; Erikson, 1996; Stryker, 1980). Finally, networks serve a variety networks but only when accompanied by qualitative research that of functions, including emotional support, instrumental aid, appraisal, describes why they operate and look the way they do. There is no and monitoring (Pearlin & Aneshensel, 1986). standard way to chart network relationships. They may be derived ●● Network influence requires the consideration of interactions among from a list on a survey where individuals are asked to name people these three aspects. Structural elements (e.g., size) of a network they trust, admire, or dislike or with whom they share information. may tap the amount of potential influence that can be exerted by Alternatively, the information may come from observing the the network (i.e., the “push”). However, only the content of the behavior of individuals who they talk to in their work group network can provide an indication of the direction of that influence (Homans, 1961). Network information can be collected through (i.e., the “trajectory”). For example, large networks can influence archival sources such as citation records (Hargens, 2000) or by individuals on the Upper West Side of Manhattan to seek out medical documenting the behavior of organizations or countries (Alderson professionals (Kadushin, 1966) while keeping individuals in Puerto & Beckfield, 2004). Even simulated data can be and have been Rico out of the medical system (Pescosolido, Wright, et al. 1998). The used to examine network processes (Cederman, 2005; Eguiluz intersection of the structure and content of social networks together et al., 2005; Moss and Edmonds, 2005). Clearly, deciding which calibrates whether and how much individuals will be pushed toward kinds of social networks are of interest, how to elicit the ties, or away from doctors and alternative healers or even rely only on and how to track their dynamics remain critical issues (Berkman, family for assistance (Freidson, 1970; Pescosolido, 1991). 1986; House, Robbins, and Metzner, 1982; Leik & Chalkey, 1996; ●● Networks may be in sync or in conflict with one another. Different O’Reilly, 1998; Suitor et al., 1996; Wellman et al., 1996). contexts can circumscribe different sets of networks (Simmel, 1955). ●● Socio-demographic characteristics are potential factors that shape Family, peer, and official school-based networks, for example, may the boundaries of social networks but provide, at best, poor measures reinforce messages or clash in priorities for teenagers. The level of of social interaction (Collins, 1988; Morgan, Patrick, and Charlton, discordance in the “culture” of networks and the interface of social 1984; White et al., 1976). Originally, networks were circumscribed circles may be critical to understanding the behavior of social actors by the place where people lived and their customs (Fischer, 1982; (Pescosolido, Wright, & Sullivan, 1995). They may also be different Pescosolido & Rubin, 2000; Simmel, 1955; Wellman, 1982). from the perspective of interacting parties in ways that provide insight into social action and outcomes (Pescosolido & Wright, 2002). But a process of “disembedding” (Giddens, 1990) from local places ●● Social interactions can be positive or negative, helpful or harmful. has been replaced by a “re-embedding” at the global level. While They can integrate individuals into a community and, just as people may continue to see gross differences in, for example, powerfully, place stringent isolating regulations on behavior. The the number of network ties by these “actor attributes” (Monge little research that has [p. I-211 ↓]explored negative ties in people’s & Contractor, 2003) or “composition variables” (Wasserman & lives has found them to have powerful effects (Berkman, 1986; Faust, 1994), these static characteristics only indirectly tap the real Pagel, Erdly, and Becker 1987). Portes (1998), Rumbaut (1977), underlying social forces at work, the content, structure, and function and Waldinger (1995) all document how tight social interactions of social interactions. within ethnic groups lead to restricted job opportunities for those Used in combination with social network factors, these inside and outside of the ethnic networks. characteristics offer two possibilities. First, complicated issues ●● More is not necessarily better with regard to social ties. As such as the idea that men tend to report more networks but that Durkheim (1951) pointed out, too much oversight (regulation) or women’s networks are more intimate (Campbell & Rosenfeld, support (integration) can be stifling and repressive (Pescosolido, 1985; Moore, 1992) can now be more readily examined with 1994). Further, “strong” ties are not necessarily optimal, because analytical techniques (Carrington et al., 2005; Freeman, 2004; “weak” ties often act as a bridge to different information and Koehly & Pattison, 2005). Second, networks may operate resources (Granovetter, 1982), and holes in network structures differently for different groups. That is, considered as potential (Burt, 1980) provide opportunities that can be exploited. The focus interactive factors, rather than simply shaping ones, attribute on social support, and now social capital, may have obfuscated the variables may provide insights into how social network processes focus on the “dark” aspects of social networks. create different pathways of beliefs and behaviors for social actors. ●● Networks across all levels are dynamic, rather than static, ●● Individuals form ties under contextual constraints and interact structures and processes. The ability to form and maintain social given social psychological and neurological capacities. Thus, social ties may be just as important as their state at one point in time. networks exist in a multi-level environment. Some of these levels, There may be changes in the structure of networks or changes such as organizations, may also be conceptualized in network terms. in membership. In fact, early work on this topic suggests that For example, an individual’s network ties within the religious sphere turnover rates may hover around 50 percent, while the structure exist within geographic areas that themselves have a structure of (size) tends to remain stable (Perry, 2005). As Moody, McFarland, religious network types and a more general social capital profile and Bender-deMoll (2005) note, “An apparently static network (Pescosolido, 1990). Such a view leads to additional research pattern emerges through a set of temporal interactions” (p. 1209). questions about whether network structures operate in the same way Further, the underlying reasons for changing networks may mark in different contexts (Pescosolido, 1994). Similarly, other factors important insights into the influence of networks (Perry, 2005; such as laws may set structural conditions on relationships. Pescosolido & Wright 2004; Suitor, Wellman, and Morgan, 1996; Individuals’ social networks are not divorced from the body and the Wellman, Wong, Tindall, and Nazer, 1996). This focus represents physical/mental capacities that individuals bring to them (Leventhal, some of the newest work in sociology and some of the greatest Leventhal, & Contrada, 1997; Orlinsky & Howard, 1987; Rosenfield theoretical, methodological, and analytical challenges (Bearman, & Wenzel, 1997). As Fremont and Bird (2000) report, when social Moody, and Stovel, 2004; Snijders, 1998). In fact, Carrington et al. interactions are the source of social stress, the impact appears to be (2005) refer to the analysis of social networks over time as the “Holy more devastating in magnitude (Perry, 2005). Grail” of network research. New analytical methods and visualization

Psychology.EliteCME.com Page 35 Social psychological characteristics such as self-reliance may also Wenzel, 1997; Suitor & Pillemer, 2002). Professionals have long influence the effect of network ties. Biological challenges may lie at known that children with physiological or neurological deficits the heart of dramatic changes in individuals’ social network systems experience difficulties establishing social relationships (Perry, 2005). both for those affected directly and for caregivers (Dozier, 1993; Sociologists know that these early social relationships affect adult Dozier, Cue, & Barnett, 1994; Lysaker et al., 1994; Rosenfield & educational outcomes (Entwisle, Alexander, & Olson, 2005).

SOCIAL MOVEMENTS AND SOCIAL CHANGE Although such factors as physical environment, population, technology, movements as training grounds for leaders of the political establishment. and social inequality serve as sources of change, it is the collective effort Such heads of state as Cuba’s Fidel Castro and South Africa’s Nelson of individuals organized in social movements that ultimately leads to Mandela came to power after serving as leaders of revolutionary change. Sociologists use the term social movement to refer to organized movements. Poland’s Lech Walesa, Russia’s Boris Yeltsin, and the Czech collective activities to bring about or resist fundamental change in playwright Václav Havel all led protest movements against Communist an existing group or society (Benford, 1992). Herbert Blumer (1955) rule and later became leaders of their countries’ governments. recognized the special importance of social movements when he defined Because social movements know no borders, even nationalistic them as “collective enterprises to establish a new order of life.” movements like those led by Castro and Walesa are deeply influenced In many nations, including the United States, social movements have had by global events. Increasingly, social movements are taking on an a dramatic impact on the course of history and the evolution of the social international dimension from the start. Global enterprises, in particular, structure. Consider the actions of abolitionists, suffragists, civil rights lend themselves to targeting through international mobilization, whether workers, and activists opposed to the war in Vietnam. Members of each they are corporations like McDonald’s or governmental bodies like the social movement stepped outside traditional channels to bring about social World Trade Organization. Global activism is not new, however; it began change, yet each had a noticeable influence on public policy. In Eastern with the writing of Karl Marx, who sought to mobilize oppressed peoples Europe, equally dramatic collective efforts helped to topple Communist in other industrialized countries. Today, activist networking is facilitated regimes in a largely peaceful manner, in nations that many observers had by the Internet and by relatively cheap travel costs. Participation in thought were “immune” to such social change (Ramet, 1991). transnational activism is much wider now than in the past, and passions Though social movements imply the existence of conflict, their activities are quicker to ignite (Della Porta & Tarrow, 2005; Tarrow, 2005). can also be analyzed from a functionalist perspective. Even when they How and why do social movements emerge? Obviously, people are are unsuccessful, social movements contribute to the formation of public often discontented with the way things are. But what causes them to opinion. Initially, people thought the ideas of Margaret Sanger and other organize at a particular moment in a collective effort to effect change? early advocates of birth control were radical, yet contraceptives are now Sociologists rely on two explanations for why people mobilize: the widely available in the United States. Moreover, functionalists view social relative deprivation and resource mobilization approaches.

Relative deprivation approach Those members of a society who feel most frustrated and disgruntled by In addition to the feeling of relative deprivation, two other elements social and economic conditions are not necessarily the worst off in an must be present before discontent creates a social movement. People objective sense. Social scientists have long recognized that what is most must feel that they have a right to their goals, that they deserve better significant is the way in which people perceive their situation.As Karl than what they have. For example, the struggle against European Marx pointed out, although the misery of the workers was important to colonialism in Africa intensified when growing numbers of Africans their perception of their oppressed state, so was their position in relation decided that it was legitimate for them to have political and economic to the capitalist ruling class (Marx & Engels, 1955). independence. At the same time, the disadvantaged group must The term relative deprivation is defined as the conscious feeling of perceive that its goals cannot be attained through conventional means. a negative discrepancy between legitimate expectations and present This belief may or may not be correct. Whichever is the case, the actualities (Wilson, 1973). In other words, things are not as good as group will not mobilize into a social movement unless there is a people hoped they would be. Such a state may be characterized by shared perception that members can end their relative deprivation only scarcity rather than a complete lack of necessities. Relatively deprived through collective action (Morrison, 1971). people are dissatisfied because they feel downtrodden relative to some Critics of this approach have noted that people do not need to feel appropriate reference group. Thus, blue-collar workers who live in deprived to be moved to act. In addition, this approach fails to explain two-family houses on small plots of land, though hardly at the bottom why certain feelings of deprivation transform into social movements, of the economic ladder, may nevertheless feel deprived in comparison whereas in similar situations, no collective effort is made to reshape to corporate managers and professionals who live in lavish homes in society. Consequently, in recent years, sociologists have paid increasing exclusive suburbs. attention to the forces needed to bring about the emergence of social movements (Alain, 1985; Finkel & Rule, 1987; Orum & Dale, 2009).

Resource mobilization approach It takes more than desire to start a social movement. It helps to and continuity of leadership.” As people become part of a social have money, political influence, access to the media, and personnel. movement, norms develop to guide their behavior. Members of Resource mobilization refers to the ways in which a social movement the movement may be expected to attend regular meetings of utilizes such resources. The success of a movement for change organizations, pay dues, recruit new adherents, and boycott “enemy” depends, in part, on what resources it has and how effectively it products or speakers. An emerging social movement may give rise mobilizes them. In other words, recruiting adherents and marshalling to special language or new words for familiar terms. In recent years, resources is critical to the growth and success of social movements social movements have been responsible for such new terms of (Gamson, 1989; Tilly, 2003; Walder, 2007). self-reference as Blacks and African Americans (to replace Negroes), Sociologist Anthony Oberschall (1973) argued that to sustain senior citizens (to replace old folks), gays (to replace homosexuals), social protest or resistance, there must be an “organizational base and people with disabilities (to replace the handicapped).

Page 36 Psychology.EliteCME.com Leadership is a central factor in the mobilization of the discontented distributed in 1988 as part of a successful effort by students, faculty, into social movements. Often, a charismatic leader, such as Dr. Martin and alumni to force the appointment of the university’s first deaf Luther King Jr, will head a movement. As Max Weber described it president. In 2007, after that president’s retirement, students protested in 1904, charisma is that quality of an individual that sets him or her once again over the election process. The mobilization of resources is apart from ordinary people. Of course, charisma can fade abruptly, one key to the success of a social movement. which helps to account for the fragility of certain social movements Why do certain individuals join a social movement while others in (Morris, 2000). similar situations do not? Some of them are recruited to join. Karl Yet many social movements do persist over long periods because their Marx recognized the importance of recruitment when he called on leadership is well organized and ongoing. Ironically, as Robert Michels workers to become aware of their oppressed status and to develop (1915) noted, political movements that are fighting for social change a class consciousness. Like theorists of the resource mobilization eventually take on some of the aspects of bureaucracy that they were approach, Marx held that a social movement (specifically, the revolt of organized to protest. Leaders tend to dominate the decision-making the proletariat) would require leaders to sharpen the awareness of the process without directly consulting followers. The bureaucratization of oppressed. They would need to help workers to overcome feelings of social movements is not inevitable, however. More radical movements false consciousness, or attitudes that do not reflect workers’ objective that advocate major structural change in society and embrace mass position, in order to organize a revolutionary movement. Similarly, actions tend not to be hierarchical or bureaucratic (Fitzgerald & one of the challenges faced by women’s liberation activists of the late Rodgers, 2000). 1960s and early 1970s was to convince women that they were being Gallaudet University in Washington, D.C., is the only four-year deprived of their rights and of socially valued resources. liberal arts college for deaf students in the United States. A leaflet was

Gender and social movements Sociologists point out that gender is an important element in battles to voting rights to animal rights, passion tends to be part of understanding social movements. In male-dominated societies, the consensus-building force. Yet calls for a more serious study of the women find it more difficult than men to assume leadership positions role of emotion are frequently seen as applying only to the women’s in social movement organizations. Though women often serve movement, because emotion is traditionally thought of as being disproportionately as volunteers in these movements, their work is not feminine (Ferree & Merrill, 2000; V. Taylor, 2004). always recognized, nor are their voices as easily heard as men’s. New social movements refers to organized collective activities that Gender bias causes the real extent of women’s influence to be address values and social identities, as well as improvements in the overlooked. Indeed, traditional examination of the sociopolitical quality of life. These movements may be involved in developing system tends to focus on such male-dominated corridors of power as collective identities. Many have complex agendas that go beyond a legislatures and corporate boardrooms, to the neglect of more female- single issue, and even cross national boundaries. Educated, middle- dominated domains such as households, community-based groups, class people are significantly represented in some of these new social and faith-based networks. But efforts to influence family values, child movements, such as the women’s movement and the movement for rearing, relationships between parents and schools, and spiritual values lesbian and gay rights. are clearly significant to a culture and society (Ferree & Merrill, 2000; New social movements generally do not view government as their ally Noonan, 1995). in the struggle for a better society. While they typically do not seek Scholars of social movements now realize that gender can affect to overthrow the government, they may criticize, protest, or harass even the way people view organized efforts to bring about or resist public officials. Researchers have found that members of new social change. For example, an emphasis on using rationality and cold movements show little inclination to accept established authority, even logic to achieve goals helps to obscure the importance of passion and scientific or technical authority. emotion in successful social movements. In movements from labor

Summary Sociology is the study of associational life. In examining patterns these as independent or particular features of society, sociologists seek of association, sociologists explore the interactions of people, to embed them within the complex whole of the social world. Students communities, and organizations. In this sense, sociology is not the will find sociology to be a broad, demanding department that provides study of people; it is the study of the relationships among people. That them with the conceptual and methodological tools to make sense of study includes the associations between people and the products of the opportunities and social problems of different global communities. human interaction, such as organizations, technologies, economies, Norms are the established standards of behavior maintained by a cities, culture, media, and religion. In the kinds of questions it asks, society. All societies have ways of encouraging and enforcing what sociology is a deeply humanist discipline and sociologists demand the they view as appropriate behavior while discouraging and punishing analytic rigor of scientific investigation. what they consider to be improper behavior. Students studying social psychology and sociology are encouraged ●● Formal norms generally have been written down and specify strict to ask big questions, and sociologists work to give them the tools to punishments for violators. provide answers. These tools might mean ethnographic observation, ●● Informal norms are generally understood but not precisely pouring through historical archives, looking at census data, analyzing recorded. Standards of proper dress are a common example of social networks, or interviewing people in various walks of life. informal norms. As a bridging discipline that seeks the scientific exploration of All societies have developed certain common practices and beliefs, questions that matter to human communities, such as inequality and known as cultural universals. Many cultural universals are, in fact, social injustice, sociology addresses many of the same areas of life as adaptations to meet essential human needs, such as people’s need for neighboring social science disciplines. Yet sociologists often approach food, shelter, and clothing. these areas quite differently. For example, problems of economic and Sociology is a very wide discipline. Conventionally, this subject political life are a central concern to sociologists. Rather than explore concentrates on social stratification, social class, religion, law, and Psychology.EliteCME.com Page 37 secularization. Sociology is an important branch of study that involves implied presence of others. By this definition, scientific refers to the the integrated knowledge on social sciences and humanities in order empirical method of investigation. Thoughts, feelings, and behaviors to improve civic competence. In school, social science includes include all measurable psychological variables in a human being. anthropology, archeology, economics, geography, history, philosophy, Sociology and social psychology are equally important, as they give political science, psychology, religion, and sociology, as well as the young people the information needed to develop a positive view content from humanities, mathematics, and natural sciences. of society. Sociology and social psychology teach the necessity of Social psychology is a more focused social science as opposed to learning the skills of speaking, writing, and thinking, which help the broader sociology. While sociology focuses more on situations people in decision making and problem solving. This also helps within society, social psychology studies the impact that the social students to thinks rationally, humanely, and critically. Sociology environment and group interactions have on attitudes and behaviors. teaches people to appreciate the cultural diversity and significant Social psychologists typically explain human behavior as a result of elements of culture and allows them to assimilate the principles of the interaction of mental states and immediate social situations. In politics and other systems to participate in the democratic society. general, social psychologists have a preference for laboratory-based, These branches of the field help people understand the influence of empirical findings. Social psychology theories tend to be specific and science and technology on society as well as individuals. It helps focused, rather than global and general. The primary methods of data individuals to understand the cultural values and personal values that collection include sample surveys, field observations, vignette studies, exist. It also aids them in learning the cause and effect of relationships, field experiments, and controlled experiments. change, continuity and turning points, and divergent perspectives and to apply this knowledge to the future benefit of society. Social psychology is the scientific study of how people’s thoughts, feelings, and behaviors are influenced by the actual, imagined, or

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Psychology.EliteCME.com Page 39 ELEMENTS OF SOCIAL PSYCHOLOGY Final Examination Questions Select the best answer for questions 1 through 20 and mark your answers on the Final Examination Answer Sheet found on page 85 or take your test online at Psychology.EliteCME.com.

1. ______is the study of the social features of humans 8. Feminists share the view of conflict theorists that mass media and the ways in which they interact and change. ______and misrepresents social reality. a. Natural science. a. Processes. b. Social science. b. Guides. c. Political science. c. Stereotypes. d. Gerontology. d. Tampers with. 2. ______can be thought of as attempts to explain events, forces, 9. Courts or judges, military officers, police officers, school systems materials, ideas, or behavior in a comprehensive manner. or teachers, and government agencies or bureaucrats, enforce a. Motives. ______. b. Research findings. a. Informal social control. c. Theories. b. Formal social control. d. Data reports. c. Formal socialization. 3. ______is a process aimed at changing a person’s (or a d. Informal socialization. group’s) attitude or behavior toward some event, idea, object, 10. ______is often defined as the attainment of a deeper or other person(s), by using written or spoken words to convey understanding of theory, the creation of new theory, and the information, feelings, or reasoning. creation of an overarching theoretical perspective. a. Change management. a. Enlightment. b. Response theory. b. Renaissance. c. Persuasion. c. Metatheory. d. Reorganization. d. Ultra-theory. 4. ______suggests that when people are presented with 11. ______are evident not only in work and behavior but also an idea or any kind of persuasive proposal, their natural reaction is in how people react to others. to immediately seek a way to sort the information subconsciously a. Cognitive barriers. and react to it. b. Learning styles. a. Cognitive dissonance theory. c. Gender roles. b. Group think. d. External stimuli. c. Cross cultural cognitive theory. 12. ______is the ideology that one sex is superior to the other. d. Social judgment theory. a. Prejudice. 5. ______theory emphasizes that we observe b. Bias. ourselves in the same manner that we observe others, and draw c. Gender roles. conclusions about our likes and dislikes. d. Sexism. a. Self-perception. 13. ______theory suggests that elderly people who remain b. Schemata. active and socially involved will be best adjusted. c. Drive. a. Attribution. d. Social exchange. b. Activity. 6. Sociology resulted from a process caused by two major forces: the c. Relationship. Industrial Revolution and the ______. d. Social exchange. a. French Revolution. 14. ______involves, but is not limited to, the study of the b. Vietnam War. relation between state and society. c. Cold War. a. Sociology of religion. d. American Revolution. b. Fundamental social science. 7. ______culture refers to ways of using material objects and c. Political sociology. to customs, beliefs, philosophies, governments, and patterns of d. Disengagement theory. communication. 15. According to Doob, ______“refers to the emphasis on the a. Material. structures and activities that transmit social inequality from one b. Cross. generation to the next.” c. Non-material. a. Generational sociology. d. External. b. Social reproduction. c. Natural progression. d. Stratification.

Page 40 Psychology.EliteCME.com 16. The term community ______was developed in the late 19th century to account for the rapid development of industrial patterns that seemingly caused rifts between the individual and their local community. a. Saved. b. Liberated. c. Gained. d. Lost. 17. ______targets the architectural aspect of network ties. a. Structure. b. Content. c. Social advancement. d. Attributes. 18. ______is defined as the conscious feeling of a negative discrepancy between legitimate expectations and present actualities. a. Social control. b. Power. c. Relative deprivation. d. Community lost. 19. ______refers to the ways in which a social movement utilizes resources. a. Social change. b. Resource mobilization. c. Resiliency. d. Social networking. 20. Researchers have found that members of ______show little inclination to accept established authority, even scientific or technical authority. a. New social movements. b. Political sociology. c. Social change theory. d. New communities.

PYMA10ESE18

Psychology.EliteCME.com Page 41 Chapter 2: Narcissistic Personality Disorder – Has it Become an Epidemic?

4 CE Hours

By: Kathryn Brohl, MA, LMFT Revised and edited by: Wade Lijewski, Ph.D.

Learning objectives Upon completion of this course, the learner should be able to: ŠŠ Describe at least three relationship characteristics of individuals ŠŠ Define narcissistic personality disorder (NPD) as it relates to the with NPD. Diagnostic and Statistical Manual of Mental Health Disorders, ŠŠ Identify at least five diagnostic criteria for NPD as they relate to Fifth Edition (DSM-5) (2013). the DSM-5. ŠŠ Identify personality disorder as it relates to the DSM-5. ŠŠ Recognize challenges to treating individuals with NPD. ŠŠ Compare NPD to other Cluster B Personality Disorders, outlined ŠŠ Describe treatment for individuals with NPD. in the Statistical Manual of Mental Health Disorders, Fifth Edition, ŠŠ Compare and describe ICD Revision 10 personality disorder (2013). criteria to DSM-5 personality disorder criteria. ŠŠ Explain the male and female prevalence of NPD. ŠŠ Explain how NPD affects relationships.

Introduction Narcissism has been examined by mental health professionals for years, society is more accepting of persons with NPD, or does the trend in and yet something has occurred recently within our society that seems to cultivating entitlement as it relates to expressing one’s opinions and have blurred narcissism traits with the clinical diagnosis of narcissistic behaviors more loudly simply mean that people are feeling more personality disorder (NPD) and accepted societal behavior. Recently, a empowered? And as a result, are people becoming desensitized to the shift has occurred in shared cultural values toward narcissism and self- feelings of others? Furthermore, are mental health professionals seeing admiration and some of these traits have become social norms. individuals with narcissistic traits more often than individuals who For example, reality television continues to grow in popularity, actually have been clinically impaired by NPD? as persons with questionable talent become entitled celebrities Everyone is narcissistic to a degree. Without a healthy amount of overnight on shows such as The Real Housewives or Jersey Shore. narcissism, a person might become too much of an empath. An empath Other high profile figures feel free to share their slanted grandiose resides at the other end of the narcissistic/empathic spectrum. While opinions without prior experience or knowledge behind those opinions. a narcissist normally has few conscious worries, an empath cares less YouTube, Facebook, Twitter, and blogs make it possible to become an about themselves and more about the feelings and emotions of others. instant celebrity through provocative behaviors. Gossip magazines and To be able to live a stable life and maintain healthy relationships, a television programs also showcase these behaviors. People appear to healthy development that is somewhere in the middle of the narcissistic/ have progressively become desensitized to the feelings of others, which empathic spectrum should be attained through natural self-development. demonstrates that narcissism has become a larger societal consideration. This course will discuss NPD in detail and examine the characteristics According to authors Twenge and Campbell (2009), narcissism goes of people with the disorder, as well as the treatment, including ways to beyond the reported 1 in 16 Americans who have been impaired by support those affected by someone with the disorder. the disorder. This information leads to the question of whether modern

The back story In Greek mythology, Echo was a wood nymph who loved a mortal named Narcissus became angry “Hands off! I would rather die than you Narcissus. He was a beautiful creature loved by many, but Narcissus loved should have me!” He threw Echo to the ground. Echo left the woods. no one. He enjoyed attention, praise, and envy. In Narcissus’ eyes, no one Her heart was broken. matched him and he considered no one worthy of him. Narcissus continued to attract many admirers, all of whom he briefly Echo’s passion for Narcissus was rivaled only by her passion for talking entertained before scorning them. Eventually, the gods grew tired of and she had to have the last word. One day, she enabled the escape of the his behavior and cursed him. They wanted him to know what it felt goddess Juno’s adulterous husband by engaging Juno in conversation. like to love and never be loved in return. Their curse dictated that there Upon learning of Echo’s treachery, Juno cursed Echo by removing her was only one whom he would love, someone who was not real, and voice with the exception that she could only repeat what was said to her. could never love him back. Echo frequently waited in the woods to see Narcissus, hoping for a One day, Narcissus came upon a pool of water. As he gazed into it he chance to be noticed. One day as she lingered in the bushes he heard caught a glimpse of what he thought was a beautiful water spirit. He her footsteps and called out “Who’s here?” Echo replied “Here!” did not recognize his own reflection and was immediately enamored. Narcissus called again “Come,” Echo repeated, “Come!” Narcissus Narcissus bent down his head to kiss the vision. As he did the called once more “Why do you shun me? Let us join one another.” reflection mimicked his actions. Taking this as a sign of reciprocation, Echo was overjoyed that Narcissus had asked her to join him. She Narcissus reached into the pool to draw the water spirit to him. The longed to tell him who she was and of all the love she had for him but water displaced and the vision was gone. He panicked. Where had his she could not speak. She ran toward him and threw herself on him. love gone? When the water became calm once again the water spirit Page 42 Psychology.EliteCME.com returned. “Why, beautiful being, do you shun me? Surely my face is with him to come away from the pool. Echo also pleaded with him. He not one to repel you. The nymphs love me, and you yourself look not was transfixed; he wanted to stay there forever. Narcissus, like Echo, indifferent upon me. When I stretch forth my arms you do the same; finally died from grief. His body disappeared and where his body once and you smile upon me and answer my beckoning the same.” Again lay a flower grew in its place. The nymphs mourned his death and as he reached out and again his love disappeared. Frightened to touch the they mourned, so did Echo. (Thomas Bulfinch, updated: 30th April water, Narcissus lay still by the pool gazing in to the eyes of his vision. 2008, retrieved 8/26/2013) He cried in frustration. As he cried, Echo also cried. He did not move, The story of Echo and Narcissus is used as a warning to those who love he did not eat or drink, he only suffered. As he grieved, he became someone that cannot love them back and is often used as a basis for gaunt, gradually losing his beauty. The nymphs that loved him pleaded understanding the implications of Narcissistic Personality Disorder (NPD).

Personality disorders Narcissistic personality disorder (NPD) is just one of several types shows symptoms for at least one year. Minors cannot be diagnosed of personality disorders. Personality disorders are conditions in with antisocial personality disorder. which people have traits that cause them to feel and behave in socially ●● 35 percent of patients admitted to a methadone maintenance distressing ways, limiting their ability to function in relationships and program have a personality disorder. (SAMHSA, 2009) in other areas of their life, such as work or school. The Diagnostic and Statistical Manual for Mental Health Disorders, ●● Personality disorders affect about 15 million adults in the United Fifth Edition (DSM-5), created a significant amount of controversy, States. Approximately 10 percent to 13 percent of the U.S. and the writers were often challenged by the larger clinical community population meets the diagnostic criteria for a personality disorder that disagreed with some of their revisions in this 2013 version. As at some point in his or her life. Most people can live relatively a result, the National Institutes of Health (NIH) has not endorsed normal lives with mild personality disorders; however, in times of the newer version and it appears that, over time, the International extreme stress, symptoms can increase and become disruptive in Classification of Disorders Revision 10 or 11 (ICD-10 or -11) may everyday activities. eventually be adopted as the clinical classification diagnosing guide ●● Personality disorders are usually only diagnosed for people over throughout the United States. Therefore, both diagnostic guidelines are the age of 18, although there is an exception if the individual described in this course.

DSM-5 The DSM-5 work group recommended a major reconceptualization ___ 2. Intimacy. Impaired capacity for close relationships of personality psychopathology with core impairments in personality (e.g., unable to establish or maintain closeness and intimacy; functioning, pathological personality traits, and prominent pathological inability to function as an effective attachment figure; inability personality types. Personality disorders are diagnosed when core to establish and maintain relationships). impairments and pathological traits are severe and other criteria are ___ 3. Cooperativeness. Failure to develop the capacity for met. The criteria are as follows: pro-social behavior (e.g., failure to develop the capacity for ●● Five identified severity levels of personality functioning. socially typical moral behavior; absence of altruism, the sense ●● Five personality disorder types, each defined by core personality of unselfish concern). disorder components and a subset of: ___ 4. Complexity and integration of representations of ○○ Six broad, higher order personality trait domains, with 4-10 others. Poorly integrated representations of others (e.g., forms lower order, more specific trait facets comprising each, for a separate and poorly related images of significant others). total of 37 specific trait facets. (American Psychiatric Association (APA), 2010) ●● A new general definition of personality disorder based on severe or Adaptive failure: extreme deficits in core components of personality functioning and ●● Is associated with extreme levels of one or more personality traits. elevated pathological traits. ●● Is relatively stable across time and consistent across situations with Changes that affect a person’s health resulting from exposure to an an onset that can be traced back to adolescence. unfamiliar environment, referred to as adaptive failure, is manifested ●● Is not solely explained as a manifestation or consequence of in one or both of the following areas: another mental disorder. ●● Impaired sense of self-identity as evidenced by one or more of the ●● Is not solely due to the direct physiological effects of a substance following: (e.g., drug abuse, medication) or a general medical condition (e.g., ___ 1. Identity integration. Poorly integrated sense of self or severe head trauma). identity (e.g., limited sense of personal unity and continuity; According to the DSM-5 the “current” approach describes personality shifting self-states; beliefs that the “self” presented to the disorder as an “enduring pattern of inner experience and behavior that world is a false appearance). deviates markedly from the expectations of the individual’s culture, is ___ 2. Integrity of self-concept. Impoverished and poorly pervasive and inflexible, has an onset in adolescence or early adulthood, differentiated sense of self or identity (e.g., difficulty is stable over time, and leads to distress or impairment.” The newer identifying and describing self attributes; sense of inner DSM-5, as opposed to the DSM-IV, reflects the decision of the APA’s emptiness; poorly defined interpersonal boundaries; definition board of trustees to preserve continuity with current clinical practice, of the self-changes with social context). while introducing a new approach that aims to address numerous ___ 3. Self-directedness. Low self-directedness (e.g., unable to shortcomings of the current approach to personality disorders. According set and attain satisfying and rewarding personal goals; lacks to the APA, “…the typical patient meeting criteria for a specific direction, meaning, and purpose in life). personality disorder frequently also meets criteria for other personality ●● Failure to develop effective interpersonal functioning as disorders. Similarly, other specified or unspecified personality disorder manifested by one or more of the following: is often the correct (but mostly uninformative) diagnosis, in the sense ___ 1. Empathy. Impaired empathic and reflective capacity (e.g., that patients do not tend to present with patterns of symptoms that finds it difficult to understand the mental states of others). correspond with one and only one personality disorder.”

Psychology.EliteCME.com Page 43 DSM-5 general criteria for personality disorders include: ●● Borderline personality disorder (BPD). ●● Moderate or greater impairment in personality (self/interpersonal) ●● Histrionic personality disorder. functioning. ●● Narcissistic personality disorder (NPD). ●● One or more pathological personality traits. Cluster C personality disorders are dominated by difficulties with ●● The impairments in personality functioning and the individual’s anxiety and inhibited behavior. These disorders include: personality trait expression are relatively inflexible and pervasive ●● Avoidant personality disorder. across a broad range of personal and social situations. ●● Dependent personality disorder. ●● The impairments in personality functioning and the individual’s ●● Obsessive compulsive personality disorder (OCD). personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early Belonging to the Cluster B category, the DSM-5 reports that NPD is also adulthood. associated with anorexia nervosa and substance use disorders (especially ●● The impairments in personality functioning and the individual’s related to cocaine). Histrionic, borderline, antisocial, and paranoid personality trait expression are not better explained by another personality disorders may be also associated with the condition. mental disorder. What separates NPD from histrionic, antisocial, and borderline personality ●● The impairments in personality functioning and the individual’s disorders—in which the interactive styles are coquettish, callous, and personality trait expression are not solely attributable to the needy, respectively—is the grandiosity characteristic of NPD. The relative physiological effects of a substance or another medical condition stability of self-image also distinguishes NPD from BPD. An excessive (e.g., severe head trauma). pride in achievements, a relative lack of emotional display, and disdain ●● The impairments in personality functioning and the individual’s for others’ sensitivities distinguishes NPD from histrionic personality personality trait expression are not better understood as normal for disorder, as well. Antisocial people and those with NPD share a tendency an individual’s developmental stage or sociocultural environment. to be tough-minded, glib, superficial, exploitative, and lack empathy. Personality disorders include: schizoid personality disorder, schizotypal Yet, individuals with NPD do not necessarily have impulsive, personality disorder, antisocial personality disorder, borderline personality aggressive, or deceitful characteristics, and usually they do not have disorder, narcissistic personality disorder, avoidant personality disorder, a history of conduct disorder in childhood or criminal behavior in dependent personality disorder, obsessive-compulsive personality disorder, adulthood. Individuals with OCD and NPD are perfectionists and personality change due to another medical condition, and other specified believe that others cannot do things as well as they can. However, the personality disorder and unspecified personality disorder. These disorders disorders differ when those with OCD display self-criticism, while are clustered into A, B or C descriptive similarities. (DSM-5, 2013) those with NPD may believe they have achieved perfection. Likewise, Cluster A personality disorders are those that include symptoms of withdrawal and suspiciousness distinguish persons with paranoid and social isolation, and/or odd, eccentric behavior. These disorders include: schizotypal personality disorder from those with NPD. If paranoia ●● Paranoid personality disorder. does exist with people with NPD, it usually originates from fears of ●● Schizotypal personality disorder. having flaws or imperfections revealed. ●● Schizoid personality disorder. Cluster B personality disorders are those that include symptoms Cluster B category of personality disorders includes antisocial of dramatic or erratic behaviors (counter-social behaviors). These personality disorder, histrionic personality disorder, narcissistic disorders include: personality disorder, borderline personality disorder. ●● Antisocial personality disorder.

ICD-Revision 10 The International Classification of Diseases (ICD) is one of the most Diagnosis of a personality disorder, therefore, would not usually be long-standing diagnostic classifications of mental and physical disorders. appropriate before the age of 16 years, although the presence of conduct It is a categorical classification, organized into 17 major sections, which disorder during childhood or adolescence can indicate a predisposition divide conditions into types depending upon their defining features. The toward the syndrome. (The ICD-10 Classification of Mental and ICD-10 Classification of Mental and Behavioral Disorders (1992) is Behavioral Disorders World Health Organization, Geneva, 1992) part of a series of clinical descriptions and guidelines that make up the F60.8 Narcissistic Personality Disorder (NPD) 10th revision of the International Classification of Diseases and Related The ICD-10 does not specifically define the characteristics of this Health Problems (1992). Disorders of personality are listed in the ICD- personality disorder. Instead, it is classified in the category “Other 10 under subsections F60 to F69. Specific Personality Disorders.” In its notes on selected categories, the ICD suggests that this was ICD-10 states that NPD is “a personality disorder that fits none of the not an easy category to write guidelines for, with concerns about the specific rubrics F60.0-F60.7.” This personality disorder does not meet difference between observation and interpretation made by clinicians, the diagnostic criteria for any of the following: as well as the number of criteria that must be filled before diagnosis ●● F60.0 Paranoid personality disorder. can be confirmed, still unresolved by the ICD working committee. It ●● F60.1 Schizoid personality disorder. also states that the personality disorders described are not mutually ●● F60.2 Dissocial (antisocial) personality disorder. exclusive and can overlap in some of their characteristics. ●● F60.3 Emotionally unstable (borderline) personality disorder. Personality disorders are defined as deeply ingrained and enduring ●● F60.4 Histrionic personality disorder. attitude and behavior patterns that deviate markedly from the culturally ●● F60.5 Anankastic (obsessive-compulsive) personality disorder. expected range. They are not secondary to other mental illnesses, ●● F60.6 Anxious (avoidant) personality disorder. or attributable to gross brain damage or disease, although they may ●● F60.7 Dependent personality disorder. precede and coexist with other disorders. Disorders of personality are regarded as developmental conditions which tend to appear in late childhood or adolescence and continue to manifest into adulthood.

Page 44 Psychology.EliteCME.com PERSONALITY DISORDERS Personality disorder, as previously defined, tends to appear in c. The abnormal behavior pattern is pervasive and clearly late childhood or adolescence and continues into adulthood. It is maladaptive to a broad range of personal and social situations. therefore unlikely that the diagnosis of personality disorder would d. The above manifestations always appear during childhood or be appropriate before the age of 16 or 17 years. General diagnostic adolescence and continue into adulthood. guidelines applying to all personality disorders are presented below; e. The disorder leads to considerable personal distress but this may supplementary descriptions are provided with each of the subtypes. only become apparent late in its course. Diagnostic guidelines f. The disorder is usually, but not invariably, associated with Conditions not directly attributable to gross brain damage or disease, significant problems in occupational and social performance. or to another psychiatric disorder, meeting the following criteria: For various cultures, it may be necessary to develop specific sets a. Markedly dysharmonious attitudes and behavior, involving usually of criteria with regard to social norms, rules, and obligations. For several areas of functioning, e.g., affectivity, arousal, impulse control, diagnosing most of the subtypes, clear evidence is usually required ways of perceiving and thinking, and style of relating to others. of the presence of at least three of the traits or behaviors given in the b. The abnormal behavior pattern is enduring, long-standing, and not clinical description. (Long, 1995-2011, ICD-10) limited to episodes of mental illness.

Narcissistic Personality Disorder (NPD) According to the DSM-5, the prevalence estimates for NPD range negative subjective experiences. Their self-reflection never seems to from 0 percent to 6.2 percent based on community samples. Of provide them with the affirmation they subconsciously desire. those diagnosed with NPD, 50 percent to 75 percent are men. While Individuals with NPD generally believe that the world revolves individuals with the disorder may have special difficulties adjusting around them. This condition is characterized by their inability to to the onset of physical and occupational limitations that are inherent empathize with others and a desire to keep the focus on them at all through aging, adolescents, on the other hand, may display narcissistic times. Additionally, NPD involves arrogant behavior and a need for traits but will not necessarily have NPD when they grow older. admiration, all of which must be consistently evident at work and in Narcissists can cause havoc and destruction to the lives of those relationships. People who are narcissistic are frequently described as around them. However, according to many clinicians, narcissism is cocky, self-centered, manipulative, and demanding. Narcissists may also a completely natural human trait present in everyone and is a concentrate on unlikely personal outcomes (e.g., fame) and may be necessity to survive. convinced that they deserve special treatment. NPD is a mental disorder in which people have an inflated sense of Narcissists tend to hold themselves in high regard. However, their own importance and a deep need for admiration. According to narcissism is not the same thing as self-esteem; people who have high the DSM-5, the essential feature of the disorder is a pervasive pattern self-esteem are often humble, whereas narcissists rarely are. It was of grandiosity. Those diagnosed can be lacking in empathy, meaning once thought that narcissists have high self-esteem on the surface, but they do not recognize others’ desires, feelings, and experiences. Those deep down they are insecure. However, new evidence indicates that with NPD may also assume that others are totally concerned about their narcissists are actually secure or grandiose at both levels. Some believe welfare. When they do discuss personal concerns, they may be discussed that narcissists are insecure because they tend to be defensive when in inappropriate and lengthy detail, while failing to inquire how the other their self-esteem is threatened (e.g., being ridiculed), but narcissists person is doing, disregarding the other person’s needs and feelings. can be aggressive. The sometimes dangerous lifestyle may more Narcissism is a less extreme version of NPD. Narcissism involves generally reflect sensation-seeking or impulsivity (e.g., risky sex, bold cockiness, manipulativeness, selfishness, power motives, and vanity. financial decisions). (Psychology Today, Retrieved 8/26/2013) Narcissism is also defined as extreme selfishness and having a Personality disorders and substance use disorders commonly occur grandiose view of the self (talents, looks, intelligence, etc.) with a together. Although the high prevalence rates of comorbid Axis II constant need for adoration and admiration. During adolescence, disorders and substance use disorders are documented in research people are taught they must love themselves before they can love literature, little is known about the exact nature of their relationship another. Most people are subject to self-reflection at certain times either in etiology or outcomes. The limited research on treatment for because it gives them a better understanding of who they are, as well clients with comorbid personality disorders indicates that some current as helps them understand others. treatment modalities are as effective for these consumers as for those When others learn to become comfortable with themselves, they with sole substance use disorders. become comfortable around other people. This would be the difference Diagnostic criteria between healthy narcissism and so-called malignant narcissism. Many The DSM-5 (2013) states that a person with NPD exhibits a “pattern people argue that the word malignant is deceiving as it portrays that of grandiosity (in fantasy or behavior), need for admiration, and lack a person with NPD is responsible for his or her own disorder. What it of empathy, beginning by early adulthood and present in a variety of actually means is that the narcissistic trait of that person is malignant, contexts, as indicated by five or more of the following”: not the person him/herself. Simply, it is not their fault. (Sparster, 1. Has a grandiose sense of self-importance (e.g., exaggerates retrieved 8/29/2013) achievements and talents, expects to be recognized as superior Once a healthy amount of narcissism has been established, most without commensurate achievements). people find their self-reflection begins to fade and they can live their 2. Is preoccupied with fantasies of unlimited success, power, lives after learning to become comfortable with themselves. The brilliance, beauty, or ideal love. majority of people find a partner who loves them for who they are. 3. Believes that he or she is “special” and unique and can only be However, between 1 percent and 4 percent of the general population understood by, or should associate with, other special or high- do not completely make it through this developmental stage and the status people (or institutions). process of self-reflection and self-evaluation continues throughout 4. Requires excessive admiration. their lives. They see themselves as damaged goods, usually due to

Psychology.EliteCME.com Page 45 5. Has a sense of entitlement (i.e., unreasonable expectations of criticism or defeat, work functioning can be low, for fear of potential especially favorable treatment of automatic compliance with his or defeat. Those with NPD can become ironically self-critical when faced her expectations). with defeat or criticism and experience social withdrawal, depressed 6. Is interpersonally exploitative (i.e., takes advantage of others to mood, and dysthymia or major depressive disorder. achieve his or her own ends). As with all personality disorders, the person must be at least 18 years 7. Lacks empathy—is unwilling to recognize or identify with the old before being diagnosed with NPD and it typically decreases in feelings and needs of others. intensity with age, with many people experiencing few of the most 8. Is often envious of others or believes that others are envious of extreme symptoms by the time they are in their 40s or 50s. him or her. 9. Shows arrogant, haughty behaviors or attitudes. Clinicians speak of two major types of NPD, overt or covert, exhibited by different presentations. Often envious of others, people with NPD can also believe that others are envious of them and begrudge someone else’s successes and Overt NPD possessions, feeling they are more deserving. At the same time, they Overt narcissists express their disorder more openly. They may be can very harshly devalue others’ contributions, especially when others very successful and have a high achieving career or public persona. have been recognized or praised for accomplishments. They gain attention by being very charming or inflicting intimidation or demands. They need the spotlight and feel their audience is in awe They can also perseverate on overdue admiration and privilege. They of their intellect, power, magnetic personality, or prowess. An overt compare themselves favorably with privilege or famous people. narcissist may be very animated when the conversation is directed to Those with NPD believe they are superior to others and have little him or her but show little interest or enthusiasm when the conversation regard for others’ feelings. But behind this mask of ultra-confidence is directed toward others. An indication of an overt narcissist is someone lies a fragile self-esteem, vulnerable to the slightest criticism. who enjoys showing off in front of large groups of people, possibly (Mayo Clinic, retrieved 8/26/2013) Persons with the disorder are showcasing sexual behavior, and acting in a provocative manner. extremely sensitive to injury from criticism or defeat. Whether or not it is externally or internally exhibited, any degree of criticism can Covert NPD leave the narcissistic individual feeling degraded, empty, hollow, or Covert narcissists are indirect in their methods to gain the constant humiliated. Their defense is often displayed through rage, disdain, or attention they seek. They may be quite reserved and even aloof. A defiant counterattack. It is not uncommon for narcissists to socially covert narcissistic person gains his attention by secondary means such withdrawal or mask an appearance of humility to protect their as that of a helper, humanitarian, or misunderstood artist. He or she grandiosity. Relationships with people with NPD often suffer due to gains status and admiration within by this involvement rather than their insensitivity, need for admiration, and entitlement. displaying an obvious quest for the spotlight. If the covert narcissist is a doctor or minister, the grandiose payoff is made by feeling as if Someone with NPD can achieve many things, due to ambition and he or she is a chosen one to lead others. The good deed has little to do confidence associated with a hypomanic mood and periods of grandiosity. with caring for other people, but everything to do with pride and self- By contrast, when performance is disrupted due to an inability to tolerate elevated importance. (Payton and Day, 2002)

Myths related to narcissistic personalities (Sparkster, retrieved 8/26/2013) ●● Myth 4. All narcissists are the same. ●● Myth 1. Narcissists are people who are in love with themselves. There are many types of narcissists, though they all suffer with Technically, narcissists are actually in love with the false self, the one common trait—a complete lack of empathy. There are overt innocent, angelic, good-as-gold persona that they project to fool narcissists, covert narcissists, cerebral narcissists, the inverted those around them. In fact, the narcissist does not actually love narcissist, the classic narcissist, the somatic narcissist, and more. either one’s real self or a false self, but is compulsively obsessed All narcissists lack empathy and are unable, or unwilling, to relate with the false self-projection he or she has worked many years to the emotions of others all of the time, but they can act as though to achieve—this gives the illusion that he or she is in love with they do. (retrieved 8/28/2013) the self. The person that everyone knows is nothing more than a Authors, Twenge and Campbell have also discussed the myths fabrication, layers of twisted secrecy constructed to protect the surrounding narcissism. In some respects they are in contrast to disturbed abuser that lives beneath the facade. Sparkster’s myths pertaining to narcissism. ●● Myth 2. Narcissists are just people with high levels of self-esteem. ●● Myth 1. Narcissism is “really high” self-esteem. Healthy and functional people can have high levels of self-esteem Narcissism and self-esteem differ. While narcissists may think they without being narcissistic, at least not to the point of a personality are smarter, better looking, and more important than others, they disorder. Unlike a healthy person, a narcissist’s self-esteem do not think they are more caring or compassionate. People with must be constantly regulated, and the narcissist has no empathy. self-esteem view themselves positively, but also see themselves as Therefore, in relationships, narcissists are only concerned with loving and moral. what their partner can do for them, but never the other way around. ●● Myth 2. Narcissists are insecure and have low self-esteem. The narcissist does not genuinely care about a partner’s feelings, Psychologists sometimes call this the mask model because it though will pretend to. A narcissist can show high levels of self- suggests that narcissism is a mask for low self-worth. According entitlement and the acted out empathy is all just a part of a facade. to the authors, there is little evidence that extroverted” narcissists ●● Myth 3. Narcissists are vain and big-headed. have low self-esteem. The Implicit Association Test (IAT) was Although a high level of narcissism can result in people becoming adapted by researchers to uncover how narcissists actually feel more obsessed with their own physical appearance and self-image, about themselves, and the results indicated that narcissists have a true malignancy of narcissism goes much deeper, resulting very similar views of themselves on the inside and the outside. In in an unreasonable balance of self-entitlement, dysfunctional other words, they are secure and positive that they are winners, but relationships, and what can only be described as backward logic, also believe that caring about others is not that important. which is persistent over a long period of time.

Page 46 Psychology.EliteCME.com Diagnosing NPD Personality disorders such as NPD are typically diagnosed by a trained ___ 7. A. I find it easy to manipulate people. OR mental health professional, such as a psychologist or psychiatrist. B. I don’t like it when I find myself manipulating people. Family physicians and general practitioners are generally not trained ___ 8. A. I try not to be a show-off. OR or well-equipped to make this type of psychological diagnosis. So, B. I will usually show off if I get the chance. while a patient can initially consult a family physician about this problem, they should refer the patient to a mental health professional ___ 9. A. I am much like everybody else. OR for diagnosis and treatment. There are no blood or genetic tests used to B. I am extraordinary person. diagnose personality disorder. When psychologists assess NPD, they ___ 10. A. I like having authority over other people. OR more often use the Narcissistic Personality Inventory (NPI), developed B. I don’t mind following orders. in the 1980s by Robert Raskin and Howard Terry at the Institute of Personality Assessment and Research at the University of California Scoring at Berkeley. The form that is more often used pairs 40 narcissistic Questions 3, 5, 7, and 10: Give yourself 1 point if you answered A. statements with non-narcissistic statements. Respondents are not told Questions 1, 2, 4, 6, 8, and 9: Give yourself 1 point if you answered B. the test measures narcissism. The following list of questions provides a 0-3 points: You have scored low in narcissism. sampling of the inventory. 4-5 points: You have scored about the same in narcissism as the Choose A or B with each of the following pairs. Only mark one answer average college student. This is a slightly above-average score for for each attitude pair. someone older than 40. ___ 1. A. I prefer to blend in with the crowd. OR 6-7 points: You have scored above average in narcissism. B. I like to be the center of attention. 8-10: You have scored significantly above average in narcissism. ___ 2. A. The thought of ruling the world frightens the hell out of (Twenge and Campbell, 2010) me. OR B. If I ruled the world it would be a much better place. Many people with NPD do not seek treatment. People with personality disorders, in general, do not often seek treatment until the disorder ___ 3. A. I can live my life any way I want to. OR starts to significantly interfere or otherwise impact their lives.This B. People can’t always live their lives in terms of what most often happens when coping resources are stretched too thin to they want. deal with stress or other life events. ___ 4. A. I don’t particularly like to show off my body. OR A NPD diagnosis is made by mental health professionals comparing B. I like to show off my body. symptoms and life history, as well assessing any other inventories. ___ 5. A. I will never be satisfied until I get all that I deserve. OR They will make a determination whether symptoms meet the criteria B. I will take my satisfactions as they come. necessary for a personality disorder diagnosis. ___ 6. A. I am no better or no worse than most people. OR B. I think I am a special person.

Symptoms NPD is characterized by dramatic, emotional behavior, which is in the Although some features of NPD may seem like having confidence or same category as antisocial and borderline personality disorders. NPD strong self-esteem, it is not the same. This disorder goes beyond the symptoms may include: border of healthy confidence and self-esteem. People with NPD often ●● Believing that one is better than others. put themselves onto a pedestal. In contrast, people who have healthy ●● Fantasizing about power, success, and attractiveness. confidence and self-esteem do not value themselves more than they ●● Exaggerating one’s achievements or talents. value others. ●● Expecting constant praise and admiration. When one has NPD, one may come across as conceited, boastful, or ●● Believing that one is special and acting accordingly. pretentious, and monopolize conversations. They may belittle or look ●● Failing to recognize other people’s emotions and feelings. down on people they perceive as inferior and may have a sense of ●● Expecting others to go along with one’s ideas and plans. entitlement. When they do not receive the special treatment to which ●● Taking advantage of others. they feel entitled, they may become very impatient or angry. They may ●● Expressing disdain for those one feels are inferior. insist on having the best of everything—the best car, athletic club, ●● Being jealous of others. medical care, or social circles, for example. ●● Believing that others are jealous. ●● Trouble keeping healthy relationships. Underneath all this behavior often lies a fragile self-esteem. Narcissists ●● Setting unrealistic goals. have trouble handling anything that may be perceived as criticism. The ●● Being easily hurt and rejected. person may have a sense of secret shame and humiliation. To make ●● Having a fragile self-esteem. oneself feel better, one may react with rage or contempt and efforts to ●● Appearing as tough-minded or unemotional. belittle the other person to make one appear better. (Mayo Clinic staff, retrieved 8/28/2013)

A brief self-assessment Heitler provides a brief self-assessment to share with clients when Consequently, it can be challenging for people to sustain a relationship appropriate. (Heitler, 2012) While narcissists can be very enjoyable to with narcissists. The bottom line is that healthy people in healthy talk with and to do things with, they can also be somewhat provocative relationships are able to sustain both selfishness and altruism. in how they communicate; especially when their partners or friends When differences arise, socially effective people are better able to hit bumps in the road. Narcissists change topics, become defensive, compromise because they routinely hear and take into consideration or get angry when their partner or friend needs to discuss difficulties. both their own and other people’s concerns. The ability to find these Psychology.EliteCME.com Page 47 win-win solutions is a major reason why emotional health is associated Score: 0 1 2 3 4 5 6 7 8 9 10 with being able to live life mostly in a good mood. Sign #3: The rules don’t apply to me. Additionally, narcissists can be very generous. They may, for instance, “I can have affairs, cut into a line where others are waiting, cheat on give away large sums of money to charity. Generous giving makes the my taxes, and ignore rules that get in the way of doing what I want. giver feel good and also feels like the right thing to do. At the same Rules are for other people to follow.” time, when there is a situation in which someone with narcissistic Narcissists experience themselves as above others, so the rules don’t tendencies wants something, and that desire is in conflict with what apply to them. someone else wants, the selfish side takes over. Score: 0 1 2 3 4 5 6 7 8 9 10 Heitler introduces these questions: ●● Are you someone that your guy friends, girl friends, or spouse like Sign #4: Your concerns are really criticisms of me, and I hate being a lot, and yet often also finds demoralizing to be with when serious criticized. issues come up? “If you insist on my listening and taking your concerns seriously I’m ●● Do people tell you that you seem to take up all the space in the likely to get mad. Criticism hurts. I can criticize others, and often do, but room, or that “it’s all about you?” if you criticize me you’re hurting my feelings so I’ll hurt you back.” The brief self-assessment Narcissists paradoxically manifest an inflated idea of their own Expanding on this core definition of narcissistic functioning as importance, yet are quick to feel deflated by negative feedback. unilateral listening, here are six signs of narcissism. Score each Score: 0 1 2 3 4 5 6 7 8 9 10 dimension from 0 to 10. Zero is not at all. Ten is all the time. First assess yourself. Then circle back to score someone in your life that is Sign #5: When things go wrong between us, it’s always your fault. difficult to deal with. The goal: See your and others’ patterns clearly. “I can’t be expected to apologize or to admit blame. I’m above others and above reproach. Don’t threaten me with expecting me to say how Sign #1: Unilateral listening. I’ve contributed to a problem or I’ll get mad at you.” For example: “What I want is all that matters. When we make decisions together, what you want, your concerns, your feelings...these are mere This trait may come from confusing the part with the whole. If I’ve whispers, inconveniences, and irrelevancies. When we discuss issues, done one thing that’s not right, then I must be all bad. my opinions are right. Yours are wrong or else of minimal importance. If Score: 0 1 2 3 4 5 6 7 8 9 10 you expect to have input, you are undermining me.” Sign #6: If I’m angry, it’s your fault. Instead of listening to be responsive, narcissistic listening listens to “You made me mad. You didn’t listen to me. You criticized me. You’re dismiss, negate, ignore, minimize, denigrate, or otherwise render trying to control me. Your view is wrong. So you need to apologize, irrelevant, other people’s concerns. not me.” Score: 0 1 2 3 4 5 6 7 8 9 10 “It’s never my fault if things didn’t go well. I’m not responsible for the Sign #2 It’s all about me. problem. Someone else is. I’m not responsible either for my anger. If “I know more, I know better, I’m more interesting. When we talk, I’m mad, that’s your fault.” it’s mostly about me. In conversations, I take up most of the air time. Narcissists may seem generally quite socially agile. At the same time, Maybe that’s why people say I suck up all the air in a room.” they also can be quick to anger, and when they do, will promptly “When I want something, I need to have it. Never mind how you feel blame their anger on others. Narcissistic people see themselves about it; it’s all about me. I’m big and important and you are merely as special, and can also be thin-skinned. Any feedback can feel also here, mostly to do things for me, like a third arm.” threatening. The immediate response will be to issue blame. Narcissistic people are sometimes, and even often, generous. The Narcissists tend to be hypersensitive about control. Any request, difficulty with trusting a narcissist to take actions that are sympathetic therefore, to a narcissist is at risk for triggering irritation. Asking a to your interests comes at the times when what they want is contrary narcissist to do something your way rather than theirs is particularly to what someone else wants. Odds are, at these times they will act in a likely to sound to them like you are telling them what to do. Their manner that is selfish, that is, responsive only to their own concerns. anger in response is your fault. Causes Researchers today do not know what causes NPD. As with other mental There are many theories about the possible causes of NPD. Most disorders, the cause is likely complex. Although the cause of NPD is not professionals subscribe to a biopsychosocial model of causes meaning, known, some researchers think that extreme parenting behaviors, such the causes of are likely due to biological and genetic factors, social as neglect or excessive indulgent praise, may be partially responsible. factors such as how a person interacts in their early development with The cause may be linked to a dysfunctional childhood, such as excessive their family and friends and other children, and psychological factors the pampering, extremely high expectations, abuse, or neglect. It is also individual’s personality and temperament, shaped by their environment possible that genetics or psychobiology, the connection between the and learned coping skills to deal with stress. This suggests that no single brain and behavior and thinking, plays a role in the development of factor is responsible, but, it is the complex and likely intertwined nature NPD. The literature is mixed with regard to causal factors. of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be passed down to their children. Risk factors NPD is rare and affects more men than women. It often begins in early ●● Lack of affection and praise during childhood. adulthood. Although some adolescents may seem to have traits of ●● Neglect and emotional abuse in childhood. narcissism, this may simply be typical of the age and does not mean ●● Excessive praise and overindulgence. they will develop the disorder. ●● Unpredictable or unreliable caregiving from parents. Risk factors for NPD may include: ●● Learning manipulative behaviors from parents. ●● Parental disdain for fears and needs expressed during childhood.

Page 48 Psychology.EliteCME.com Children who learn from their parents that vulnerability is Complications unacceptable may lose their ability to empathize with others’ needs. Complications of NPD, if left untreated, can include: They may also mask their emotional needs with grandiose, egotistical ●● Substance abuse. behavior that is calculated to make them seem emotionally bulletproof. ●● Alcohol abuse. (Mayo Clinic staff, retrieved 8/28/2013) ●● Depression. ●● Suicidal thoughts or behavior. ●● Relationship difficulties. ●● Problems at work or school. (retrieved 8/26/2013, Mayo Clinic)

Research Various research studies have examined specific aspects of NPD. Some vs 45.2 percent in Unipolar patients, chi(2)2=10.1, p<0.006). The of these research studies are described below. differences in the distribution and prevalence of Personality Disorders Title: Gray Matter Abnormalities in Patients with Narcissistic between the two patient groups are discussed. PMID: 15460367 Personality Disorder. Top of FormLars Schulze, Isabel Dziobek, [PubMed - indexed for MEDLINE] Aline Vater, Hauke R. Heekeren, Malek Bajbouj, Babette Renneberg, Title: Pessimistic Mood in Decompensated Narcissistic Patient. Yang Isabella Heuser, Stefan Roepke. PS, Huang TL. Department of Psychiatry, Chang Gung Memorial Abstract Hospital, Kaohsiung, Taiwan, ROC. Chang Gung Med J. 2004 Apr; Background: Despite the relevance of narcissistic personality disorder 27(4):318-21. (NPD) in clinical settings, there is currently no empirical data available We report the negative emotional state as pessimistic mood of a case regarding the neurobiological correlates of NPD. In the present study, with narcissistic personality disorder during the period of narcissistic we performed a voxel-based morphometric analysis to provide initial decompensation. In addition, we identified the clinical differences insight into local abnormalities of gray matter (GM) volume. between pessimistic mood and depressive disorder. A 28-year-old Methods: Structural brain images were obtained from patients with unmarried woman experienced herself, her life and the external NPD (n = 17) and a sample of healthy controls (n = 17) matched object as futile and disappointing after repeated failure to satisfy her regarding age, gender, handedness, and intelligence. Groups were grandiose fantasies about the search for ideal love. The patient then compared with regard to global brain tissue volumes and local gave up her formerly gratifying activities, and fell into a prolonged state abnormalities of GM volume. Regions-of-interest analyses were of negative emotions and passivity dominated by pessimistic mood calculated for the anterior insula. characterized by an overwhelming sense of futility. The patient did not respond to medical treatment with antidepressants firstly. However Results: Relative to the control group, NPD patients had smaller after a 2-year course of intensive psychotherapy, the patient was able GM volume in the left anterior insula. Independent of group, GM to restore her zest to find a new boyfriend with a more rational and volume in the left anterior insula was positively related to self-reported realistic attitude. Clinically, decompensated narcissistic patients do not emotional empathy. Complementary whole-brain analyses yielded exhibit the typical attitude of worthlessness or guilty feelings, and are smaller GM volume in frontoparalimbic brain regions comprising the devoid of certain specific depressive emotions (e.g., sadness, sorrow, rostral and median cingulate cortex as well as dorsolateral and medial etc.). In contrast, decompensated narcissistic patients with pessimistic parts of the prefrontal cortex. mood exhibit a dominant sense of futility and other negative emotions Conclusion: Here we provide the first empirical evidence for structural presented as outrage and disappointment. The purpose of this case abnormalities in frontoparalimbic brain regions of patients with NPD. report was to emphasize the importance to recognize clinical features of The results are discussed in the context of NPD patients’ restricted pessimistic mood for the differential diagnosis and management of the ability for emotional empathy. (Journal of Psychiatric Research, 2013) decompensated narcissistic patient. (Publication Types: Case Reports PMID: 15239200 [PubMed - indexed for MEDLINE] Title: Comorbidity of DSM-IV Personality Disorders in Unipolar and Bipolar Affective Disorders: A Comparative Study. Schiavone P, Dorz Title: Personality Disorders and Violence Among Female Prison S, Conforti D, Scarso C, Borgherini G. Affective Disorders Unit, Casa Inmates. Warren JI, Burnette M, South SC, Chauhan P, Bale R, Friend di Cura Parco dei Tigli, Padova, Italy. R. Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, VA. J Am Acad Psychiatry Law. 2002;30(4):502-9. The aim of this study was to compare the prevalence of Personality Comment in: J Am Acad Psychiatry Law. 2002;30(4):510-2. Disorders assessed by Structured Clinical Interview for Axis-II in 155 in-patients diagnosed with Unipolar Disorder vs inpatients with The current study seeks to expand our understanding of the Bipolar Disorder (39). The most frequent Axis II diagnoses among increasingly well documented relationship between mental disorder Unipolar inpatients were Borderline (31.6 percent), Dependent (25.2 and violence, specifically by examining the relationship betweenAxis percent), and Obsessive-Compulsive (14.2 percent) Personality II disorders and community institutional violence among a cohort of Disorders. Among Bipolar inpatients, the most prevalent personality 261 incarcerated women. Drawing from an initial screening of 802 disorders were Borderline (41 percent), Narcissistic (20.5 percent), female inmates in maximum security, we sampled to identify 200 Dependent (12.8 percent), and Histrionic disorders (10.3 percent). nonpsychotic women who met criteria for one of the four Cluster Using chi squared analysis, few differences in distribution emerged B personality disorders, and 50 nonpsychotic women who did not between the two groups: Unipolar patients had more recurrent meet criteria for these disorders. Each inmate was interviewed with Obsessive-Compulsive Personality Disorder than Bipolar patients the Structured Clinical Interview for DSM-IV Axis II Personality (chi(1)2=6.24, p<.005). Comorbid Narcissistic Personality Disorder Disorders (SCID-II). Information regarding instant offense and was significantly more frequent in the Bipolar than in the Unipolar institutional behavior was obtained from prison files and a self-report group (chi(1)2=6.34, p<0.01). Considering the three clusters (DSM-IV inventory. The analyses indicated a high degree of comorbidity classification), there was a significant difference between the groups, between the various Cluster B diagnoses and a significant association Cluster C (fearful, avoidant) diagnoses being more frequent in the with various types of violent crime and nonviolent criminality. Unipolar than in the Bipolar group (48.4 percent vs 20.5 percent, Significant relationships were found between Antisocial Personality respectively). Cluster B (dramatic, emotionally erratic) diagnoses were Disorder and institutional violence, and Narcissistic Personality found more frequently in patients with Bipolar Disorders (71.8 percent Disorder and incarceration for a violent crime. Cluster A diagnosis

Psychology.EliteCME.com Page 49 was unexpectedly found to be associated with both incarceration for Title: Brief Communication: Pathological Narcissism in Bipolar a violent crime and incarceration for prostitution. (PMID: 12539904 Disorder Patients. Stormberg D, Ronningstam E, Gunderson J, Tohen [PubMed - indexed for MEDLINE] ) M. Department of Psychiatry, Harvard Medical School, Boston, MA. J Title: Differentiating Narcissistic and Antisocial Personality Personal Disord. 1998 Summer;12(2):179-85. Disorders. Gunderson JG, Ronningstam E. McLean Hospital, The occurrence of pathological narcissism in bipolar patients, and the Belmont, MA. J Personal Disord. 2001 Apr;15(2):103-9. diagnostic relation between narcissistic personality disorder (NPD) and The conceptual, clinical, and empirical overlap between the constructs bipolar disorder (BD), were investigated. The Diagnostic Interview for of narcissistic personality disorder (NPD) and antisocial personality Narcissism (DIN) was administered to bipolar patients when manic disorder (ASPD) is reviewed and their descriptive discriminability and when euthymic. The scores were compared to those of an NPD is investigated. Twenty-four patients with NPD and 16 patients with sample and a control group of general psychiatric patients. Euthymic ASPD were compared on 33 characteristics for pathological narcissism bi-polars do not exhibit a higher level of pathological narcissism or a assessed with the semi-structured Diagnostic Interview for Narcissism. higher prevalence of NPD than psychiatric patients in general. However, The results confirm a sufficiently broad array of similarities that the when manic, bipolar patients do appear similar to the narcissistic group, question of whether these categories should be kept separate (as they sharing 12 out of 14 of the identifying criteria for NPD. The results are in DSM-IV) is underscored. The results also indicate important support the inclusion of mania in the differential diagnosis of NPD. areas of difference. The NPD sample was best discriminated from the (PMID: 9661104 [PubMed - indexed for MEDLINE]) ASPD sample by their grandiosity, that is, the tendency to exaggerate Title: Pathological narcissism and narcissistic personality disorder in their talents, and to regard themselves as more unique and superior. Axis I disorders. Ronningstam E. Department of Psychiatry, Harvard (PMID: 11345846 [PubMed - indexed for MEDLINE]) Medical School, Boston, MA. Harv Rev Psychiatry. 1996 Mar-Apr; Title: The Etiology of Narcissistic Personality Disorder. Fernando J. 3(6):326-40. Psychoanal Study Child. 1998;53:141-58. This paper presents available information on the comorbidity of This paper presents a view of the etiology of narcissistic personality narcissistic personality disorder (NPD) and pathological narcissism disorder which, while not new, is at variance with the commonly with major mental illness. A review of empirical studies reporting held position that this disorder is the outcome of the insufficient on the prevalence of NPD in Axis I disorders, and of theoretical and gratification of the normal narcissistic needs of infancy and childhood. clinical literature on narcissistic pathology in major mental illness, The contrary thesis is presented: that narcissistic personality disorder forms the basis for an analysis of this interface. The results show that is the outcome of narcissistic over-gratification during childhood. A prevalence rates of NPD in Axis I disorders rarely exceed those found fixation to this over-gratification interferes with the normal maturation in the general psychiatric or personality disorder populations (i.e., and integration of the superego, leading to difficulties in self-esteem less than 22 percent). NPD was found at high rates in individuals with regulation and to a tendency to massive externalization. Clinical a substance use disorder (12-38 percent) or bipolar disorder (4-47 material is presented to support this view. (Publication Types: Case percent); it was present at very low rates or absent in persons with Reports (PMID: 9990828 [PubMed - indexed for MEDLINE]) obsessive-compulsive disorder. Higher prevalence rates were reported in the studies that used the Millon Clinical Multiaxial Inventory I or Title: Identifying the Unique and Common Characteristics Among the II than in those that employed the Structured interview for DSM-III DSMIV Antisocial, Borderline, and Narcissistic Personality Disorders. Personality Disorders or the Structured Interview for DSM-III-R Holdwick DJ Jr, Hilsenroth MJ, Castlebury FD, Blais MA. Department Personality Disorders--Revised. There is no evidence implicating a of Psychology, University of Arkansas, Fayetteville, AK. Compr significant relationship between NPD and any specific Axis I disorder. Psychiatry. 1998 Sep-Oct;39(5):277-86. A comparison of theoretical and clinical studies with empirical ones A clinical chart-review study of the Cluster B personality disorders reveals major differences in the views regarding the presence and (PDs) was conducted to evaluate the specificity of DSM-IV criteria for significance of NPD in Axis I disorders. However, the results highlight the Antisocial Personality Disorder (ANPD), Borderline Personality trends of interacting comorbidity between NPD and substance use Disorder (BPD), and Narcissistic Personality Disorder (NPD). Eight- disorders, bipolar disorder, depression, and anorexia nervosa. (PMID: six outpatients meeting DSM-IV criteria for a PD were identified 9384963 [PubMed - indexed for MEDLINE]) through a retrospective chart-review procedure. Records of these 86 Title: Changes in Pathological Narcissism. Ronningstam E, patients were independently rated on all of the ANPD, BPD, and NPD Gunderson J, Lyons M. Psychosocial Research Program, McLean symptom criterion for the DSM-IV. High inter-rater reliabilities were Hospital, Belmont, MA. Am J Psychiatry. 1995 Feb;152(2):253-7. obtained for the presence or absence of a PD and symptom criteria for ANPD, BPD, and NPD (all kappa > or = 0.80). The sample consisted Objective: This study investigated types of change that occur over of ANPD (n = 20), BPD (n = 25), NPD (n = 15), and other personality time in the psychopathology of narcissistic patients. Method: Baseline disorders (OPD; Cluster A and C; n = 26). Five ANPD criteria reliably scores on the Diagnostic Interview for Narcissism of 20 patients, differentiated ANPD patients from BPD and NPD patients (1, 2, 3, 6, 7), clinically diagnosed as having narcissistic personality disorder, and two criteria did not differentiate this group from either intra-cluster were contrasted with their scores 3 years later by means of tests and category (4, 5). BPD criteria also differentiated BPD patients from chi-square statistics. The authors then compared these changes in ANPD and NPD patients; however, the specific criteria that effectively narcissism with the patients’ accounts of their life events during the differentiated categories were dependent on the group comparisons. interval between the two assessments. BPD criteria (1, 2, 3, 6, 7) differentiated BPD and ANPD patients. BPD Results: A significant decrease in the overall level of pathological and NPD patients could be discriminated on other BPD criteria (2, 3, 5, narcissism was found, particularly in the areas of interpersonal 6, 7, 8). NPD criteria showed a similar ability to differentiate patients. relations and reactiveness. At follow-up, 60 percent of the subjects NPD criteria differentiated NPD and BPD patients on DSM-IV criteria had reached the cutoff score on the diagnostic interview that indicated of 1, 3, 4, 5, 7, and 9. NPD and ANPD patients could be differentiated significant improvement, and 40 percent remained unchanged, with on other NPD criteria (1, 2, 3, 4, 5, 9). The results of this study provide a high level of pathological narcissism. A high baseline level of general support for the use of specific criteria for these three disorders narcissism in interpersonal relations was associated with absence in the differential comparison of related and unrelated PDs. The utility of change at follow-up. Examination of life events in the interval of items that describe essential features are discussed. (PMID: 9777280 between assessments suggests that changes in pathological narcissism [PubMed - indexed for MEDLINE])

Page 50 Psychology.EliteCME.com are related to three kinds of experiences: achievements, new durable research seems to have validated sexual narcissism as a characteristic relationships, and disillusionments. of borderline and histrionic personality disorders, it is yet to be tested Conclusions: The instability of narcissistic psychopathology found in with narcissistic personalities. In an effort to further explore this this study raises questions about the construct validity of narcissistic relationship as well as the validity of sexual narcissism, this study personality disorder as a diagnostic category and about the core systematically compared a sample (ages 24-33 years) of males with construct of pathological narcissism. (PMID: 7840360 [PubMed - narcissistic personality disorder with an adequately matched sample of indexed for MEDLINE]) males without personality disorders. Title: Sexual Narcissism: A Validation Study. Hurlbert DF, Apt C, Results: As compared to the control group, narcissistic men were found Gasar S, Wilson NE, Murphy Y. Faculty of P to have significantly lower self-esteem, more negative attitudes toward sex, greater egocentric patterns of sexual behavior, more conservative hilosophy, Department of Psychology, University of Ljubljana, or traditional gender role orientation, and greater sexual preoccupation. Slovenia. J Sex Marital Ther. 1994 Spring;20(1):24-34. Despite these findings, there were no significant differences between Sexual narcissism, an egocentric pattern of sexual behavior, has the groups on sexual depression and the narcissistic men evidenced recently been described in the literature and has been discovered to significantly higher sexual esteem. Implications for these findings are be associated with cluster B type personality disorders. Although the discussed. (PMID: 8169963 [PubMed - indexed for MEDLINE])

Narcissists at work Persons with NPD can be visionaries and gifted workplace A brash, arrogant, self-promoting personality is off-putting. However, contributors. Conversely, their personality disorder can also create not so when it comes to job interviews, according to a new study that bullying in the workplace, when indifference, self-absorption, control, found narcissists scored better on simulated job interviews than non- punitive actions, and fierce temper emerge. Leadership coach and narcissists. writer, Richard McKnight, has written of Steve Jobs, who was a Conducted by researchers at the University of Nebraska-Lincoln, the brilliant innovator and possibly had narcissistic traits. study determined that in the condensed version of a job interview, “When I began reading Walter Isaacson‘s biography of Steve Jobs, narcissists’ compulsion to speak at length about their accomplishments I wasn’t sure I could get past the first chapter. The late Mr. Jobs implied confidence and expertise, not obnoxiousness, by seasoned job comes off as forbidding, to say the least. I wasn’t sure I could read recruiters. Conducted in two parts, the Nebraska study first examined 600 pages about a man who is repeatedly described by his official the performances of 72 participants, a mix of narcissists and non- biographer as “cruel,” indifferent to his children, and a “control narcissists, in a videotaped job interview setting. Naturally, it is good freak.” According to Isaacson, Jobs was a profane man who would to list accomplishments when trying to impress a potential employer, publicly castigate your ideas one day and claim credit for them but the experiment found that narcissists went beyond this. Also, when the next, and would resort to crying if no other method worked in the interviewers challenged the interviewees on their accomplishments, getting his way.” the non-narcissists tended to temper their boasts, but the narcissists “Jobs was more than just a notoriously difficult person, of course, dug in and attempted to talk about them even more loudly. which is what makes his story fascinating, so I read every word. In the second experiment, 222 recruiters evaluated video applications Many writers covering his death have compared him — as his from narcissistic and non-narcissistic job seekers with similar biographer does — to Thomas Edison and Henry Ford. Isaacson qualifications. Recruiters consistently gave higher ratings to the calls him “the greatest business executive of our era.” I come away narcissistic applicants, whom researchers noted, were more inclined agreeing.” to speak at length about themselves, as well as to both smile and “To me, however, as a leadership educator and coach, Jobs’ business compliment others more than non-narcissists. accomplishments sit uncomfortably alongside his methods. I’m University Nebraska-Lincoln assistant professor of management Peter left with a vexing question: If Steve Jobs was a great business Harms, a co-author of the study, said in a university press release that leader, how are we to reconcile his exceptionally abrasive personal his team’s findings show that “what is getting narcissists the win is the style and self-centered, even brutal, approach with the popular delivery.” Harms also points out that the study highlights the challenges formulation of the leader as a nurturer of talent and leadership as the faced by HR teams as they recruit new employees. “These results show act of getting out of the way so others can rise to greatness? Was he just how hard it is to effectively interview, and how fallible we can be not a leader or do I have to revise my definition of leadership?” when making interview judgments,” he noted in the release. “We don’t “Job’s case is, as the saying goes, the exception that proves the necessarily want to hire narcissists, but might end up doing so because rule: His bullying style was a tolerated idiosyncrasy requiring they come off as being self-confident and capable.” elaborate “work-arounds,” not an asset. Jobs surrounded himself Companies that staff up with narcissists may be in for a rude with people who were not only what he called “A-players,” but awakening, according to a study published last year in the journal also people who, vitally, could tolerate his exceptionally high Psychological Science by scientists from the University of Amsterdam. standards, badgering and idea stealing.” The Dutch team found that while workers with large egos inspire “Don’t be confused by Steve Jobs’s repellent style. His biographer confidence, and that their fellow employees believe they will make wasn’t. Near the end of the book, Isaacson writes, ‘The nasty edge good leaders, narcissists are often so consumed with their supposed to his personality was not necessary. It hindered him more than it greatness that their job performance is poor. helped him.’” (McKnight, Philadelphia Business Journal, January A study by researchers from the Universities of Michigan and Virginia 6, 2012) released in 2012, found elevated levels of the stress hormone cortisol People with NPD may fare better in job interviews in narcissistic men. Elevated cortisol can lead to high blood pressure Narcissistic individuals can likely be bullies at work simply because and heart disease. (University of Nebraska, Last Updated: 04/03/2012) their personalities exhibit a pattern of grandiosity, need for admiration, NPD at work and, most importantly, lack of empathy. Among the qualities people Narcissistic managers play a major role in bullying at work. usually find endearing and attractive, narcissism is not high on the list. Narcissistic individuals lack empathy, which cannot be measured

Psychology.EliteCME.com Page 51 (Hemphill, 2011). A certain amount of healthy narcissism can help ●● “You’re not part of our team.” (Translation: “You can’t be in my administrators motivate and inspire workers. But when narcissism club.”) takes on pathologic features, it can derail an organization from its ●● “You haven’t paid your dues, so you’re not entitled.” (Translation: mission, and promote workplace bullying. “I’m entitled.”) Narcissistic bullies at work often feel contempt for their targets, often ●● “You’re more of an independent contributor to the organization.” considering them to be worthless, inferior, or undeserving of respect. (Translation: “I’m the visionary.”) Signs of contempt for another range from disregard to scorn or hate. ●● “I make more money.” (Translation: “I have higher status.”) Bullies exclude, isolate, segregate, or bar targets from participating ●● “You’re not socially on par with me.” (Translation: “We are not fully in the workplace. equals.”) ●● “You’re not as attractive or as physically fit as me.” (Translation: Bullies often feel entitled because of their power positions and “We are not equals.”) organizational relationships with people in power. They view themselves privileged to control, dominate, and subjugate others. Depending on Often, Machiavellian (characterized by craftiness and deceit, and based their worldview, normally incubated in childhood, they have acquired on the book The Prince by the 15th-century Florentine statesman and intolerance for persons and situations that do not share their particular writer Niccolò Machiavelli) in their behaviors, narcissistic bullies will beliefs. They may even have a completely different perspective usually spend time with supervisees for their own gain. Narcissists can about their professional mission versus that of their organization. be very aggressive, and are not above exploiting others; and in social Consequently, targets who do not subscribe to their way of thinking are welfare, use the excuse that it is better for the overall good of the not worthy of their respect. Narcissistic bullies normally have: organization. ●● The power to exclude the target victim who is viewed as unworthy. Narcissistic bullies also perceive themselves to be experts about almost ●● The feeling of entitlement and privilege to control and dominate everything at work. It does not matter if they know nothing about another person. technology or counseling practice; they still believe they are right. ●● Intolerance for differences (in other words, “difference” means Narcissists at work feel free to assume dual roles because they think inferior and not worthy of respect). they can do a better job. Narcissists usually believe themselves to be more special than the Narcissists believe their concerns are more important than the rest of the population and have acquired an inflated sense of self- concerns of others. It is normal to spend time with an administrator importance. They also generally bond with one another—people who who recounts his or her entire vacation, without asking how the form a mobbing consortium are more likely to receive comfort by other person is doing. They forget important workplace celebrations, admiring each other; one could even say their own reflections. They arrive late to meetings, text during meetings, and feel free to change may agree they are especially smart, witty, talented, and correct in everyone’s schedule to accommodate their own. They believe it is their shared worldviews. okay to make promises without fulfilling them, and do not share the Regarding work, narcissists tend to believe they are the only ones truth if it works against them. They believe they are entitled to better who can run their organizations, understand clients, pull together treatment because of their status, and come and go at their own whim. budgets, and be seen as visionaries. No one reports his or her own When someone else shares an accomplishment, they will talk about accomplishments as persuasively as a narcissist. Narcissists, in their own, and/or forget to congratulate or thank staff. general, do not like to “hang out” with “regular folks” unless the Narcissists also frequently disregard the needs of others. They will focus is on them. They totally buy into their own projections and give themselves raises before other, more deserving, individuals. They perceptions. Their thinking may settle on any of the following will pay attention only to those who share the same views, and they proposed thoughts and beliefs about their targets: feel free to take credit for other people’s work. They take power away ●● “You’re not assertive enough.” (Translation: “You’re weak.”) from others when others are doing better work, and will easily ignore ●● “You’re not as smart as me.” (Translation: “I’m the smartest.”) coworker achievements when said achievements threaten to overshadow ●● ”You couldn’t do my job.” (Translation: “I’m special.”) their own. All in all, narcissism within an organization creates the perfect recipe for dishing out workplace bullying. (Brohl 2013)

Narcissism and relationships In her best-selling and well researched novel, The Paris Wife, author Beth didn’t know what hit her when she met a handsome man who Paula McLain described an exchange between Ernest Hemmingway wandered into her dental office as a recent transplant from another and his first wife, Hadley, after she confronts him about his affair with city. To her love struck eyes, her soon-to-be husband seemed more a woman who would become the second Mrs. Hemming. like a prince charming than the callous, deceitful spendthrift he “It was well past midnight when Ernest came home drunk. “I don’t later proved to be. Looking back, she explains, there were signs of want you here’ I said, ‘Go home to your lover if that’s what you want.” trouble from the start, but they were far from obvious at the time. “She’s headed to Bologna,” he said, “and how would you know Narcissists are also deceiving, leaving many people completely what I want?” oblivious of their true destructive nature. Friends and family of I sat up quickly and slapped him as hard as I could, and then did narcissists who have stayed close to them throughout their lives again. He barely flinched. “Play the victim if you want, but no remain fooled by the angelic facade they present and believe that such one’s a victim here. You should have kept your mouth shut. Now it’s seemingly good, honest, and caring people deserve their respect, despite all shot to hell.” the mistakes they may have made in their lives. The narcissist knows otherwise. If their friends and family were to discover the actual amount “Are you telling me you would have been perfectly happy to just of damage they caused, anyone who would attempt to confront them go on this way, in love with her, saying nothing about it?” would feel their wrath. It would be shocking and potentially devastating. “Something like that,” he said.” Covert narcissists leave a secret trail of damage behind them and Persons with NPD do not need to be famous or rich. They often begin the trail can remain invisible to close family and friends. Family and their relationships using charm and considerable charisma. An example friends will most likely be the only real friends the narcissist has left of this would be: by the age of 40.

Page 52 Psychology.EliteCME.com Overt narcissists are less cautious about revealing their secrets and their sense of perfect autonomy; to admit to a feeling of any kind will be openly provocative in their narcissistic behavior. The narcissist suggests they can be affected by someone or something outside of generally uses shock tactics and large volumes of alcohol as an excuse themselves. They will change the subject when feelings come up, for being out of control, as they claim that they did not know what especially their own, and as quick as they might be to anger, it is they were doing. After one-night stands and on irregular occasions, often like pulling teeth to get them to admit that they have reached they may continue to have affairs in secret with as few people knowing the boiling point. about it as possible. ●● A fragmented family story: Narcissism seems to be born of Narcissists commonly damage relationships, marriages, and families neglect and abuse, both of which are notorious for creating an with their lies, cheating, and deceit while using distortion campaigns to insecure attachment style. But the very fact that narcissists, for all destroy their victims’ reputation without the victim even being aware. their posturing, are deeply insecure, also gives us an easy way to Anyone that has remained in a relationship with a narcissist for a long spot them. Insecurely attached people cannot talk coherently about time is also sure to have had their reputation, friendships, relationships, their family and childhood; their early memories are confused, and identity destroyed by cleverly plotted distortion campaigns. The contradictory, and riddled with gaps. Narcissists often give narcissist can continue to get away with their behavior doing whatever themselves away because their childhood story makes no sense, and they want, and using and manipulating anyone around them as they the most common myth they carry around is the perfect family story. successfully playing the victim. If your date sings praises for his or her exalted family take note. ●● Idol worship: The fact that no one can be perfect is not a view People who have been victimized by narcissists may feel emotionally normally shared by idol-worshipping narcissists. But then they and mentally devastated, may be feeling anxious, depressed, tense, will inevitably discover a fatal flow in the person they have and perhaps even suicidal if they have been victimized long enough. been worshipping. And stand back once that happens. At this Given the extreme circumstances, this is completely normal and recognition that the idol is simply human, narcissists feel rage. Be understandable. Victims often feel alone, cut off from the world, and mindful of someone who shares compulsive flattery or pressure to isolated during their experience. conform to an ideal image. The longer they are subject to narcissistic abuse, the more adversely ●● A high need for control: For the same reason narcissists often a victim’s health is affected. Victims often suffer with depression, loathe the subject of feelings, they cannot stand to be at the anxiety, mental anguish, stress-related illnesses, weight loss, insomnia, mercy of other people’s preferences; it reminds them that they irrational fears, post-traumatic stress (nightmares and flashbacks), and are not invulnerable or completely independent—that, in fact, more. In extreme cases, the symptoms can be much worse and people they might have to ask for what they want—and even worse, who are being, or have been, abused severely may be at high risk of people may not feel like meeting the request. Rather than express committing suicide or having a heart attack or stroke. Unfortunately, needs or preferences themselves, they often arrange events (and unless the victim can escape the narcissist, the abuse will continue. maneuver people) to orchestrate the outcomes they desire. In the The narcissist, in turn, has no empathy and cannot understand the extreme form, this can manifest as abusive, controlling behaviors. damage he or she has inflicted. The efforts at control are often far subtler than outright abuse. Be watchful for anyone who leaves you feeling nervous about Narcissists fabricate and develop stories over time that can be used approaching certain topics or sharing your own preferences. to divert the blame to other people for damages caused in the past, Narcissists have a way of making choices feel off-limits without and who would never suspect them of their lies or false accusations. expressing any anger at all—a disapproving wince, a last-minute (Sparkster, retrieved 8/26/2013) call to preempt the plans, chronic lateness whenever you are Craig Malkin, author and psychologist, has discussed early warning in charge of arranging a night together. It is more like a war of signs that clients are with narcissists. He states, “Early in my training, attrition on your will than an outright assault on your freedom. I had the pleasure of working with one of the foremost authorities (Malkin, June 21, 2013, Huffington Post) on narcissism in our field, and in part because of that experience, I Sparkster identifies specific comments that reflect narcissistic went on to work with quite a few clients who’d been diagnosed with feedback. If the above statements sound like someone familiar, then it narcissistic personality disorder. That’s where I learned that the formal is a possibility that they may be a narcissist. Some of their comments diagnostic label hardly does justice to the richness and complexity may include: of this condition. The most glaring problems are easy to spot— the ●● “I’m not really narcissistic, I just pretend to be.” apparent absence of even a shred of empathy, the grandiose plans and ●● “You will believe my lies because they are the truth... they are my posturing, the rage at being called out on the slightest of imperfections truth.” or normal human missteps— but if you get too hung up on the obvious ●● “I’m not speaking to you. You do not deserve my words.” traits, you can easily miss the subtle (and often more common) features ●● “I don’t know what you’re talking about. It’s all in your head.” that allow a narcissist to sneak into your life and wreak havoc.” ●● “You’re paranoid, you need to get to the doctor to sort your head out.” Dr. Malkin’s signs that someone may be living or involved in some ●● “I don’t know what you’re talking about. I could never do way with a narcissist include: something like that.” ●● Projected feelings of insecurity: Narcissists say and do ●● “That never happened, you must be imagining things. You need to things, subtle or obvious, that make a person feel less smart, see a shrink.” less accomplished, less competent. Think of a supervisor who ●● “I love you. I could never hurt you like that. Where are these ideas questions your methods after their own decision derails an coming from?” important project, or the girlfriend who frequently claims not The last statement is the most relevant as it indicates that ideas to understand what you have said, even when you have been are coming from somewhere and that there must be a source. The perfectly clear, or a friend who shares “back-handed” compliments narcissist knows perfectly well the true source of these ideas but has, such as, “You did great, for once.” Narcissists will shine the light most likely, been making a concerted effort outside of their partner’s back to themselves to look “better” than folks they may feel are awareness to distort any information the partner may have been stealing their thunder or they are insecure around. picking up on, in order to hide the true source of these ideas. ●● Emotion-phobia: Having a feeling in the presence of another person suggests to narcissists that they can be touched emotionally To a narcissist, secrets should be protected. Narcissists will protect by friends, family, partners, and even failure. Feelings challenge their secrets. Persons in a relationship with narcissists will be deemed

Psychology.EliteCME.com Page 53 the crazy ones and the narcissist will be out to destroy others’ opinions Narcissists believe themselves to be powerful and knowing. They can of those persons if they are cornered. Push hard enough and partners go through life without feeling empathy and can, therefore, use and will end up facing all the people they know seemingly trying to manipulate others around them. Even when it comes to having affairs, convince them that you they paranoid. narcissists will absolutely deny their participation. There could be The narcissist has the ability to use someone’s words, the truth, dates, solid physical evidence, but the narcissist will tell their partners they or small details, to confuse. Narcissists know exactly how to plant are imagining things, leaving victims feeling confused and diminished. the seeds of a lie into the subconscious of their victim(s), which will The road to recovery can be a long and drawn out path and in cases be accepted and provides a respite from the confusion. The narcissist that involve posttraumatic stress (PTS). It can often take victims up to knows he or she is somehow different and denial is a way of defending 5 years to fully recover. Of course, in cases where damage to physical a repressed knowledge of the true inner self. The fact that there is health has been caused, it is possible that the victim may never fully something different about them is projected onto the victim. recover completely, and so they need to ensure that no narcissist is ever going to compromise their psychological and physical health again.

Treating NPD Treatment of NPD typically involves long-term psychotherapy with operating from a deeply wounded place. Narcissists are empty people a therapist that has experience in treating this kind of personality who fill their emptiness with self-importance, with little or no capacity disorder. There are many types of help available for the different for genuine empathy. personality disorders. Treatment may include individual, group, If someone with NPD voluntarily signs up for group therapy, the or family psychotherapy. Medications, prescribed by a patient’s diagnosis is probably wrong. In their minds, narcissists do not need physician, may also help relieve some symptoms of personality therapy and, therefore, do not need to change. Occasionally, for legal, disorders, including problems with anxiety and distorted perceptions. marital, or social reasons, the narcissist finds his or her way into group They may also be prescribed to help with specific troubling and therapy. According to Tomasulo, the results can be quite interesting. debilitating symptoms. (PsychCentral 8/26/13) He states: Psychotherapy for patients with personality disorders focuses on helping “The effort for the narcissist to take over the group, establish them see the unconscious conflicts that are contributing to or causing himself or herself as the most important person in the group, or the symptoms. It also helps people become more flexible and is aimed at smartest, or the most resourceful will manifest very quickly. But reducing the behavior patterns that interfere with everyday living. the treatment within the group isn’t to directly confront the person Narcissists usually avoid therapy. However, they can learn to be with NPD. The facilitator must support the group’s reaction to the more caring about others, and narcissism can be reduced when these narcissist. What you change is how people deal with narcissism, individuals are included in social groups. Psychotherapy may be used not the narcissist.” to help those with NPS relate to others in a less maladaptive manner. Tomasulo continues as he relates a story from one of his facilitated groups. (Psychology Today, retrieved 8/26/2013) “John was the self-imposed answer man for the group. He had Twenge and Campbell (2010), discussed “humility, self-compassion, and advice, information, and knew what everyone should do in very mindfulness” as themes in treating narcissism. For example, humility situation. In short order, members were telling him they didn’t want has been studied and outcomes find that humble people are usually his advice, and explained to him why he was so annoying and they surrounded by friends and family who support them and allow them could understand why, by age 42, he had already had four wives. to see themselves accurately. In addition, focusing on self-compassion John was never bothered by the feedback and continued his with clients who fight reality consequently suffer more because of their unbridled advice-giving. The facilitator was frustrated too. None self-promotion efforts. They tend not to allow themselves to be human. of her direct interventions with John, trying to get him to realize Compassionate people experience less anger, more positive emotions the negative impact of his behavior, worked. and happiness, and formulate more constructive responses to criticism. After a consultation, the facilitator switched tactics. She began Meditation is one helpful way to begin to address self-compassion and it having the members talk about what it was like to have someone in continues to promote mindful awareness. their life that didn’t listen, that always set themselves up as better, Mindfulness practice is beneficial for relationships, calming the ego, and couldn’t see how hurtful he or she was being. and diffusing disagreements. The practice also prevents individuals The group unified over their feelings, and then were each from taking themselves or life events too personally, and provides one encouraged to talk about the people in their lives with whom they with the ability to see the world more as it is. (Please refer to Elite’s had had these feelings. Mindfulness Practice CE course.) John was speechless. In psychotherapy and through mindfulness practice, people with personality disorders can better recognize the effects of their behavior The strategy worked for helping the group members feel empowered, on others. Behavior and cognitive therapies also focus on resolving share strategies for coping with the self-absorbed in their lives, and symptoms or traits that are characteristic of the disorder, such as the connected to each other through their experience. inability to make important life decisions or initiate relationships. John never talked about his needs while he was giving advice. It took a Can group therapy help? very long while, but eventually the need to be appreciated and admired The general understanding is that people with NPD are not fixable, and caused John to understand the group norm, to talk about one’s needs that one should stay away from them. Many therapists tell their clients and feelings and why one has them. The change in his behavior came to avoid or leave a narcissist because people with NPD are destructive. as a result of the members being empowered. They stopped accepting his dominance, talked about their own needs, and he eventually made According to Tomasulo (2011), someone with NPD is immersed into changes that were helpful not only in the group, but in his personal the secondary drives of narcissism, aggression, and materialism. It can life as well. It wasn’t a quick fix, but it was a lasting one.” (Tomasulo, be so profound that the primary drives of compassion, empathy, and 2011, retrieved 8/26/2013) humanitarianism are lost. The worst narcissists use a false presentation of the primary drives as a way to cover their pathology. They espouse being empathic, nonaggressive, and anti-material, all the while Page 54 Psychology.EliteCME.com Treating clients affected by narcissistic relationships In addition to grief counseling, trauma-informed care, cognitive the codependence, strip control away from the narcissist, and take behavior therapy, and group support, neurolinguistic programming responsibility once again. (NLP) can help victims of narcissism in their healing process. NLP can Victims need time to rebuild their self-esteem and self-worth, be help victims recover their inner center of locus and move beyond re-establish their identity, build a network of friends, and get their experience. themselves into a better financial position. Victims need to distance Clients who have been involved with a narcissist need reassurance that themselves from the narcissist, which can be difficult because the they are not responsible for the narcissist’s behavior, even though the connecting threads can be very strong. People dealing with narcissistic narcissist may have everyone around them fooled into thinking he or personalities will most likely become dependent and the only person she would never hurt anyone. It also helps encourage clients to detach they may feel they can turn to for help could be the narcissist who from trying to prove themselves right. manipulated them in the first place. Victims may have a mountain of The therapist should let clients know that having a relationship with problems and insecurities that have built up over the course of their a narcissist often wears people out. Victims, once passionate about experience and may have been convinced that they are the problem, certain interests, may now feel worthless and devalued because when, in reality, they are of sound mind. they have been put through the process of devaluation. It would be Expressing feelings or displaying emotion with a narcissist can prove natural if clients, as a result, were to dissociate from their immediate futile. Narcissists will say whatever they need to say to get their own experiences. The therapist should remind them that narcissists use way, and to them what they are saying are just words, nothing more. mental abuse as a manipulation weapon. Showing signs of emotional insecurity is seen by the narcissist as The therapist should reinforce the idea that changing a narcissist vulnerability and opens victims up to more abuse. is highly unlikely and that narcissists will more than likely repress When a victim or relative of a narcissist does successfully manage awareness of their narcissistic traits and convince everyone that the to get the person with NPD to acknowledge that he or she has a victims are the crazy ones. Their deceit is pathological. problem and perhaps agree to counseling or therapy, this is usually for Seeking relationship counseling or therapy with the narcissist is one of two reasons: (a) the victim or relative has either successfully not, in general, a good idea. Narcissists have a large capacity for penetrated the narcissist’s solid exterior during a temporary period of manipulation, and they can be cold, calculating, and often manipulate self-reflection whereby the narcissist will promise to change or (b) as the most experienced therapist or counselor into taking their sides. soon as they go for counseling, the narcissist will present that it is the Some clinicians have found narcissists who involve themselves in a victim or relative who is the problem and will behave as though it was therapeutic career to mask their narcissistic traits, thus upholding the he or she who wanted counseling or therapy. Therapists must be wary false sense of self and projecting them as good people, while placing of the narcissist’s manipulations in these instances. them in a position of authority. A major challenge in treating narcissism is empathy—not the narcissist’s Professional mental health clinicians find that victims very often grieve lack of it, although it is challenging, but the empathy that the victim does their relationships and accepting that someone they know has NPD can have, which is inevitably being exploited by the narcissist. This often be extremely difficult to cope with. It takes time for victims to learn leaves victims repeatedly questioning themselves, while the narcissist about what they have been through, what they are going through, and successfully plays the victim, fooling those around them. to grieve the disappointment of their hopes for the relationship. Victims of narcissists often have an overwhelming desire to prove The most common piece of advice offered to those dealing with the truth to the people around them. It is better for victims to care narcissistic personalities is usually to cut off all contact. However, for less about what other people believe and focus on themselves. Doing many people this simply is not a choice. For those unable to cut all ties otherwise may seem like an attempt to ostracize the narcissist, even with the narcissist(s), it is important to maintain a healthy distance and though it’s the victim who has been truly ostracized. keep communication to an absolute minimum. In other words, “love Just as many narcissists carry out their abuse covertly, victims must from afar.” escape covertly. The narcissist should not find out about the escape Most victims of narcissistic abuse will have had their self-esteem, plan or, more than likely, it will be sabotaged. If someone lives with self-worth, and emotions worn down and so it is important for them a narcissist and gives him or her any indication the victim is planning to learn how to regain control. This means learning to break free of to leave, then the victim will probably be leaving before appropriate preparations have been made.

Has NPD become an epidemic or has it just not been diagnosed properly? It appears that many narcissistic traits have become more socially traits may have also become confused with a proper diagnosis, along accepted in recent years with the advent of social media and other with the accepted diagnosing guide. influencing factors. Yet, personality disorders are not diagnosed What makes diagnosing all the more confusing is the disparity between lightly. Each licensed mental health professional must make that the newer DSM-5 and the ICD-10. Conversation must continue to determination, understanding that mainstream confusion of narcissistic establish a universally accepted reference guide for diagnosis.

Summary This course has discussed NPD and examined the characteristics of Personality disorders affect about 15 million adults in the United States. persons with the disorder, as well as some of the treatment and ways to Approximately 10 percent to 13 percent of the U.S. population meets the support those who have been affected by someone with the disorder. diagnostic criteria for a personality disorder at some point in his or her NPD is just one of several types of personality disorders. Personality life. These disorders, however, have the highest rate of misdiagnosis of disorders are conditions in which people have traits that cause them to feel any categories. Most people can live relatively normal lives with mild and behave in socially distressing ways, limiting their ability to function in personality disorders, however, in times of extreme stress, symptoms relationships and other areas of their life, such as work or school. can increase and become disruptive in everyday activities.

Psychology.EliteCME.com Page 55 Personality disorders such as NPD are typically diagnosed by a trained development with their family and friends), and psychological factors mental health professional, such as a psychologist or psychiatrist. (i.e., the individual’s personality and temperament) shaped by their Family physicians and general practitioners are generally not trained environment and learned coping skills to deal with stress. or well-equipped to make this type of psychological diagnosis. So, In summarizing NPD symptoms, an individual would exhibit five or while the patient can initially consult a family physician about this more of the following: problem, they should refer the patient to a mental health professional ●● Has a grandiose sense of self-importance (e.g., exaggerates for diagnosis and treatment. There are no blood or genetic tests used to achievements and talents, expects to be recognized as superior diagnose a personality disorder. When psychologists assess NPD, they without commensurate achievements). more often use the NPI, developed in the 1980s by Robert Raskin and ●● Is preoccupied with fantasies of unlimited success, power, Howard Terry at the Institute of Personality Assessment and Research brilliance, beauty, or ideal love. at the University of California at Berkeley. ●● Believes that he or she is special and unique and can only be The two major diagnosing guides, DSM-5 and ICD-10 differ in their understood by, or should associate with, other special or high diagnosing criteria for personality disorders, and NPD is also identified status people (or institutions). differently. ●● Requires excessive admiration. According to the DSM-5, the “current” approach describes personality ●● Has a very strong sense of entitlement, e.g., unreasonable disorder as an “enduring pattern of inner experience and behavior that expectations of especially favorable treatment or automatic deviates markedly from the expectations of the individual’s culture, compliance with his or her expectations. is pervasive and inflexible, has an onset in adolescence or early ●● Is exploitative of others, e.g., takes advantage of others to achieve adulthood, is stable over time, and leads to distress or impairment.” his or her own ends. ●● Lacks empathy, e.g., is unwilling to recognize or identify with the According to the ICD-10, a personality disorder is a severe disturbance feelings and needs of others. in the characterlogical constitution and behavioral tendencies of ●● Is often envious of others or believes that others are envious of the individual, usually involving several areas of the personality, him or her. and nearly always associated with considerable personal and social ●● Regularly shows arrogant, haughty behaviors or attitudes. disruption. Personality disorder tends to appear in late childhood or adolescence and continues to manifest into adulthood. It is therefore There are many types of help available for the different personality unlikely that the diagnosis of personality disorder will be appropriate disorders. Treatment may include individual, group, or family before the age of 16 or 17 years. psychotherapy. Medications, prescribed by a patient’s physician, may also be helpful in relieving some of the symptoms of personality According to the DSM-5, the prevalence estimates for NPD range disorders, including problems with anxiety and perceptions. from 0 percent to 6.2 percent and are taken from community samples. Of those diagnosed with NPD, 50 percent to 75 percent are men. In addition to grief counseling, trauma-informed care, cognitive behavior therapy, and group support, NLP can be help support victims There are many theories about the possible causes of NPD. Most of narcissism through their healing process. NLP can be of great help professionals subscribe to a biopsychosocial model of causes, when assisting victims with recovering their inner center of locus and meaning the causes of are likely due to biological and genetic moving beyond their experiences. factors, social factors (such as how a person interacts in their early

Resources ŠŠ Brohl, K., (2013), Social Service Workplace Bullying; A Betrayal of Good Intentions, ŠŠ Recent Research On Narcissistic Personality Disorder - Internet Mental Health: Lyceum Books, Inc., Chicago, Illinois Editor’s Choice Psychol Rep. 2004 Aug;95(1):121-8. ŠŠ Bulfinch, T. (2008) Extracts taken from theThe Age of Fable (retrieved 8/26/2013). ŠŠ Substance Abuse and Mental Health Administration (SAMSHA) ŠŠ Harms, Peter, (2013), University of Nebraska-Lincoln, (retrieved 8/29/2013) ŠŠ Sparkster, Inside The Mind Of A Narcissist (NPD - Narcissistic Personality Disorder): ŠŠ Heitler, S. (October 25, 2012) Are You a Narcissist? 6 Sure Signs of Narcissism Malignant Self-Love (Pathological Narcissism) eBook by this author out now - Know Narcissism can spoil friendships and wreck love relationships in Resolution, Not Your Enemy: Reflections Of NPD.Ebook. (retrieved 8/30/2013) Conflict, (retrieved online 8/28/2013) ŠŠ Tomasulo P., (June 21, 2011 ), Narcissistic Personality Disorder: Does Group ŠŠ Hemphill, P., (2011), Treating Sexual disorders in an Outpatient Setting. Lecture Therapy Help?, The Healing Crowd presented at the annual conference of the Professional Recovery Network, Ponte ŠŠ Twenge, J and Campbell, W. (20010) The Narcissism Epidemic, Free Press, New Vedra., Fl. York, NY ŠŠ Journal of Psychiatric Research, Volume 47, Issue 10, Pages 1363-1369, October 2013, Received 7 January 2013; received in revised form 4 April 2013; accepted 17 Additional resources May 2013. published online 17 June 2013. National Mental Health Consumers’ Self-Help Clearinghouse ŠŠ Long, P. (1995-2011), ICD-10 copyright © 1992 by World Health Organization. Toll-free: (800) 553-4539 ŠŠ Malkin, C. (June 21, 2013) Romance Redux. ŠŠ Mayo Clinic staff, retrieved 8/28/2013 Email address: [email protected] ŠŠ McClain, Paula, (2011), The Paris Wife, Ballantine Books, New York, NY. Website URL: http://www.mhselfhelp.org ŠŠ McKnight, R., (January 6, 2012), Steve Jobs’ poisonous personality was never an asset for Apple, Philadelphia Business Journal, Substance Abuse and Mental Health Services Administration ŠŠ Payton, E., (2002), The Wizard of Oz and Other Narcissists, Jullian Day Publications. (SAMHSA) ŠŠ PMID: 12539904 PubMed - indexed for MEDLINE Toll-free: (800) 789-2647 ŠŠ PMID: 7840360 PubMed - indexed for MEDLINE ŠŠ PsychCentral, 8/26/13 Holtzman, N., (retrieved 8/26/2013), Psychology Today Website URL:http://www.samhsa.gov

Page 56 Psychology.EliteCME.com NARCISSISTIC PERSONALITY DISORDER – HAS IT BECOME AN EPIDEMIC? Final Examination Questions Select the best answer for questions 21 through 30 and mark your answers on the Final Examination Answer Sheet found on page 85 or take your test online at Psychology.EliteCME.com.

21. DSM-5 general criteria for personality disorders include a 26. The University of Nebraska-Lincoln’s study determined that in ______impairment in personality (self/interpersonal) the condensed version of a job interview, narcissists’ compulsion functioning. to speak at length about their accomplishments implied a. Mild to moderate. ______, not obnoxiousness, by seasoned job recruiters. b. Mild. a. Humility and forthrightness. c. Moderate or greater. b. Authenticity. d. Moderate. c. Confidence and expertise. d. Directness. 22. Individuals with NPD ______impulsive, aggressive, or deceitful characteristics. 27. Narcissists often begin their relationships using: a. Always have. a. A false name. b. Never have. b. Charm and charisma. c. Sometimes have. c. Others’ accomplishments as their own. d. Do not necessarily have. d. Helpful influencers.

23. The ICD-Revision 10, not the DSM-5, classifies NPD in the 28. Victims of narcissists often suffer with: category of: a. Paranoid fantasies and impaired thinking. a. “Other Specific Personality Disorders.” b. Fantasies of harming the narcissist. b. “Acute Personality Deficit Disorders.” c. Mountains of debt and job loss. c. “Antisocial Specific Personality Disorders.” d. Depression, anxiety, stress-related illnesses. d. “Other Undefined Personality Disorders.” 29. Treatment of NPD typically involves: 24. When psychologists assess NPD, they more often use the: a. Time limited and structured treatment. a. Prevalence and Intensity Inventory. b. Long-term psychotherapy. b. Behavioral Assessment Inventory. c. Working with spouses or partners. c. Narcissistic Personality Inventory (NPI). d. The extended family. d. Narcissist Aptitude Inventory. 30. Therapists should reinforce the idea with clients that changing a 25. NPD symptoms may include: narcissist: a. Adopting a white-collar profession. a. Is within their reach. b. Fantasizing about power, success, and attractiveness. b. Can be a challenge but worth it. c. Fantasizing about a famous American heroes. c. Can only be accomplished with family therapy. d. Avoiding marriage at all costs. d. Is highly unlikely.

PYMA04NPE18

Psychology.EliteCME.com Page 57 Chapter 3: Suicide Assessment And Prevention For Health Professionals 6 CE Hours

Reviewed and edited by: Christopher Cronin, Ph.D.

Course overview Several states have put forth a specific goal: “to decrease deaths the national suicide rate was 12 per 100,000 people in the population. and hospitalizations due to suicide and suicide attempts.” This is in This course presents an overview of suicide deaths, methods of keeping with the National Healthy People 2020 objectives. In 2009, suicide, at-risk populations, and suicide prevention strategies.

Learning objectives ŠŠ Describe the importance of suicide and suicide prevention. ŠŠ Describe an understanding of suicide risk assessment and related ŠŠ Compare the data related to suicide in the world with the United interventions. States. ŠŠ Identify and correctly assess populations at risk for suicide such as ŠŠ Demonstrate an understanding of the etiology of suicide and adolescents, veterans, and older adults. methods of committing suicide. ŠŠ Describe the National Violent Reporting System and its ŠŠ Identify the risks and screening programs for suicide. importance in understanding the significance of suicide in the United States. Introduction Suicide is defined by the World Health Organization (WHO) as the WHO recognizes the importance of increasing awareness of mental intentional act of killing oneself. Attempted suicide is defined as illness and suicide. It aims to support countries committed to making the failed intentional act of killing oneself. WHO has reported that suicide prevention a priority. The World Health Organization Mental even though suicide deaths are preventable, many governments Health Action Plan was implemented in 2013. Member states and policymakers consider suicide a low priority (World Health committed to reducing the rates of suicide in their individual countries Organization, 2014). On a global scale, the incidence of suicide by 10% by 2020. has continued to increase. WHO reported that in 2012, more than Why it is crucial for states to address the rising suicide rates 800,000 people died secondary to suicide. Because of the increasing According to the Suicide Prevention Resource Center, suicide and number of suicides yearly, it comes as no surprise that in 2013, WHO suicide attempts take a tremendous emotional and economic toll on implemented the first mental health action plan, which was adopted the families and loved ones of those who engage in suicidal behaviors. by the World Health Assembly. The World Health Organization’s plan Suicidal behaviors result in medical costs for individuals and families, includes decreasing the rate of suicide by 10% worldwide by 2020 lost income for families, and lost productivity for employers and the (World Health Organization, 2014). community as a whole. WHO also reported that suicide is the second most common cause of The financial benefits of implementing suicide preventative measures death among young people between ages 15 and 29 years. A shocking will, hopefully, convince policymakers and lawmakers that suicide number of suicides occur in middle-income and low-income countries; prevention is not only the right thing to do morally speaking but up to 75% of all suicides worldwide occur in low-income families also an investment that will save dollars as well as lives. A study by (World Health Organization, 2016). Shepard, Gurewich, Lwin, Reed, and Silverman (2015) demonstrated Figure 1. Mean Medical and Work-Loss Costs per Injury Death by that the average cost of one suicide was $1,795,379. Approximately Intent, United States 2013 97% of this cost was associated to lost productivity. The remaining 3% of the cost was associated with medical treatment. The yearly total cost of suicides and suicide attempts totaled $93.5 billion. The study also demonstrated that for every $1 spent on psychotherapeutic interventions, other interventions that promoted linkages between different care providers saved $2.50 in the cost of suicides (Bolton, Katz, Isaak, Tilston-Jones, & Sareen, 2013). Incidence of suicide in different populations Worldwide the availability of data on suicide is very sparse partly because suicide and suicidal behavior is considered illegal in many countries. Improved monitoring of suicides and suicidal behavior is necessary for better and more accurate data on suicide. The World Health Organization estimated that in 2012, 804,000 suicides occurred worldwide, corresponding to a suicide rate of 11.4 per 100,000 population. The WHO report suggests that this number is significantly underestimated given the hindrances involved with reporting suicides Source:http://www.cdc.gov/mmwr to the authorities (World Health Organization, 2014).

Page 58 Psychology.EliteCME.com In many nations, suicide has not been identified as a public health Although suicide rates are lower among younger age groups than problem and, therefore, does not get the attention that it deserves older adult groups, suicide remains one of the top-four causes of death partly because the estimates of suicide rates worldwide are inaccurate among people ages 44 and younger. Suicide rates have been increasing and, therefore, not identified as critical (Shrivastava, Shrivastava, & among most age groups, and the suicide rate among people 45 to 64 Ramasamy, 2015). years of age has shown an especially sharp increase. Figure 2. Suicide Rates by Age, United States, 2000–2014

Source: WISQARS Fatal Injury Reports 1999-2014

Figure 3. Ten Leading Causes of Death United States 2014, All Races, Both Sexes

Source: WISQARS Fatal Injury Reports 1999–2014

Psychology.EliteCME.com Page 59 Suicide rates vary significantly by race and ethnicity. In 2014, the American Indians and Alaska Natives, suicide rates peak during rate of suicide among American Indians/Alaska Natives was 17.47 adolescence and young adulthood and then decline. This is a very per 100,000; among Caucasians, it was 17.61. In contrast, the suicide different pattern compared to other racial and ethnic groups where the rate among Asian/Pacific Islanders was 6.26; the rate for African inverse is true. Americans was 5.63; and the rate among Hispanics was 5.86. Among Figure 4. Rate of Suicide by Race/Ethnicity, United States 2000–2014

Source: WISQARS Fatal Injury Reports 1999–2014 Figure 5. Suicide Rate by Age for American Indian/Alaska Native Compared to United States

Source: WISQARS Fatal Injury Reports 1999–2014

Data from official vital statistics regarding suicide Data from official vital statistics indicate that suicide surpassed Most of these deaths were classified as either accidental or motor vehicle traffic crashes as the leading cause of injury mortality undetermined. Suicide is likely the most underestimated cause of in the United States in 2009. However, this increase may have death by both clinical medicine and public health officials given that occurred several years prior but remained undetected. The rate of its true incidence is underestimated by death investigations that are pharmaceutical and other drug-intoxication deaths rose by 125% inadequate for validly establishing different manners of death. Without between 2000 and 2013 (Rockett, Lilly, Jia, Larkin, Miller, Nelson, & valid data, it is difficult to accurately identify risks and risk groups and Caine, 2016; Rockett, Hobbs, Wu, Jia, Nolte, Smith, & Caine, 2015). subsequently design appropriate interventions. The variation in death

Page 60 Psychology.EliteCME.com investigation procedures and practices between different states could in certifying their drug-intoxication deaths between the years 2008 affect the manner of death comparisons at a national level (Rockett et and 2010 as opposed to 92% of centralized medical examiner al., 2016; Rockett et al., 2015). system states. States with a mix of decentralized coroner and Poisoning is less likely to be included in the deaths related to medical examiner systems documented about 73% of cases; 71% of suicide compared to deaths caused by firearm trauma, hanging, or decentralized medical examiner system states specified at least one asphyxiation. In the United States, it has been suggested that the drug in certifying drug intoxications deaths (Rockett et al., 2016; category of accidental deaths include many more suicides annually Rockett et al., 2015). compared to the undetermined category given its much larger absolute Five variables were identified that could affect the incidence of suicide numbers and the recommendation from professional organizations in communities: that utilization of the undetermined category should be reserved for 1. Age distribution. those rare cases where available evidence could support more than one 2. Gender ratio. manner of death (Rockett et al., 2016; Rockett et al., 2015). 3. Urbanization rate. Certain studies have suggested that authorities consider repeated drug 4. Poverty rate. use as evidenced by multiple needle marks and prescription shopping 5. Region. by going from prescriber to prescriber as ascertained through drug- Age and gender showed an association with potential suicide monitoring programs. A suicide manner-of-death determination, in misclassification by medical examiners and coroners at the individual principle, requires that a medical examiner or coroner confirms that level. the mechanism of death was self-inflicted and that it was the person’s The poverty and urbanization rates influenced whether there was an intention to die (Rockett et al., 2016; Rockett et al., 2015). available level of expertise and resources to support high-quality Factors affecting the appropriate reporting of suicides certification medical and legal death investigations independent of the death- include social stigma, punitive life insurance policy, lack of psychiatric investigation system type. The last sociodemographic variable, region, and psychological input into manner-of-death determinations, lack was an important consideration because of significant historical of reliable witness testimony, low autopsy rate, and training deficits differences in suicide rates between certain regions—suicide rates tend among death investigators and public health officials. to be higher in states west of the Mississippi River. State-by-state distribution of drug deaths: Report of a study During the observation period 2008 to 2010, drug-intoxication death A descriptive study examined data between 2008 and 2010 and showed rates ranged from 4.8 per 100 000 population in North Dakota to 23.4 differences between states in the distribution of fatal drug intoxications in New Mexico. Drug-intoxication suicide rates varied between 0.6 across the homicide, suicide, accident, and undetermined manner-of- per 100 000 in North Dakota and 3.7 per 100 000 in New Mexico. death categories. The study also evaluated the documentation of one Percentages peaked in the West and Midwest and were lowest in or more specific drugs on the death certificate. The homicide category Oklahoma, Massachusetts, Connecticut, and a corridor extending from was negligible and made up less than 1% of drug-intoxication deaths Louisiana, Mississippi, Alabama, and Georgia in the South through to (Rockett et al., 2016; Rockett et al., 2015). Ohio, Maryland, Pennsylvania, and New Jersey. When analyzed by In the United States, the undetermined category ranged from 1% of all region, Western, Midwestern, and Northeastern states, respectively, drug-intoxication deaths in Wyoming to 85% in Maryland. Overall, showed 43%, 41%, and 33% higher odds than southern states of it was higher than 5% in 11 states and 15% or higher in 8 states. The classifying a nonhomicide drug-intoxication death as suicide (Rockett documentation of one or more specific drugs on the death certificate in et al., 2016; Rockett et al., 2015). drug-intoxication deaths ranged from 34.8% in Louisiana to 99.4% in There was a positive association between citation of one or more West Virginia. specific drugs on the death certificate in states and classification by Rockett et al. (2015) proposed that decentralized county coroner a state of a nonhomicide drug-intoxication death as suicide versus systems were more likely to have the least forensic expertise and accident or undetermined. However, centralized medical examiner resources, the least uniform death-investigation protocols, the states showed no statistically significant difference from decentralized least standardized measurement, and the least quality control. And county coroner system states in their odds of suicide classification. they were the most sociopolitically vulnerable or handicapped in Compared to medical examiner systems, county coroner systems determining the most accurate etiology of suicide. Furthermore, the are disproportionately located in more rural and less affluent areas coroner system and the medical examiner system generally operate of the country. Coroner offices comprise approximately 68% of the on disparate philosophical and forensic approaches in their respective medicolegal death investigation offices nationwide, but a majority of processes of death investigations (Rockett et al., 2016; Rockett et al., them serves populations of fewer than 25,000. 2015). Using the words abuse, addiction, or misuse on the death certificate Medical examiners are appointed, are usually physicians with training may lead to categorization of drug-intoxication fatalities, including in pathology and forensic pathology, and tend to be board certified possible suicides, as mental disorders across sociodemographic groups. in one or both disciplines. They may serve multiple counties within Suicide rate in the United States: Report of a study the same state and sometimes may serve an entire state. On the other Despite multiple suicide prevention efforts, the suicide rate in the hand, coroners are lay county-level officials who are generally elected United States has changed relatively little over the past 100 years. and have very little medical knowledge—if any at all. Although some The National Institute for Health and Clinical Excellence (NICE), in coroners may employ certified forensic pathologists in their offices, 2011, published self-harm guidelines. O’Neil, Peterson, Low, Carson, this is not a requirement. Coroners, in general, have less experience Denneson, Haney, Shiroma, and Kansagara (2012) reported that with toxicological terminology than do their medical examiner when there is behavior that is self-directed and deliberately results in counterparts (Rockett et al., 2016; Rockett et al., 2015). injury or the potential for injury to oneself, there is evidence, whether In addition, coroners are more likely to feel greater budgetary implicit or explicit, of suicidal intent. The group conducted a review constraints when considering whether to obtain toxicological tests focused on counties and populations of interest because of their while conducting forensic death investigations as a whole. With similarity to U.S. veteran and military populations. this caveat in mind, it was not totally unexpected when only 62% O’Neil et al. (2012) attempted to answer certain fundamental of decentralized county coroner states specified at least one drug questions. The first question they sought to answer: Are there any

Psychology.EliteCME.com Page 61 effective specific interventions for reducing rates of suicidal self- suicide rate can also be directly measured using data from the Centers directed violence in military and veteran populations? They found for Disease Control’s National Violent Death Reporting System that there were no randomized controlled trials that had addressed (NVDRS). self-directed violence prevention interventions in military and veteran To prevent the occurrence of violent deaths in the United States, health care settings. public health authorities need accurate, timely, and comprehensive The second question they sought to answer: was What lessons surveillance data. The NVDRS began in 2000 when the Centers for can be learned from suicidal self-directed violence prevention and Disease Control began planning and writing goals for the system. The intervention research conducted outside of veteran or military settings system has four system-specific goals (Parks, Johnson, McDaniel, & that can be applied to veteran and military populations? O’Neil et al. Gladden, 2014): (2012) specifically investigated the effectiveness of pharmacotherapy 1. To collect and analyze timely, high-quality data that monitor the in preventing the incidence of suicide. They noted that antidepressant magnitude and characteristics of violent death at the national, state, trials did not show a benefit for reducing suicide. However, they and local levels. warned that the rates of suicide may have been too low to detect a 2. To ensure data are disseminated routinely and expeditiously to difference in the suicide rates. public health officials, law enforcement officials, policymakers, They then performed a systematic review of psychotherapeutic and the public. interventions that included different studies of antipsychotic 3. To ensure data are used to develop, implement, and evaluate medications. Overall, positive findings were reported from trials programs and strategies intended to reduce and prevent violent that included flupenthixol (Depixol, Fluanxol), clozapine (Clozaril, deaths and injuries at the national, state, and local levels. FazaClo), and fluphenazine (Prolixin), although the studies were 4. To build and strengthen partnerships among organizations and performed on a very small sample population. communities at the national, state, and local levels to ensure that data are collected and used to reduce and prevent violent deaths They then examined studies that compared antidepressant medications and injuries. versus placebo, one antidepressant versus another, and antidepressant therapy versus cognitive behavioral therapy. Most of these studies Before the implementation of the NVDRS, single data sources, such were of short duration and low participant numbers and would as death certificates or law enforcement data systems, were used to not have had the statistical power and duration of follow-up to provide data regarding violent deaths. But they provided only limited allow the medication to effect a change in suicide rates anyway. information and a narrow context from which to understand patterns Consequently, they were felt to be of low strength and, therefore, of deaths collected by the system. This data system fills this gap in insufficient for determining the effectiveness of various combinations surveillance by providing detailed information on circumstances of antidepressant medications for reducing suicidal self-directed precipitating violent deaths. The NVDRS was the first data system to violence. Multiple previously published studies reported an overall link multiple-source documents on violence-related deaths to enable insufficient to low strength of evidence for the effectiveness of any researchers to understand each death more completely and accurately psychotherapeutic intervention in prevention of self-directed violence (Parks et al., 2014). (O’Neil et al., 2012). It was also the first system to link multiple deaths related to one Individual psychotherapy results reported mixed findings related to another, such as multiple homicides, multiple suicides, and cases cognitive behavioral therapy. Positive findings were reported related of homicide followed by the suicide of the suspected perpetrator. to dialectical behavior therapy for people with borderline personality It compiles information from multiple data sources, as mentioned disorder (VA Suicide Prevention Program, 2016). earlier, then merges documents for each death and links deaths that are related—such as multiple homicides, a homicide followed by Positive findings have been found for interpersonal psychotherapy, for a suicide, or multiple suicides—into a single incident (Parks et al., problem-solving therapy, for psychoanalytically oriented partial day 2014). hospitalization for people with borderline personality disorder, and for transference-focused psychotherapy. Null findings have been found for The NVDRS defines a violent death as a death resulting from the outpatient day hospitalization. Notably, these results were presented intentional use of physical force or power against oneself, another in previous reports as coming from very few studies with small person, or a group or community. The information is collected on sample sizes, many methodological flaws, and short-term follow-up unintentional firearm-injury deaths—such as incidents in which the assessment periods, suggesting that all findings are of insufficient to person causing the injury did not intend to discharge the firearm— low strength and should be interpreted with caution (O’Neil et al., and deaths of undetermined intent. All the information collected is 2012). then organized and coded on the basis of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision In their study, O’Neil et al. (2012) reported that they found no (ICD-10) or on the basis of manner of death assigned by the coroner, randomized controlled trials addressing the question: What is the medical examiner, or law enforcement (Parks et al., 2014). effectiveness of referral and follow-up services for reducing the rates of suicidal self-directed violence in military and veteran populations? Following are the specific variables analyzed by the NVDRS (Parks et al., 2014): National violent death reporting system ●● The manner of death, which deals with the intent of the person The Healthy People 2020 objectives previously mentioned represent inflicting the fatal injury, such as homicide/legal intervention, national goals to prevent disease, disability, injury, and premature suicide, or unintentional. death and to promote health equity and improve the health of all ●● The mechanism of injury, which addresses the method used groups. Healthy People 2020 includes objectives for reducing suicides to inflict a fatal injury and the circumstances surrounding the by 10%, homicides by 10%, and firearm-related deaths by 10%. It also injury, that is, the events that preceded and were identified by includes calls for an increase in the number of states that link data on investigators as relevant and contributory to the infliction of a fatal violent deaths from death certificates, law enforcement, and coroner/ injury. medical examiner reports at the state and local levels. The status of ●● Whether the person who died was a victim of a violence-related progress toward the Healthy People 2020 objective to reduce the injury.

Page 62 Psychology.EliteCME.com ●● Whether the person who died was a suspect who inflicted a fatal Each state is required to report all deaths within six months of the injury on a victim. end of each calendar year for the preceding one-year time frame. ●● Whether the decedent was both a suspect and a victim of a Subsequently, the states then have an additional 12 months to complete violence-related injury. each incident record. Even though most states meet these timelines, ●● Whether the death was an incident (an occurrence in which one or additional details sometimes arrive after a deadline has passed. Based more people sustained a fatal injury that was linked to a common on experience, the CDC estimates that case counts might increase by event within a 24-hour period) and if so, whether the type of 1% to 2% after the initial 18-month data-collection period (Parks et al., incident was documented. 2014). The NVDRS is an incident-based system. All decedents associated NVDRS findings: Report of a study with a specific incident are grouped in one record. Decisions about The NVDRS collects and organizes data regarding violent deaths whether two or more deaths should be grouped under the same obtained from death certificates, coroner/medical examiner incident are made on the basis of the timing of the injuries rather than reports, law enforcement reports, child fatality review team data, on the timing of the deaths. Examples include two or more related supplementary homicide reports, hospital data, and crime laboratory homicides when the fatal injuries were inflicted less than 24 hours data. Data collection for this report began in 2003 with seven apart, two or more related suicides or deaths of undetermined intent states that were initially included in the study: Alaska, Maryland, when the fatal injuries were inflicted less than 24 hours apart, and a Massachusetts, New Jersey, Oregon, South Carolina, and Virginia. homicide followed by a related suicide when both fatal injuries were In 2004, six more states joined the study: Colorado, Georgia, North inflicted less than 24 hours apart (Parks et al., 2014). Carolina, Oklahoma, Rhode Island, and Wisconsin. California, For the purposes of the NVDRS, suicide is defined as a death resulting Kentucky, New Mexico, and Utah joined in 2005. Ohio and Michigan from the use of force against oneself when a preponderance of the joined in 2010 for a total of 19 states (Parks et al., 2014). evidence indicates that the use of force was intentional. This category The data from California stopped being collected after 2009. Ohio and includes deaths of persons who planned only to injure rather than kill Michigan did participate in data collection, but the data collected were themselves. It also includes deaths associated with risk-taking behavior not statewide until 2011. Consequently, the data from these three states without clear intent to inflict fatal injury but associated with high risk were excluded from this report. Of note, the 16 states included make for death and suicides in which a passive assistance was provided to up approximately 27.6% of the United States population (Parks et al., the deceased, such as when information is provided to someone on 2014). how to complete the act. Of note, this category does not include death Once the data are collected on the manner of death (also known as the secondary to substance abuse, acute or chronic. Nor does it include intent) for each person, a group of trained people (called abstractors) deaths secondary to erotic behaviors, such as strangulation (Parks et takes into account information from all source documents. Typically, al., 2014). the manner of death assigned is most consistent with that reported in Homicide is defined as “death resulting from the use of physical all the source documents. If a discrepancy occurs among the source force or power, threatened or actual, against another person, group, or documents, the abstractor must assign a manner of death on the basis community when a preponderance of evidence indicates that the use of of the preponderance of evidence in the source documents. Five force was intentional.” abstractor assigned manners of death were used in this study (Parks et Included in this category is arson without an intent to injure a person al., 2014): and stabbing with unspecified intent. This category does not include 1. Suicide. death from unborn fetuses, vehicular homicide without intent to injure, 2. Homicide. unintentional firearm deaths, and combat deaths or acts of war. 3. Unintentional harm. 4. Undetermined intent. An unintentional firearm death is one that results from a penetrating 5. Legal intervention. injury or gunshot wound with supporting evidence that indicates that the shooting was not directed intentionally at the deceased. Examples According to the NVDRS, an estimated 55 000 persons die annually include the death of a person as a result of celebratory firing that in the United States as a result of violence-related injuries. This report was not intended to frighten or harm anyone, a soldier shot during a summarizes data from the CDC regarding violent deaths from 16 U.S. noncombat field exercise, or a person who received a self-inflicted states for 2010. Results are reported by sex, age group, race/ethnicity, wound while playing with a firearm. This category does not include marital status, location of injury, method of injury, circumstances of deaths caused by nonpowered firearms, such as pellet guns (Parks et injury, and other selected characteristics (Parks et al., 2014). al., 2014). The NVDRS captured 15,781 fatal incidents involving 16,186 deaths Death of undetermined intent is a death that results from the use of in 2010 from the previously discussed participating states. The major force or power against oneself or another person with the evidence cause of death was suicide, accounting for almost 62.8% of all deaths. indicating that one manner of death is no more compelling than The second most common cause of death was homicide, followed by evidence indicating another. This category includes coroner or medical deaths involving legal intervention. Deaths involving legal intervention examiner rulings, such as accident or suicide, undetermined injury, and include deaths caused by law enforcement and other individuals self-inflicted injury. legally authorized to use deadly force. Of note, the category of death involving legal interventions excludes legal executions. Deaths from A death from legal intervention is a death in which the deceased is undetermined intent accounted for approximately 12.2%; unintentional killed by a law enforcement officer or other peace officer while acting firearm deaths accounted from 0.7% (Parks, et al., 2014). in the line of duty, including military, police, and National Guard. This category excludes legal executions. In this report, legal intervention Suicides occurred at higher rates among males, Caucasians, American deaths are grouped with homicides (Parks et al., 2014). Indians/Alaska Natives, and people between ages of 45 and 54 years. In this study, the suicides most often occurred in a house or The circumstances preceding death are defined as the precipitating an apartment and involved the use of firearms. Most suicides were events that might have contributed to the infliction of a fatal injury. preceded by intimate partner problem, mental health, a physical The circumstances that preceded a fatal injury are reported based on health problem, or a crisis during the previous two weeks. Participants the content from the coroner or medical examiner and law enforcement between ages 20 and 24 had the highest rates of homicides, with higher investigative reports. homicide rates occurring among African American males.

Psychology.EliteCME.com Page 63 Homicide is the second-leading cause of death for people between rates among males were noted among decedents older than 85 years. ages 15 and 24 years and the third-leading cause of death for persons Among all ethnic groups, Asian and Pacific Islander males had the aged 1 to 4 and 25 to 34 years. Suicide is the second-leading cause of lowest rates of suicide (Parks et al., 2014). death for people between ages 25 and 34 years and, the third-leading Among females, women between the ages of 35 and 64 years had the cause for persons aged 10 to 14 and 15 to 24 years. Most of the highest rate of suicide, corresponding to 54.3%, more than half of homicides involved the use of a firearm. Homicides tended to occur in suicides among males. Similar to the male group, American Indians a house, apartment, or on a street or on a highway. Homicides tended and Alaska Natives had the highest rates of suicide, followed by to be precipitated primarily by interpersonal conflict or arguments or in Caucasian women. The lowest rate of suicide among women was association with another crime (Parks et al., 2014). noted among African Americans. Of all the suicide decedents older This report confirms the previously reported findings that violent than age 18, 30% had never been married, 39.1% were married, and deaths that result from interpersonal violence or are self-inflicted tend 22% were divorced at the time of death (Parks et al., 2014). to disproportionately affect people younger than 55 years, males, and Among female decedents, the most common method used to commit certain specific populations. In 2010, homicides and suicides were suicide was poisoning, which was used about 37% of the time, mostly precipitated by mental health problems, relationship problems, followed by firearms, which were used about 30.6% of the time. interpersonal conflicts, and recent crises (Parks et al., 2014). In males, firearms were used in more than half of the total number Data from this study can be used to monitor and potentially predict the of suicides, corresponding to 51.7%. The second most commonly occurrence of violence-related fatal injuries and assist public health used method of suicide was hanging, strangulation, or suffocation, authorities in the evaluation, development, and implementation of accounting for about 25% of suicides. The most common location for programs and policies to reduce and prevent violent deaths at the local, self-inflicted injuries was a house or an apartment, corresponding to state, and even national levels. These data can also be used to enhance 75.4% of all suicides. Natural areas were the second most common existing programs. The ultimate goal of the NVDRS is to have location, about 4.1%, followed by streets or highways, about 3.2%. Of participation from all 50 states (Parks et al., 2014). note, 134 suicides occurred in a jail or prison setting (121 males and In this study, data were obtained from individual information sources 13 females), corresponding to 1.3% of all suicides (Parks et al., 2014). and entered into a source-specific data system. In addition to allowing Multiple tests were conducted to assess the presence of alcohol or independent entry of individual sources, this approach permits later other drugs, including antidepressants, cocaine, and opiates; 66.4% review of what each source contributed with subsequent identification of all suicide decedents tested positive for alcohol. About 23.8% of of missing sources. This approach allows for comparisons of the the cases tested positive for antidepressants. A total of 44% of the thoroughness and comprehensiveness of data sources from specific decedents had a diagnosed mental health problem; about a third of states; thus it allows states to provide feedback to sources regarding these were receiving mental health treatment. Greater than 75% of the consistency of their data (Parks et al., 2014). those with a diagnosis of a mental health disease had a diagnosis of A total of 15,781 incidents and 16,186 deaths occurred during 2010, depression (Parks et al., 2014). corresponding to a crude death rate of 19.7 deaths per 100,000 For all the suicide decedents, the study conductors obtained population. Suicide as a category accounted for the highest cause of information surrounding the deaths for a total of 9032 suicide violent death, 10,167, corresponding to 62.8% of the total, and 12.4 decedents. Of these, 20.9% had a history of previous suicide attempts; deaths per 100,000 population. Homicide and legal-intervention 33.3% left a suicide note; 33.2% disclosed their intent before accounted for 24.4% of the total, 3949 cases. The total number of committing suicide. Other conditions that affected suicide decedents deaths from undetermined intent was 1973, equaling 12.2% of the were intimate partner problems, noted in 31.2% of decedents; a total. Lastly, unintentional firearm deaths accounted for only 0.7% crisis of some kind in the preceding two weeks, noted in 26.9% of of the total number of violent deaths, 97 deaths in total (Parks et al., decedents; physical health problems, noted in 22.4% of cases; job 2014). problems in 15.4% of deaths; and financial problems in 13.6% of Firearms accounted for 49.6% of included deaths; poisoning for deaths (Parks et al., 2014). 17.3%; and hanging, strangulation, and suffocation for 16.7%. A total More female decedents were observed to have a depressed mood at a of 33.5% of decedents tested positive for alcohol. Among those who time of their death than males did, 42.7% versus 39.8%. More females tested positive for alcohol, 63.1% had a blood alcohol concentration received a mental health diagnosis than males did, corresponding to greater than or equal to 0.08 g/dL, the legal limit in all states. Opiates, 61.9% of decedents compared to 38.9% of males. It was not surprising including heroin and other narcotics, were identified in 24% of cases to learn that the percentage of females and males being treated for their tested for these substances, antidepressants in 20.4%, marijuana in mental health diagnosis was lower, corresponding to 47.1% of females 15.2%, cocaine in 7.8%, and amphetamines in 4%. These data indicate and 26.5% of males (Parks et al., 2014). that a large number of violent deaths occur under the influence of Overall, the homicide rate was 4.8 deaths per 100 000 population. alcohol or other narcotics (Parks et al., 2014). Most homicide decedents aged 18 years or older had never been There was little variation in the rates of suicide by months of death. married, corresponding to 57.3%; up to 21.8% were married at the The overall suicide rate was 12.4 per 100 000 population. The rate for time of their death. In the case of homicide decedents, the relation males was nearly 4 times greater than that for females: 19.8 compared of the victim to the suspect was unknown in 52.5% of homicides, to 5.3 per 100,000 population, respectively. American Indian/Alaska committed by an acquaintance or friend in 11% of homicides, Natives had the highest rate of suicide deaths at 16.5 per 100,000 committed by a spouse or intimate partner in 10.2%, and committed population. Caucasians were next in line with a rate of 15.4 per by a stranger in 4.5% of cases. The homicide rate for males was almost 100,000 population (Parks et al., 2014). 4 times greater than that for females, corresponding to 7.7 and 2.1 per When stratifying the decedents by age group, researchers noted that 100 000 population, respectively (Parks et al., 2014). suicide rates were higher among persons aged 45 to 54 years, 55 to Non-Hispanic African Americans accounted for the highest rates 64 years, and 35 to 44 years, corresponding to 19.3, 16.8, and 15.9 of homicide, corresponding to 15.2 deaths per 100 000 population. per 100,000 population, respectively. The lowest rates of suicide were American Indians and Alaska Natives were second with 10 deaths per noted among children aged 10 to 14 years, corresponding to 1.3 per 100 000 population. Age-specific homicide rates were highest amongst 100,000 population. Adolescents had a suicide rate approximately half those between the ages of 20 and 24 years, corresponding to 11.7 that of decedents between ages 35 and 64 years. The highest suicide deaths per 100 000 population (Parks et al., 2014).

Page 64 Psychology.EliteCME.com There are several limitations of the National Violent Death reporting to 15.4 per 100 000 inhabitants in Flanders versus 8.8 per 100 000 system, including the fact that only 16 states participated in the study. inhabitants in the Netherlands. In spite of these differences in suicide Furthermore, the study relied on the availability of partnerships rates, the incidence of lifetime suicidal ideations was similar: 8.2% in between state health departments, vital statistics registrars’ offices, the Netherlands, 8.4% in Belgium. Suicide attempts were 2.3% and coroner/medical examiners, and law enforcement personnel. Data 2.5% for the Netherlands and Flanders, respectively. Although suicidal sharing and communication among partners has proved to be ideations and behaviors are assumed the most common precedents of extremely challenging, especially when states have independent suicide on an individual level, this study suggests at the global level, county coroner systems rather than a centralized coroner/medical an association between suicidal ideation and the incidence of suicide examiner system (Parks et al., 2014). itself (Reynders et al., 2015). Comparing demographically similar populations: Report of a It is argued that from the epidemiological perspective, the suicidal study process is not a linear transition from ideation to attempt to suicide. Reynders, Kerkhof, Molenbergh, and Van Audenhove (2015) From the discussion above, one could assume that people from compared two regions with similar socioeconomic indicators, the Netherlands tend to cope differently and more effectively with language, and geographic and demographic characteristics but very psychological and suicidal problems compared to Flemish people different suicide rates. The two regions discussed in their study that resulting in higher suicide rates among the Flemish (Reynders et al., met those conditions are Flanders and the Netherlands. The Flanders 2015). refers to the northern Dutch-speaking regions of Belgium. The Reynders et al. (2015) further reasoned that people with a suicidal researchers compared the data for the year 2012. They noted that past differ from people with no suicidal past as it relates to intentions, the fertility rate was 1.75 and 1.72; the percentage of students in all attitudes, and stigma associated with help-seeking behaviors and levels of education was 25.3 percent and 25.2 percent; the population attitudes toward suicide. They hypothesized that compared to density was 478.2/km2 and 496.9/km2; the unemployment rate was people with no suicidal past, people with a suicidal past had weaker 4.5 percent and 5.3 percent; and the percentage of people at risk of motivation to seek psychological help, perceived more stigma, poverty was 15 and 15.7 for Flanders and the Netherlands, respectively experienced more self-stigma and shame related to help-seeking (Reynders et al., 2015). behaviors, and had more approving attitudes toward suicide. The This study included people between the ages of 18 and 65 years researchers had anticipated that these differences would be more randomly selected. Equal samples were collected in each region. apparent in Flanders than in the Netherlands. Each respondent received a questionnaire and a guided letter with Results showed that among people with a suicidal history, women instructions. Participants were specifically asked for their personal received professional psychological help more frequently than men did lifetime experiences with suicidal ideations and suicidal behaviors. and that they expressed the intention to seek informal and professional Three questions were asked, each referring to a phase of the process of help more frequently than men did. Men reported that they would suicide: 1) death wish, 2) suicide plan, 3) suicide attempt (Reynders et cope passively with psychological problems more often and that they al., 2015). were more likely to experience self-stigmatization when seeking help The participants were specifically asked if they would seek help if (Reynders et al., 2015). they were confronted with psychological problems. The researchers Additionally, a higher proportion of men were more likely to have then distinguished the three types of help: 1) professional help, expressed disapproving attitudes toward suicide. Also, those with a including help from a primary care provider, a psychotherapist, or a suicidal past were less often married and more often unemployed. psychiatrist; 2) informal help, which referred to help from friends and The researchers also noticed that people with a suicidal past were less family; 3) passive coping, which meant not seeking help. This implied likely to seek help in the future compared to people with no suicidal that respondents would do nothing and hoped that the psychological past. When comparing the Flemish and the Dutch men, they noticed problems would resolve on their own. The participants were also that compared to Dutch men, Flemish men were less inclined to seek asked if they had ever received help for psychological problems from professional help for psychological problems, had less often received a general practitioner, a psychotherapist, or a psychiatrist (Reynders et professional help, and had less positive attitudes toward seeking al., 2015). professional help. The results among women were similar to those of The concept of psychological problems was explained using two the men’s, with the Dutch being more likely to express an intention vignettes describing a man and woman with depressive symptoms— to seek professional and informal help for psychological problems feeling fatigue, helpless, worthless, down, feeble, and sad—over (Reynders, et al., 2015). several weeks. They had little energy for fulfilling daily tasks or doing In conclusion, people with no suicidal past were more vulnerable sports. They also had diminished interests, sleeping problems, and psychologically when dealing with psychological problems in suicidal thoughts (Reynders et al. 2015). that they perceived and experienced more stigma when seeking The researchers found a great difference in the suicide rates between help; consequently, they perhaps would be less inclined to seek these two Dutch-speaking regions. The Flemish suicide rates were psychological help in the future (Reynders et al., 2015). almost 80% higher than those of the Netherlands, which corresponds

The cost of suicide During 2013, the rate of fatal injury was 61 per 100,000 population, System. For each decedent, lifetime work-loss costs were calculated with combined medical and work-loss costs exceeding $214 billion. based on the sex and age of the decedent. The sex- and age-specific Costs from fatal injuries were almost one third of the total costs of probability of surviving to a particular age was multiplied by the mean medical bills and work loss, $671 billion in 2013. earnings of people of that sex and in that age group, using U.S. Census The magnitude of the economic burden associated with injury- Bureau earnings data. An assumption made during calculation was associated deaths only underscores the imperative need for effective that no one would live past the age of 102 years (Florence, Simon, prevention. The number of injury-associated deaths in the United Haegerich, Luo, & Zhou, 2015; Florence, Haegerich, Simon, Zhou, & States during 2013 was obtained from the National Vital Statistics Luo, 2015).

Psychology.EliteCME.com Page 65 Lifetime medical costs were calculated based on the injury diagnosis In 2013, of all injury-related deaths, 20% were related to suicides; the and mechanism, the decedent’s age, and the place of death. Factored cost of these deaths totaled $50.8 billion. Homicides contributed to into the medical costs were data regarding the cost of transport, only approximately 8% of injury-related deaths, with associated costs examination by a coroner or medical examiner, and health care in of $26.4 billion. multiple settings, including emergency departments, hospitals, and Even though the rates of fatal injury increased with age, there was a nursing homes. difference in the pattern of injury intent, with higher homicide rates As previously mentioned, the total estimated lifetime medical and among young persons and higher suicide rates among middle-aged work-loss costs associated with fatal injuries in 2013 were $214 and elderly adults. Firearm-related fatal injuries accounted for 75% of billion. Males accounted for 78% of these costs and for 67% of injury the homicide-associated costs and 48% of the suicide-associated costs. deaths. Haegerich Of the total number of injury deaths, almost two These numbers are especially relevant today when the debates for gun thirds were unintentional, and these deaths contributed to a majority control laws are heightened (Florence, Simon, et al., 2015; Florence, of the cost equaling $129.7 billion, corresponding to 61% (Florence, Haegerich, et al., 2015). Simon, et al., 2015; Florence, Haegerich, et al., 2015).

Etiology of suicide The etiology of suicide is complex and heterogeneous with varying thoughts about death or wanting to be dead with no plan or intention etiology in different geographic regions, sociopolitical settings, to act. age groups, and sexes. Given that there is no effective algorithm to Approximately 30% of adolescents with suicide ideation will go on predict suicide in clinical practice, it is imperative to gain improved to attempt suicide within one year. People who attempt suicide who recognition and understanding of clinical, psychological, sociological, present to an emergency department have a 12-month risk of suicide of and biological factors to aid in the detection of high-risk individuals 1.6% and a risk of repeated suicide attempt of 16.3%, with a five-year treatment selection. The use of psychotherapeutic, neuromodulatory, risk of suicide of 3.9% (Perlis et al., 2016). or pharmacological techniques for the treatment of mental disorders can often contribute to the prevention of suicidal behavior. It has been Nonsuicidal self-injury is defined as self-injurious behaviors with established by mental health services that regular and timely follow- no intent to die. It differs from suicide attempts with respect to the up of people who attempt suicide is critical in the prevention of future person’s motivation. Nonsuicidal self-injurious behavior is also noted suicidal behavior (Perlis, Grandner, Chakravorty, Bernert, Brown, & in younger patients. There is also a difference in the psychopathology Thase, 2016). and functional impairment associated with suicidal and nonsuicidal behaviors. Nonsuicidal self-injury most commonly consists of The toll of suicide on global public health is staggering, with almost repetitive cutting, burning, rubbing, or picking. The main motivations 1 million people dying from suicide worldwide each year. Cultural in nonsuicidal self-injurious behaviors are to get attention, to relieve and moral beliefs regarding suicide and pessimistic views about distress, to induce self-punishment, to “feel something,” or to escape a the treatment and prevention of suicide are barriers to patient self- difficult situation (Perlis et al., 2016). disclosure of suicidal thoughts as well as barriers to the routine inquiry about suicidal ideations by clinicians. Approximately 45% of people Suicidal events are denoted as the onset or worsening of suicidal who die by suicide consult a primary care physician within one month ideation or a suicidal attempt. It is often denoted as an endpoint in of death, yet rarely is there any documentation by the physician of studies when rescue procedures are initiated. Patients included in questions regarding suicidal ideations during that visit (Perlis et al., this category are those with ideation who then received emergency 2016). intervention and might have made an attempt had he or she not been recognized and treated. At the same time, the data suggest that some The severity of suicidal behavior varies with progression from less suicides occur impulsively. Easy access to a means of suicide may to more severe forms of suicidal ideation and intentions with some contribute to an increased suicide rate. overlap between attempted and completed suicide. Suicide attempts are potentially self-injurious behaviors associated with at least some Deliberate self-harm is defined as any type of self-injurious intention to die. Some patients who have attempted suicide have behavior, including suicide attempts and nonsuicidal self-injury. reported that their main motivation was one other than to die, such as The combination of these two categories into a single one reflects a to get attention or to express hostility. Regardless, most of them have recognition that they have a high comorbidity and a shared diathesis acknowledged that there was a possibility that their behavior could and that nonsuicidal self-injury is a strong predictor of eventual suicide have resulted in death. In general, a suicide attempt is characterized by attempt. It is important to distinguish between events classified as a greater functional impairment than nonsuicidal self-injury (Perlis et a suicide attempt motivated by a true desire to die and the desire to al., 2016). attract attention, to escape, or to communicate hostility. Of note is that suicide attempts and nonsuicidal self-injury cannot be differentiated Active suicidal ideations are defined as thoughts about taking action unless a specific intent is revealed (Perlis et al., 2016). to end one’s life, including identifying a method, having a plan, or intending to perform a suicidal act. Having a specific plan or intention Accurate global estimates of suicide rates are difficult to ascertain, is associated with a much higher risk of the patient’s attempting as only 35% of the WHO member states have comprehensive vital suicide in the following 12 months. Passive suicidal ideations are registries with a minimum of five years of data.

Risk factors for suicide Suicide and mental disorders, such as depression and drug abuse, have of all DALYs. It remains the leading risk factor for suicide among been well established as having a link, particularly in high-income individuals between the ages of 14 and 49. countries. Alcohol is a significant risk factor leading to suicide. However, many suicides have been established as occurring during Alcohol has been identified as the fifth-leading risk for disability- periods of increased stress—notably periods of crises, such as illness, adjusted life year (DALY) on a worldwide scale. It accounts for 3.9% chronic pain, financial stress, and bad relationship breakups.

Page 66 Psychology.EliteCME.com Suicides have been reported to increase in populations likely to In high-income countries, suicide is most common among middle- be discriminated against, such as the lesbian, gay, bisexual, and aged and elderly men. The incidence of suicide ideation and suicidal transvestite (LGBT) group; minorities; immigrants; and other behavior peaks in adolescence and young adulthood, with a lifetime vulnerable populations, such as prisoners. prevalence of suicidal ideation of 12.1% to 33% and of suicidal Often times, patients who have attempted suicide are discharged behavior of 4.1% to 9.3%. with no community support or appropriate follow-up leaving them Economic crises resulting in unemployment and decreased personal vulnerable to reattempt suicide. In low-resource settings, geographic income have been correlated with increases in suicide, particularly in inaccessibility to health care facilities and the absence of trained men, although a direct causal relationship has not yet been established. professionals have been identified as potential obstacles. Family and home factors The national strategy for suicide prevention, published in conjunction Suicidal behaviors run in families, with the odd ratios of first- or with the surgeon general and the National Action Alliance for Suicide second-degree relatives is experiencing similar behaviors being first Prevention, was released in 2012. It delineated a few warning signs for degree relatives 1:7 and second-degree relatives 10:62 when adjusting suicide that loved ones could watch for in families and friends afflicted for degree of relation, indicating that distal factors can increase by suicide. The more of these warning signs a person displays, the suicide risk. Studies have shown that the risk of attempts is higher in greater the risk of suicide (U.S. Department of Health and Human relatives of people who have died by suicide, and that the risk of dying Services, 2012). by suicide is higher in relatives of people with a history of suicide Here are some of those warning signs: attempts. These effects are not likely to result from simple adaptive ●● Talking about wanting to die. behaviors. Adoption studies have shown a correlation between ●● Looking for a way to kill oneself. biological but not adoptive relatives (Perlis et al., 2016). ●● Talking about feeling hopeless or having no purpose. Although psychopathological disorders are common in families, the ●● Talking about feeling trapped or being in unbearable pain. transmission of suicidal behavior seems to be mediated through the ●● Talking about being a burden to others. transmission of impulsive aggression. When the heritability of other ●● Increasing the use of alcohol or drugs. psychiatric conditions is taken into account, the specific heritability ●● Acting anxious, agitated, or reckless. of suicidality is estimated at 17.4% for suicide attempts and 36% for ●● Sleeping too little or too much. suicidal ideation. Suicidal ideation seems to be transmitted along with ●● Withdrawing or feeling isolated. mood disorders and shows a distinct pattern for transmission from that ●● Showing rage or talking about seeking revenge. of suicidal behavior (Perlis et al., 2016). ●● Displaying extreme mood swings. Another well-characterized risk factor is exposure to early-life Cultural and geographic factors adversity, generally defined as parental neglect or childhood physical, It is important to recognize that cultural influences might supersede sexual, or emotional abuse. Early-life adversity might also be geographic location. The suicide rates of immigrants correlate more transmitted through families, partly explaining the familial aggregation closely with the rates of their country of origin than with the rates of suicidal behavior. Early-life adversity might induce long-term of the country where they live. In general, indigenous populations effects through epigenetic changes in gene pathways (Perlis et al., have high rates of suicide, which are likely caused by a disruption 2016). of traditional cultural and family supports, increased prevalence of Young people who die by suicide often have a high burden of adversity alcohol and substance use, and lower socioeconomic status, which and a history of childhood abuse or neglect. The highest risk for are also independent risk factors for suicide in the general population suicidal behavior across the lifespan exists when a mood disorder (Perlis et al., 2016). associated with suicidal ideation co-occurs with other disorders that It is well known that increases in suicide rates among indigenous either increase distress, such as panic disorder or post-traumatic stress peoples, such as Canadian Inuits, correlate with social changes, such disorder, or decrease restraint, such as conduct and antisocial disorders as forced settlement, assimilation, and disruption of traditional social and substance misuse. structure. On the other hand, suicide is rare in homogeneous societies Mental factors with common values, moral objections to suicide, and high social Precipitants to suicidal behaviors are called proximal risk factors; they cohesion although the latter might also lead to under-reporting (Perlis are temporally associated with suicidal behaviors. Besides past suicide et al., 2016). attempts, psychopathology is the most important predictor of suicide Geographic origin is another source of variation in the incidence and is strongly associated with other forms of suicidal behavior. of suicide. More people die by suicide each year in Europe, North Retrospective interviews with informants, commonly referred to as American, and South America than in Asia. In China, the suicide psychological autopsies, have frequently been used to investigate the rates are 3 times higher in rural areas than in urban areas. Some have association between psychopathology and suicide and consistently theorized that the easy access to highly lethal pesticides in rural have shown that roughly 90% of individuals who die by suicide had an areas, which also happens to be the most common method of suicide identifiable psychiatric disorder before death (Perlis et al., 2016). in China, is a major factor. Suicide in rural China is characterized by impulsive low-intent suicide attempts. Women in China have an Some psychiatric illnesses are more strongly associated with suicidal increased lethality of suicide attempts compared to men’s. Women behaviors than others are. Major depressive episodes, which are in China have higher rates of suicide death than in other parts of the associated with either major depressive disorder or bipolar disorder, world (Perlis et al., 2016). account for at least half of suicide deaths. Among patients with bipolar disorder, mixed-state episodes are most strongly associated with Economic factors suicide attempts, with the associated risk increasing significantly as WHO conducted a world mental health survey that included 108,000 the time spent in the mixed-depressive episodes (Perlis et al., 2016). participants with an average 12-month prevalence of 2% in high- Mixed-state bipolar disorders and psychotic episodes concurrent with income countries versus 2.1% in low-income countries, and the underlying depression can significantly increase the risk of imminent prevalence of suicide attempts of 0.3% versus 0.4% in high-income suicidal acts and require special attention. and low-income countries, respectively.

Psychology.EliteCME.com Page 67 Suicide risk is highest within the first year of illness and is associated It has also been shown that people with no history of suicide tend with feelings of hopelessness. Major clinical predictors of suicide to have more disapproving attitudes toward suicidal ideations and include the following: behaviors than people with a suicidal past have. The disapproving ●● Depressive symptoms. attitudes of others thus create and potentiate the feelings of shame ●● Young age. for seeking psychological help among people with suicidal problems. ●● Male sex. The stigma and attitudes described above are not just individual ●● Education. perceptions; rather, they are social conceptions rooted within a cultural ●● Positive symptoms. paradigm. These paradigms may vary across regions and countries, ●● Illness insight. thereby explaining the regional and nationwide differences in the Almost all individuals who intentionally end their lives, regardless of incidence of suicide and help-seeking behaviors (Reynders et al., whether they meet criteria for a psychiatric disorder, show evidence 2015). of hopelessness, depressed mood, and suicidal ideations. Individuals Social factors exhibiting suicidal behaviors have been shown to have altered levels of Several social factors are associated with an increased risk of suicide: serotonin and serotonin signaling. Evidence suggests that individuals living alone, highly introverted people, traumatic events that occurred exhibiting suicidal behaviors have specific serotonin genotype and in adulthood, and interpersonal stressors. Extreme hopelessness, phenotype patterns as well as low serotonin levels associated with helplessness, and worthlessness, which may or may not result from personality traits linked to suicidal behaviors, such as impulsive depressive psychopathologic disorders, have also been shown to aggression (Perlis et al., 2016). contribute to increased risk (Perlis et al., 2016). The other neurotransmitters implicated in depression and suicide are There is some evidence among the elderly that suggests that plans glutamate and gamma aminobutyric acid. Consequently, therapies implemented to decrease isolation and augment social support through targeting the glutamate pathway, such as ketamine (Ketalar, Vetalar) group activities and telephone outreach programs might also reduce administration, have provided some promising initial results in the mortality secondary to suicide (Perlis et al., 2016). treatment of severe depression and suicidal ideations. Sexual orientation has been shown to affect suicide risk. An analysis of Patients recently discharged from inpatient psychiatric units are at registry-based data suggests that individuals with a history of same-sex very high risk for subsequent completed suicide. The goal of declining relationships have a 3 to 4 times greater risk of dying by suicide, with regional suicide rates has been shown to be related to clear policies for a disproportionately greater risk for men than for women. Belonging to the management of dual-diagnosis patients, the extend of care services, a sexual minority is universally linked with increased rates of suicide and multidisciplinary reviews of deaths by suicide. attempts regardless of the individual’s sex. Multiple other factors, such as alcohol and drug-related disorders, Media reporting of suicide had also been shown to affect suicide rates, are common in people who die by suicide and might exacerbate particularly within the first 30 days after the suicide, with increases in underlying risks or interact with depression to increase suicidal the rate of suicide proportional to the amount of publicity, when details behaviors. of a method are provided, if the decedent was a celebrity, and whether Studies have shown that 9 out of 10 suicide victims suffered from the suicide was romanticized rather than reported in association at least one severe psychological problem; consequently, seeking with mental illness and the adverse consequences of the suicide on and receiving psychological help is presumed to be a protective survivors. Of all age groups, adolescents and young adults are more factor against suicide. Those who do not receive adequate help are at susceptible to the effects of media publicity (Perlis et al., 2016). increased risk for psychological problems, thereby increasing their risk Conversely, several factors are associated with a lower risk of suicide, of suicide. including effective coping and problem-solving skills, responsibility It has been well established in the literature by a number of for young children, a well-developed social support network, strong researchers that persons with suicidal thoughts were less likely to reasons for living, and religiosity, which is defined as the frequent seek psychological help compared to those who have psychological attendance of religious services or personal religiosity. The benefits of problems but no suicidal thoughts (Calear, Batterham, & Christensen, religiosity might be related to religious views on suicide or to social 2014; Carlton & Deane, 2000). Those who do not seek psychological support derived from the religious community. help tend to have negative attitudes and are more likely to have Emotional factors a stigma against help-seeking behaviors (Reynders, Kerkhof, Bereavement of loss of a close friend or relative or a loved one can Molenbergh, & Van Audenhove, 2015; Calear, Batterham, & cause a significant amount of emotional distress, which can, in turn, Christensen, 2014). lead to an inability to cope with the loss. It has also been shown that Reynders et al., (2015) showed that most people who seek and receive in cases of violent deaths, people are more likely to experience grief psychological help tend to experience shame and feel stigmatized after complicated by suicidal ideations. receiving the much needed help. Stigma is defined as behaviors that Physical factors are often perceived by the general public to be disgraceful or shameful Physical illness, along with concurrent depression, has been shown (Reynders et al., 2015). to be a risk factor contributing to the etiology of suicide. Examples The stigma perceived from having suicidal thoughts is distinguished of physical disease whose concurrent occurrence with mental illness from that perceived after receiving help for the management of suicidal has been shown to increase suicidal risk include asthma and chronic ideations and suicidal behaviors. Perceived stigma purports the idea obstructive pulmonary disorder, multiple sclerosis, osteoporosis, and that people are convinced that they will be discriminated against if coronary artery disease (Perlis et al., 2016). they ventured to seek help for psychological problems. These people Chronic diseases that can increase the risk of suicide independent then tend to apply the attitude of stigmatizing onto themselves, thereby of a concurrent mental health disorder include epilepsy, migraines, resulting in low self-esteem and low self-efficacy. They, therefore, and inflammatory bowel disease. Specifically, in epilepsy, depressive erroneously deduce that a way to prevent being stigmatized is to not symptoms may precede the onset of seizures or occur secondary to disclose psychological problems and to not seek help (Reynders et al., treatment. 2015). Sleep disturbances and insomnia may increase the risk of suicide ideation or suicidal behaviors and can be independent of the presence

Page 68 Psychology.EliteCME.com of depressive signs and symptoms, which might be mediated by explanation for these findings stated that being awake when one is not increased impulsivity and reward-seeking behaviors. biologically equipped to be so results in hypofrontality and diminished It has been purported that sleep disturbances may represent one executive function. This, then, represents a common pathway to contributory factor to the etiology of suicide. Large-scale research suicidal ideation and behaviors (Perlis et al., 2016). in this area did not begin until the 2000s. Since the initiation of this Athletes and veterans who have sustained chronic traumatic brain research, sleep disturbance has been well established as a risk factor injuries are very vulnerable to the possibility of suicidal behaviors and for suicidal ideations and suicidal behaviors. Insomnia, nightmares, suicidal ideations. This effect is possibly mediated by a decrease in and other sleep disorders have each been found to contribute to the effective impulse control following repeated brain injuries (Perlis et risk for suicidal ideation and behavior. Being awake at night, by al., 2016). itself, confers increased risk of suicide. The hypothesis offered as an

Methods used to commit suicide The most common means of suicide in the United States is a firearm, Specifically, adults with a diagnosis of a terminal illness—defined as followed by suffocation and poisoning. Up to 57% of suicides among an illness expected to be fatal within six months—must make two oral males involve a firearm. Firearms are the most common method of requests to their attending physician for help with physician-assisted suicide used by men of all ages, especially among men aged 65 years suicide. The requests must be separated by at least 15 days (Emanuel and older. Among women, suffocation is the most common method et al., 2016). among 15- to 24-year-olds. Poisoning is the most common method The issues surrounding the ethics and legality of euthanasia and among 24- to 64-year-olds. physician-assisted suicide remain controversial. For starters, the Among women, a greater percentage of suicide deaths involve definition of active euthanasia, also known simply as euthanasia, poisoning rather than firearms. However, almost 33% of suicide differs. One definition of euthanasia is when a person, usually a deaths, corresponding to 32% of all suicides among women, involve physician, actively or intentionally assists a patient to end his or firearms. her life by some medical intervention, such as the injection of a Approximately 30% of all global suicides are committed with the use neuromuscular relaxant. of pesticide self- poisoning. Most of these suicides occur in rural areas Switzerland was the first country to legalize the euthanasia and in low-income and middle-income countries. These are areas where physician-assisted suicide in 1942. The Canadian Supreme Court agriculture, specifically rural agriculture, is usually practiced (World ordered each province to draft laws addressing the legalization of Health Organization, 2016). euthanasia by June 2016. The province of Quebec legalized euthanasia Physician-assisted suicide and euthanasia in 2014. As of June 2016, Canada’s parliament passed legislation Aid in dying is a practice whereby a capable adult in the terminal legalizing both euthanasia and physician-associated suicide (Emanuel stages of an illness elects to ask a physician to prescribe medications et al., 2016). to hasten death. This has also been called physician-assisted suicide. In In most states, euthanasia is usually limited to voluntary cases the United States, there have been discussions about whether the term in which the patient is mentally competent and clearly requests used should be physician-assisted suicide or physician-assisted death euthanasia. Conversely, involuntary euthanasia occurs when the or physician aid-in-dying (Emanuel et al., 2016). patient is mentally competent but did not request euthanasia. Finally, Currently in the United States, five states permit physicians to aid nonvoluntary euthanasia refers to cases in which the patient is patients in dying. Of these, Oregon was the first to pass the Death with not mentally competent and is incapable of requesting euthanasia Dignity Act, in 1994, which was eventually implemented in 1997. (Emanuel et al., 2016). Subsequently, Washington passed similar legislation in 2008. Montana In most nations, involuntary and nonvoluntary cases are not defined as followed suit by allowing physician-aided dying in 2009 through a euthanasia but rather denoted “termination of life without the patient’s Montana State Supreme Court ruling. Vermont passed legislature in explicit request.” The term passive euthanasia should be avoided 2013. In late 2015, California became the fifth state to pass legislation altogether because it refers to terminating potentially life-sustaining with the End of Life Option Act (Emanuel, Onwuteaka-Philipsen, treatments instead of the administration of a specific medical Urwin, & Cohen, 2016). California’s legislative act is mostly modeled intervention to end a patient’s life. after Oregon’s Death with Dignity Act. In many nations, the termination of potentially life-sustaining It is the states’ responsibilities to ensure that detailed checks and treatments is considered ethical and legal when performed with balances are implemented to ensure that the hastening of death is the consent of either the patient or the patient’s proxy. Usually in performed only for those who are fully informed and are making the physician-assisted suicide, lethal drugs are prescribed by the physician choice themselves, without negative influence (Emanuel et al., 2016). and administered by the patient with the intent to end his or her life.

Categorizing deaths related to self-injury Substance use disorders are universally considered a risk factor pattern, this is not enough to eliminate the use of “accident” by for suicide. Under the current medicolegal system, most drug medical examiners and coroners on the death certificate. Rather, intoxication deaths are reported as accidents because the system medical examiners and coroners rely on definite evidence on the day requires a compelling amount of evidence of intent to confirm suicide. the individual dies that clearly establishes suicide as the cause of death “Accident” is an official manner of death classification used by (Rockett et al., 2016; Rockett et al., 2015). medical examiners and coroners. The Centers for Disease Control From the public health perspective, when addressing the goal to and Prevention prefers the term unintentional from a public health reduce injuries and prevent fatal outcomes, one must realize that perspective (Rockett et al., 2016; Rockett et al., 2015). factors that lead to fatal events and suicides often have many A history of repeated and deliberate drug use and associated precursory risk factors that occur long before the fatal event or suicide. life-threatening overdoses that clearly indicate intentional acts These include emotional distress, disruptive behaviors, familial fundamentally increase the probability that the person may end his disruptions, and social instability. This is directly contradictory to or her life through this at-risk behavior. Despite this well-established the medicolegal perspective, which separates the individual intent of

Psychology.EliteCME.com Page 69 the fatal suicidal act from the inferred and unintended nature of the individuals. They noted that with the exception of persons older than lethal drug overdose. Suicidal motivations are difficult to establish 75 years, the self-injury mortality rate was higher in all specified age because of evidentiary deficits from inadequately staffed and poorly groups between the years 2012 and 2014 than between the years 1999 funded forensic branches in emergency health care systems and death to 2001. Self-injury mortality accounted for approximately 32.2 and investigation departments. The term accident, therefore, serves the 36.6 years of life lost by male and female participants, respectively. purpose as a default category when definite proximal evidence remains The numbers reported for diabetes were 15.8 and 17.3 years, 15 and inconclusive. 16.6 years for influenza and pneumonia, and 14.5 and 16.2 years for Death from drug self-intoxication category kidney disease. Recently, a consensus panel met and determined that a new category The steep increase of official suicide and drug intoxication death rates should be included on the certificate of death called “death from drug between 2000 and 2014 revealed a growing crisis. Most researchers, self-intoxication.” This term includes the three major manners of clinicians, medical examiners, and coroners agree that repeated opioid death: 1) suicide, 2) accident, 3) undetermined intent. The consensus and other drug self-intoxication is a form of self-directed injury. panel consisted of participants from different fields, including However, deaths arising from such self-destructive behaviors continue psychiatrists, medical examiners, epidemiologists, emergency to be labeled as “accidental,” “unintentional,” or “indeterminate” physicians, and toxicologists (Rockett et al., 2016; Rockett et al., in spite of an individual’s clinical history of deliberate, repeated 2015). substance misuse, which fundamentally increases the probability Self-injury category of mortality: Report of a study of demise. Restricting the scope of determination of the person’s Rockett et al. created a self-injury mortality category that encompasses intentionality to the day of death as the sole way of establishing a suicide by any method as well as death from drug self-intoxication. pattern of intentional self-harm precludes the types of investigations This category includes the categories used by coroners and medical needed to better understand the biological, social, and psychological examiners, such as “accident” and “undetermined.” They then factors that influence and essentially contribute to these premature compared the differences in patterns of self-injury mortality in the fatalities (Rockett et al., 2016; Rockett et al., 2015). United States to the top-three ranked causes of death. They identified The purpose of the study conducted by Rockett et al. in 2016 the top-three causes of death—diabetes, influenza and pneumonia, highlights the critical need to resolve such inconsistencies in kidney disease—and deaths from drug intoxications that were classification to study the factors contributing to fatal self-injuries previously denoted as accidental or undetermined. The deaths from more thoroughly. Subsequent studies performed on self-injury drug intoxications were further classified into drug groups: nonopioid mortality will need to examine the vast plethora of individual and analgesics, narcotics, sedative hypnotics, autonomic drugs, and other community factors that contribute to the etiology of self-injury drugs that affect the nervous system (Rockett et al., 2016; Rockett et mortality, including social, economic, political, environmental, and al., 2015). health-related factors. A full understanding of self-injury mortality in As it stands at this writing, suicide alone is currently ranked as the the context of the various variables— including variables such as race, 10th-leading cause of death in the United States. But the estimated ethnicity, military/veteran status, state, and region—that influence its self-injury rate has been rising much faster than the suicide rate since incidence will also be valuable. 2000. Self-injury was estimated as the sum of the suicides by any Simply comparing the number of fatal self-injurious acts and the method and accidents or undetermined death by drug toxicity. This number of overdose deaths to the top-three causes of death is not the was based on the assumption that 80% of accidental drug intoxications most effective approach. This oversimplifies the contributory causes and 90% of undetermined drug intoxication deaths were in persons 15 when prioritizing appropriate interventions. Erroneously weighing years or older. The patients in this study were selected between 1999 all the deaths equally does not take into account the harm of self- and 2014. The age of 55 was used as the cutoff for separating older injury mortalities on people who are in the prime of their lives. For and younger patients (Rockett et al., 2016; Rockett et al., 2015). example, during the two periods 1999 to 2001 and 2012 to 2014, 70% There were 40,289 self-injury deaths in 1999 and 76, 227 deaths in of self-injury deaths occurred in patients younger than age 55. Less 2014. The raw data rate for self-injury mortality increased from 14.4 than 12% of this same population dies from influenza and pneumonia, per 100,000 persons in 1999 to 23.9 per 100,000 persons in 2014, diabetes, and kidney disease. This example clearly highlights the loss which corresponds to a 65% increase. This increase in mortality rate of productive years associated with self-injury mortality. exceeded that seen with kidney disease within the same observation When comparing the deaths related to suicide alone in women between period. It was also greater than the influenza and pneumonia rates 1999 and 2014, the rising trend in the incidence may be missed. But by 2006, and it was equal to the diabetes mortality rate in 2014, once the data from self-injury mortality and death by drug toxicity are corresponding to 23.9 and 24 deaths per 100 000, respectively. The combined with the suicide rates, the rate is nearly double the suicide mortality rate for influenza and pneumonia declined from 23.2 per rate alone. This underscores the rise of self-injury trends among 100 000 in 2000 to 17.3 per 100,000 in 2014. The kidney disease women. Between 1999 and 2014, there was a 30% reduction of the gap mortality rate increased from 12.7 per 100 000 in 2000 to 15.1 per between males and females with respect to the incidence of self-injury 100 000 by 2014. In 2014, the self-injury mortality rate was 1.8 times mortality. This trend is very disturbing and may continue to rise unless higher than the suicide rate compared to 1999 when it was 1.4 times effective preventative methods are employed. As of 2014, the self- higher. Males showed a higher self-injury mortality rate than females injury rate for males was still 2.6 times higher than the female rates. did within the observation period. Interestingly, however, the female Mortality from continuous self-harm can serve as an etiology for rate over the same period increased by 116%; the male rate increased certain diseases, for example, lung cancer caused by tobacco smoking by 51%. The relative risk between males and females was 3.7% in and cirrhosis caused by alcohol consumption. Suicide, on the other 1999, but it decreased to 2.6% by 2014 (Rockett et al., 2016; Rockett hand, is caused by a plethora of factors, including schizophrenia, et al., 2015). depressive disorders, bipolar disorder, and anxiety disorders as well Between 1999 and 2001, 77.1% of self-injury deaths occurred among as comorbid systemic diseases, acute alcohol and drug intoxication, persons 55 years or younger compared to 11.1% of diabetes deaths, interpersonal stresses, and adverse life events. 6% of influenza and pneumonia deaths, and 7.8% of kidney disease The strict criteria that necessitate clearly defined intentions with deaths. Based on previously published studies, Rockett et al. (2016) actions to kill oneself basically guarantee that suicide rates will be inferred that self-injury mortality affects a greater proportion of underestimated in most countries. Caucasian individuals relative to African American and Hispanic

Page 70 Psychology.EliteCME.com Suicide underestimation is apparent by the exclusion of more and communities to continue to run rampantly (Rockett et al., 2016; ambiguous or less active methods, such as poisoning and drowning, Rockett et al., 2015). from most study data. Studies do not always include opioid Also, this increase in the incidence of self-injury mortality may intoxication although it is a lethal and an increasingly accessible continue in spite of national economic improvements because method for most populations at risk, including adolescents (Rockett et currently there is a scarcity of prevention programs and a lack of al., 2016; Rockett et al., 2015). treatment services for people with mental and substance use disorders Additionally, well-documented morbidities and multiple comorbidities in the United States (Rockett et al., 2016; Rockett et al., 2015). in the medical record argue against the performance of autopsies and Increasing substance-abuse treatment needs are associated with toxicological testing, especially in cases involving middle-aged adults excessive use of health care resources and high costs of hospital and the elderly given that these groups are more likely to die from emergency care. Regardless of the motivation behind emergency disease rather than injury, especially self-injury. Consequently, some room visits—whether solely to obtain opioids to alleviate cravings or drug-intoxication suicides are erroneously classified as death from truly to receive treatment for illnesses arising from intravenous use of natural causes or diseases. Without an autopsy or toxicological testing, drugs, suicide attempts, or deliberate self-harm—the availability and these suicides may be misclassified as death from unknown causes provision of substance-abuse treatment needs can potentially put a dent or undetermined cause of death (Rockett et al., 2016; Rockett et al., in the rising rate of self-injury mortality (Rockett et al., 2016; Rockett 2015). et al., 2015). Had the incidence of registered suicides and estimated deaths by drug Currently, states are addressing health care initiatives legislated in intoxication been combined, self-injury would have ranked as the the Affordable Care Act and the Mental Health Parity and Addiction eighth-leading cause of death in the United States in 2013. This would Equity Act unequally with vulnerable minorities being adversely have ranked ahead of influenza and pneumonia and kidney disease and affected (Rockett et al., 2016; Rockett et al., 2015). behind diabetes (Rockett et al., 2016; Rockett et al., 2015). The limitations associated with the 2016 Rockett et al. study was the Rockett et al. (2016) finally compared mortality trends with patterns differences in death certificates originating from variable providers of self-injury and the previously mentioned three proximally ranked with different levels of training and practice experience. Also, the fact diseases—diabetes, kidney disease, and influenza and pneumonia— that correlation between the state registrars and the National Center between 1999 and 2001 and between 2012 and 2014. Data from this for Health Statistics was not examined is a limitation. Their choice study were used to provide a context for the rankings and to give of comparison diseases may also be a limiting factor given that some insight into injury etiology, surveillance, prevention, treatment, and major killer diseases, such as heart disease and cancer, were not eventual rehabilitation. included in their calculations. Additionally, the concept of self-injury Without a fundamental shift in public health priorities and the mortality has not been validated by other studies, and its measurement appropriate assignment of health resources, we can expect a continuing is not yet precise or well established. Finally, in the Rockett et al. study rise in the rate of self-injury mortality. And we can expect its weighty from 2016, the self-injury mortality calculations excluded self-injury psychosocial, physical, and economic toll on individuals, families, deaths from motor vehicle trauma and certain forms of poisoning (Rockett et al., 2016; Rockett et al., 2015).

At-risk populations Postnatal women coexists with other common mental health disorders, such as general Of all mental health problems, depression accounts for the greatest anxiety and even suicidal ideation. Any tools designed to screen for burden of disease and is estimated to become the second-leading depression must recognize and assess for coexisting psychological cause of global disability by 2020. Perinatal depression is defined as symptoms, including suicidal ideations and suicidal behaviors depression experienced during pregnancy or the postnatal period up (Littlewood et al. 2016). to one year after delivery. It has been well established that perinatal Veterans depression is a distinct class of depression with specific and special The Veterans Administration Health Service Department has recommendations for the identification and clinical management of implemented several programs to aid veterans at risk for suicide or this medical condition (Littlewood et al., 2016). who have attempted suicide previously. The Veterans Crisis Line is a Some estimates have suggested that 7.4% to 20% of women confidential resource that connects veterans in crisis—as well as their experience depression at some stage during pregnancy, with a rate of family members and friends—with qualified and trained responders in postpartum depression estimated to be as high as 22% of all women the U.S. Department of Veterans Affairs. who deliver a child. Veterans and loved ones can connect either via phone or via online Perinatal depression has been linked with various adverse outcomes. chat through http://www.veterancrisisline.net. Alternatively, veterans Evidence suggests an association between prenatal depression and can send a text message through their cellphones. Once the crisis line adverse neonatal outcomes, including poor self-reported health, is contacted, veterans and family members can receive confidential substance abuse and alcohol abuse, and inadequate usage of antenatal support 24 hours a day and 7 days a week. It is important to note that care services. It is well established that postnatal depression can affect veterans can seek help via this confidential resource even if they are the mother and her partner, the mother–baby interactions, and the not registered with the VA system. The responders on the crisis line whole family unit. Postnatal depression can also cause longer term are trained to assist veterans dealing with mental health problems and emotional and cognitive implications in the development of the baby, those struggling with the transition to civilian life or relationships. especially when the depression occurs in the baby’s first year of life. They are also trained to aid those coping with chronic pain or Although perinatal depression is well recognized as a mental health homelessness, among many other conditions. The VA system also condition with potentially devastating effects, it often goes undetected. attempts to hire veterans as responders. Health care professionals detect fewer than half of all cases in standard The crisis line was launched in 2007. The VA has partnered with clinical practice (Littlewood et al, 2016). community organizations and local health care providers to help Depression does not always exist in isolation. Most studies on the increase awareness about the crisis line program. Specifically, the epidemiology of depression have shown that depression commonly VA launched a spread-the-word campaign that uses online ads and

Psychology.EliteCME.com Page 71 banners to raise awareness about the crisis line. Community members Even though suicide rates decreased over time among male veterans or organizations that want to raise awareness about the crisis line are in the middle-age group, the rates remained consistently higher given specific best practices guidelines on how to raise awareness than those for either older or younger veterans. These results are the without knowingly reinforcing beliefs or stereotypes that could hinder complete opposite of the typical pattern observed in the United States, veterans or their family members from reaching out for help (VA which has the highest rates of suicide among older males. Suicide risk Suicide Prevention Program, 2016). factors are significantly elevated among individuals who have served Patients who receive health services from Veterans Health in the wars in Iraq or Afghanistan (Blow et al., 2012). Administration services are more likely to have characteristics related Suicide is influenced by multiple factors, including biological factors, to a higher risk of suicide, including older age, male gender, and such as gender; socioeconomic factors, such as employment status; substantial medical and psychiatric morbidities (Blow, Bohnert, Ilgen, and other factors, such as access to firearms. These all confer increased Ogmacop, McCarthy, Valenstein, & Knox, 2012). risk of suicidal behaviors and suicide. Incidentally, the veteran Kaplan, Huguet, McFarland, and Newsome (2007) noted some population tends to be affected by these factors or has access to these inconsistent information regarding the relative risk of suicide in risk factors, thereby increasing their risk. veterans. They found that male veterans who responded to the U.S. Blow et al. (2012) noted that middle-aged men were at the highest risk National Health Interview Survey were twice as likely to report a for suicide. Although it is unknown why this group had an elevated suicide attempt as nonveteran males were. risk, there are several potential explanations, including the fact that McCarthy et al. (2009) found that compared to the general population, these individuals represent Vietnam-era veterans who may be a cohort the suicide rates of veterans who used veteran health services from at higher risk for suicide caused by ongoing social, economic, or 2000 to 2001 were 1.66 times higher in men and 1.87 times higher in psychiatric difficulties. women. However, studies examining the risk factors contributing to Despite these limitations, to my knowledge, this is the first suicide within the veteran population have failed to find that the risk comprehensive study of suicide mortality among patients receiving of suicide is substantially higher among veterans than that found in the health care in a large national health care system. These findings general population, except within specific high-risk subgroups, such as indicate that there has been no increase in suicide rates among the veterans with a mental disorder. Veteran’s Health Administration population of patients since the start However, changes in suicidal behaviors observed in the general of the conflicts in Iraq and Afghanistan; in fact, suicide rates among population may not apply to the veteran population in general and the Veterans Health Administration patient population have decreased to high-risk individuals receiving veteran services in particular. In since fiscal year 2000. However, Veterans Health Administration users general, veterans are considered more accessible for suicide prevention are at increased risk for suicide compared with individuals the same efforts. Monitoring suicide rates among veterans is now increasingly age and gender in the general population. Comprehensive approaches important because of concerns regarding the impact of the conflicts in to suicide prevention in the Veterans Health Administration should Iraq and Afghanistan (Blow et al., 2012). focus not only on recent returnees but also on middle-aged and older veterans (Blow et al., 2012). It is well document that veterans have elevated rates of psychiatric and substance-use disorders, which has prompted Congress to mandate the Nearly 100 suicides occur each day and approximately 36,000 people implementation of a comprehensive Veteran’s Health Administration die by suicide each year. Among veterans and current military, suicide suicide prevention program, which began in 2007. More research is a national public health concern. Recent estimates suggest current needs to be performed to examine whether suicide rates among veteran or former military represent 20% of all known suicides in the United health services patients have changed since the start of the wars in Iraq States. It has been estimated that the rate of suicides among veterans and Afghanistan. There is also a need to assess the general stability utilizing Veterans Health Administration services is estimated to be of rates among patients receiving health care in the VA health system, higher than that of the general population. The gravity and enormity which is the largest integrated health system in the United States of the problem has led to the launching of several major public health (Blow et al., 2012). initiatives and a growth in research funding for suicide prevention (O’Neil et al., 2012). Blow et al. (2012) reported that 8,855,655 individuals received inpatient or outpatient veteran health services between 2000 and 2007. Adolescents They then calculated annual rates of suicide by dividing the number The National Healthy People 2020 objectives include the goal of of suicides observed in each fiscal year by the person-years accrued reducing the suicide rate from 11.3 per 100,000 people in 2007 to 10.2 during that period multiplied by 100,000. The annual veteran health per 100,000 by 2020. Another objective is to reduce the rate of suicide services rates of suicide mortality ranged from 34.3 to 39.8 suicides attempts by adolescents in grades 9 through 12 from 1.9 per 100,000 in per 100,000 person-years. Among male veteran health services users, 2009 to 1.7 per 100,000 by 2020 (Katz et al., 2013). the annual rates of suicide ranged from 36.4 to 43.1 suicides per Suicide remains one of the leading causes of death among adolescents 100 000 person-years, compared to a range from 9.8 to 13.7 among and remains of great concern as a public health issue. Understanding female veteran services users (Blow et al., 2012). the factors contributing to suicide in each community or population Overall, in each of the eight years between 2000 and 2007, suicide group remains challenging. There has been little progress on the was consistently more common among those who used veteran health current pharmacologic or psychosocial interventions (Katz et al., services than in the general United States population when matched for 2013). age and gender. However, the suicide rates in the veteran population In the United States, it has been estimated that up to 16% of all high has decreased over time, with the middle of 2003 being a pivotal school students have considered suicide over a 12-month period. Of turning point. This shift in 2003 may signify an increased awareness those students, 13% had a plan for their suicide attempt. Currently, and sensitivity to mental health issues in veteran health services, which there is a best practices registry. Although most interventions listed began the same year. The rates of mental health diagnoses increased in the registry seem practical, very few of them are actually evidence significantly after the start of the war in Iraq among first-time users based (Katz et al., 2013). of veteran health services returning from Iraq and Afghanistan over a two-year period (Blow et al., 2012).

Page 72 Psychology.EliteCME.com There is a shortage of available practitioners trained to manage suicide must be comprehensive and include health promotion, prevention in the adolescent population. Effective strategies must also include strategies, interventions when appropriate, and techniques to address prevention techniques at the core of the plan. To be effective, programs postintervention follow-up (Katz et al., 2013).

Prevention programs The goals of suicide prevention programs are to reduce the prevalence SOS Signs of Suicide™ program of suicidal ideations, suicidal attempts, and deaths secondary to SOS Signs of Suicide™ is a universal program that promotes the suicide. Most prevention programs in schools around the country are idea that suicide is related to mental illness rather than a normal put in place to reduce the risk factors in adolescents, identify those reaction to emotional stress or distress. This program includes suicide at risk, and provide treatment to patients as appropriate. Multiple awareness, suicide screening, and educational interventions. It uses prevention programs include suicide awareness courses, screening for video and guided classroom discussions among students to learn how suicidal ideations, and gatekeeper and peer leadership training (Katz et to acknowledge the signs of suicide displayed by their peers and to al., 2013). take those seriously. Then they learn how to let their peers know that In general, universal programs tend to focus on techniques they care about them and how to report these findings to an adult (Katz implemented on a school wide basis, whereas selected programs et al., 2013). target students specifically identified as being at risk. Given that most The second part of the SOS Signs of Suicide™ program is the adolescents spend most of their day at school, school-based programs screening component, which utilizes the Brief Screen for Adolescent are considered one of the most effective ways of reaching this Depression (BSAD) tool. Students identified using this tool are population (Katz et al., 2013). encouraged to seek further help. There are many school-based suicide prevention programs in The SOS Signs of Suicide™ program received a grade of B based on existence. But there have been no well-established evidence-based the high quality of the trials conducted. However, it failed to show best practice guidelines; consequently, school authorities have been statistically significant results in terms of decreasing the incidence of randomly picking programs to implement in their individual schools. suicidal ideation among the students, therefore earning a grade of D Because of an overwhelming number of programs, policymakers based on this outcome. need an evidence-based review to inform their practices and decision Two randomized controlled trials were performed to evaluate making. the effectiveness of this program in reducing suicidal attempts; Katz et al. (2013) performed a study to review all the available data increasing suicide knowledge; and improving attitudes toward suicide, and published a review of all the interventions currently used ranking depression, and help-seeking behaviors. In one study, 2,100 students them based on their effectiveness into several grades ranging from from five high schools were randomized into two groups that received a grade of A to D, with grade A the best. They identified five broad the SOS Signs of Suicide™ program in either the first or the second categories of suicide prevention programs: semester. The study showed significant short-term effects of the SOS 1. Awareness or education-type programs. Signs of Suicide™ program with significant reductions in the number 2. Screening programs. of self-reported suicide attempts as well as significant increases in 3. Gatekeeper programs. the knowledge about suicide at three months. However, no significant 4. Peer leadership programs. differences were noted between the treatment group and the control 5. Skill training programs. groups when evaluating for suicidal ideation or help-seeking behaviors Awareness or education programs (Katz et al., 2013). Awareness or education-type programs provide curricula that make The second randomized control trial included 4,133 students from nine the students more familiar with and able to recognize the signs and different high schools. One year after initiation of the trial, similar symptoms of suicide in themselves or in others. These programs are results to the previous trial were recorded. A bias identified in the trial designed to facilitate self-disclosure, particularly to the students’ peers. was that the study was designed with a self-reporting component, In general, suicide awareness and education programs are usually thereby raising the question of potential exaggeration of the effect added to the regular school curriculum. The results from these types of this study. In this second trial, the students were noted to have of programs have been mixed. Some schools have noted a change improved attitudes toward suicide and depression. in attitudes toward suicide, increased knowledge, and behavioral Based on the clinical trials, the SOS Signs of Suicide™ program changes, whereas other schools have noted some detrimental effects. received a grade of B when addressing attitudes and knowledge Katz et al. (2013) reviewed multiple programs used throughout schools outcomes and a grade of D because of its inability to show statistically in the United States and published data on the effectiveness of the significant improvement when measuring the outcome of help-seeking identified programs, thereby providing school officials with a database behaviors. The investigators felt that an improvement in understanding of programs and their associated effectiveness based on the evidence. and attitudes about suicide and depression directly led to a decrease Most programs currently used employ a hybrid model that includes in self-reporting suicide attempts. This hypothesis has not yet been both gatekeeper and screening components. It is important to note that evaluated (Katz et al., 2013). using this hybrid method increases the possibility of identifying at-risk Screening programs students. The programs are created with the goal of destigmatizing the Screening is a case-finding technique of suicide prevention that use of mental health services and stigmatizing suicide. But changes involves screening either all students or students at risk for mental in knowledge and attitudes toward mental health and suicide do not illness or suicidal ideation. Screening tools focus on identifying risk necessarily correlate with changes in behavior. Another limitation of factors, such as depression, drug abuse, alcohol abuse, and prior the program is that students contemplating suicidal usually do not suicidal ideations or attempts. Those identified as being at increased have a large peer network, which some of these programs rely on to risk are referred to a specialist for further treatment. When designing succeed. The scope of the programs is, therefore, limited in situations screening studies for patients with suicidal ideations, it is important to where the student does not have a large peer network (Katz et al., evaluate and identify the availability of referral sites before initiating 2013). screening. The screening technique always carries a risk of false positives and false negatives.

Psychology.EliteCME.com Page 73 The outcomes measured by this program include increasing school Evidence-based practice! Some clinicians have raised staff awareness of suicide and their ability to intervene based on early concerns about screening techniques causing iatrogenic recognition of warning signs detrimental effects, such as seeding the idea of suicide A randomized control trial was performed with 249 school personnel. into the minds of the children being screened. A large The results demonstrated that QPR training produced positive effects randomized control trial was performed that demonstrated on suicide knowledge, skills for identifying students at risk, and that screening did not create an increase in emotional attitudes toward suicide. Overall, there was a measurable increase in distress or suicidal ideation. On the contrary, suicidal youth the general knowledge, increased perceived preparedness, positive who had not been asked about suicidal ideation reported effects on self-assessed knowledge, and improved efficacy outcomes. that they were more distressed. Unfortunately, although gatekeeper programs were shown to be effective in identifying students at risk, only the gatekeepers who TeenScreen tool typically approached students to seek help felt comfortable enough to An example of a primary screening program is the TeenScreen do so. Consequently, the program did not show an improvement in the program. Unlike the SOS Signs of Suicide program, it incorporates subsequent use of mental health services (Katz et al., 2013). a screening component and other techniques (Katz et al., 2013). TeenScreen is a universal tool based on self-reporting and is used Evidence-based practice! The Question, Persuade, and to assess risk factors for suicide. The tool has been used in schools, Refer (QPR) tool training demonstrated positive effects on primary care settings, and other clinical settings. suicide knowledge, skills for identifying students at risk, A nonrandomized cohort study showed that the TeenScreen tool was and attitudes toward suicide. Overall, there was an increase valid and reliable in identifying students at risk. All students who in perceived preparedness, positive effects on self-assessed responded as having key risk factors for suicide on the screen were knowledge, and improved efficacy outcomes. further evaluated. Overall, the sensitivity of the tool in a student population or school setting was reported as being between 75% and 100%. When students identified using the TeenScreen method were A separate study performed by Tompkins, Witt, and Abraibesh (2009) compared to students using other screening tools, investigators noted containing a group of 78 school staff and 24 controls showed an that some students identified by the TeenScreen were not identified by increase in the knowledge of suicidal ideations and suicide prevention. other screening tools. The consequence of this increased sensitivity is As a result of a high-quality randomized control trial, the QPR tool that some students who are not actively at risk may be identified. Once received a grade of B for the knowledge and attitudes outcome. the students are identified, they are then referred to a specialist for However, when evaluating such outcomes as asking students about further workup and follow-up (Katz et al., 2013). suicide, increased number or referrals, and forming better connections with students, the tool received a grade of D (Katz et al., 2013). Recently published data on the TeenScreen program showed that students who were screened were more likely to get referrals to Peer leadership training mental health services, especially to school-based services, as well It has been clearly shown that young people are more likely to talk as community-based services, with a larger fraction of the students to peers than adults about suicidal ideations. Peer leadership puts accessing school-based services. students in a position to help suicidal peers by training them to respond appropriately and referring them to a trusted adult. Peer The TeenScreen program was given a grade of B on its ability to leadership has been shown to establish positive coping norms within increase the knowledge of students at risk for suicide. One caveat the school environment. Sources of Strength was one of the first peer when reviewing these data is that data regarding this tool were leadership training programs established (Katz et al., 2013). obtained from a nonrandomized trial; therefore, school officials should interpret the data based on the fact a randomized control trial was not Sources of Strength program performed (Katz et al., 2013). Sources of Strength is a suicide-prevention program designed to increase eight protective factors in the student population and decrease Gatekeeper training risk factors associated with suicide, including social isolation and Gatekeeper training programs focus on identifying students considered ineffective coping skills. It also creates positive coping norms and natural helpers. These programs teach them skills to identify and builds protective influences within the school. This model fosters recognize the signs and symptoms of suicide. The assumption is that positive peer support within the school environment. Peer leaders suicidal youth are under identified; therefore, school staff is trained to are usually selected by school staff and are trained to encourage their recognize the warning signs, thereby increasing the recognition and schoolmates and friends to identify and connect with trusted adults identification of students at risk. Additionally, adults are taught how to and mentors and to use all available coping resources, both formal respond appropriately to students identified as being at risk for suicidal and informal. A fundamental goal of the program is to increase the ideation and suicide attempts. The success of this program depends likelihood that students with suicidal ideations and suicide-associated largely on the subsequent referral of at-risk students to specialists for risk factors will receive help with mental health services and, further evaluation. consequently, reduce the incidence of suicidal ideations and suicide Question, Persuade, and Refer tool attempts. This program is similar to the skills training program, but in The Question, Persuade, and Refer (QPR) gatekeeper program is a this case, the peer leaders deliver the interventions (Katz et al., 2013). universal program that trains students and school staff to recognize A randomized control trial was used to evaluate the Sources of suicide risk factors in fellow classmates or students. The program is Strength program. Eighteen schools were randomized to receive based on four simple steps (Katz et al., 2013): training immediately after initiation of the program or after being Step 1: Recognize the suicide warning signs. wait listed. Surveys were administered to 453 peer leaders and 2,675 Step 2: Train all school staff in QPR techniques. students at baseline and after four months. The results showed that Step 3: Train school counselors to appropriately assess students trained peer leaders had an increase in adaptive standards regarding identified as at risk. suicide and a willingness to engage an adult in cases of suicidal Step 4: Organize the access to specialists for professional friends despite requests from their friends for secrecy (Katz et al., assessment and treatment of the students identified. 2013).

Page 74 Psychology.EliteCME.com Trained peer leaders were 4 times more likely to involve an adult in The group sessions teach at-risk students valuable life skills, including cases of suicidal friends compared to the control group. This is likely goal setting, decision making, self-esteem, academic performance, because of their perception of increased adult support and acceptability and control of drug and alcohol use. Each session includes a practice of help-seeking behaviors. This program received a grade of B on both assignment, also called a lifework assignment, in which the students attitudes and knowledge. are asked to practice their newly learned skills in everyday life (Katz To date, there have been few trials evaluating suicidal ideations or et al., 2013). suicidal attempts as outcomes. Further evaluation on the randomized Four studies have been used to evaluate the CARE program; three of control trial is needed. Overall, the program provided an opportunity those also evaluated the CAST component. Participants in the studies for student peers to positively influence schoolmates at risk for suicide were randomized to three groups: 1) CARE program only, 2) CARE and increased the perception among students that adults can be helpful plus CAST, 3) treatment as usual. All the trials noted that CARE (Katz et al., 2013). and CARE plus CAST were more effective in decreasing depressive Skills training symptoms and improving self-esteem. All groups demonstrated a Skills training programs use a risk-reduction approach for suicide decrease in anger-control problems, family distress, and suicide- prevention. They are designed to increase protective factors. In risk behaviors. Only participants in the CARE plus CAST group general, the programs teach life skills—such as coping, problem demonstrated an increase in such skills as problem solving and self- solving, and decision making—along with cognitive skills. The goal control. This combination group was also effective in reducing feelings of these programs is to indirectly prevent the development of suicide associated with depression, including hopelessness. An increase in by targeting risk factors and giving youth important skills to aid in perceived family support was also reported among those who used reducing suicidal ideation (Katz et al., 2013). the combination of CARE and CAST. Specifically among females, the combination of CARE and CAST led to a decrease in anxiety and American Indian life skills development anger. This is a culturally adapted prevention program designed to reduce suicide risk factors and improve protective factors. Students are taught In a separate study, applied parent intervention, noted as P-CARE, skills that build their self-esteem, help them identify emotions and compared the standard CARE program, denoted as C-CARE. A stressors in their lives, and increase communication and problem- third group used a combination of P-CARE and C-CARE. The final solving skills while eliminating self-destructive behaviors. This group was a minimal-intervention group. The results showed that program also helps participants create personal and community goals. the combination of C-CARE and P-CARE led to an improvement in The lessons are interactive and use personalized experiences related positive behavior and a reduction in negative behavior. Interestingly, and relevant to an American Indian’s adolescent life. The program CARE showed the greatest reduction in suicide risk behavior, has been adapted and used by 20 different Native American tribes. depression, and anger. P-CARE alone showed no significant results Expected outcomes from this program are an increased level of suicide (Katz et al., 2013). intervention skills and a decrease in feelings of hopelessness. Given the improvements in behavior showed by CAST and CARE, A study was performed in the Zuni Pueblo reservation. Fifty-nine the programs received a letter grade of B. The follow-up evaluations students were assigned to the no intervention group; 69 students were showed no significant effects in reduction of suicidal behavior included in the intervention group. Students in the intervention group outcomes; consequently, the programs received a letter grade of D performed significantly better on measures of hopelessness and on (Katz et al., 2013). the risk of suicide, including suicidal ideation. However, there were The Reconnecting Youth program no differences noted between the control and the intervention groups Reconnecting Youth is a school-based suicide prevention program in the levels of depression. The intervention group showed better that focuses on students who have poor academic achievement problem-solving skills and greater suicide intervention skills compared and are at increased risk of dropping out of school. These students to the control group. are more likely to show symptoms related to suicidal behaviors, Because this program has not been evaluated by a randomized control including substance abuse, depression, aggression, and suicidal trial, it has received a grade of C when addressing outcomes of general ideation. Participating students are taught how to build resilience by skills improvement and the incidence of suicidal ideation and suicide controlling early signs of substance abuse and emotional distress. The attempts (Katz et al., 2013). program provides a framework for appropriate social support-system building through bonding activities and parental involvement while Care, Assess, Respond, Empower program minimizing deleterious peer relationships. The program also focuses Care, Assess, Respond, Empower (CARE) is a selected program that on strengthening connections to the school. targets high-risk youth through an in-depth computer-assisted suicide assessment interview and a follow-up motivational counseling session. A concern with this program is that groups of at-risk youth participate The purpose of the counseling component is to provide students with together in the program, which could serve to strengthen deviant peer a supportive and safe environment to foster sharing and encourage relationships. Multiple studies have evaluated this program. Eggert positive coping techniques and help-seeking behaviors. The CARE and Herting (1991) noted a decrease in drug use and a corresponding program also includes a follow-up session that serves as a booster as increase in the participating students’ GPAs. Overall, the program had well as providing an opportunity for reassessment of suicide risk and no effect on school attendance. Fewer females reported having fewer protective factors. The goal of the CARE program, simply put, is to deviant peer relationships, whereas males showed no change in the decrease suicidal ideations and suicide attempts and to reduce risk number of deviant peer relationships (Katz et al., 2013). factors while increasing personal and social capital. In some settings, The Reconnecting Youth program helped reduce risk factors for the CARE program has been culturally adapted to the target population suicide—such as anger, depression, and hopelessness—and led (Katz et al., 2013). to increased self-esteem and social support. Note that not all the A component of this program—Coping and Support Training, or studies conducted to evaluate the effectiveness of this program were CAST—seeks to increase life skills and social support of students in a randomized controlled trials. But multiple separate trials have been small-group format. Students at risk are identified through the CARE conducted and have shown consistent results. As a result of this component of the program and directed to participate in CAST. The consistency, the Reconnecting Youth program was given a grade of B goal of the CAST program is to improve the ability to manage mood on outcomes of attitudes, knowledge, and skills training (Katz et al., changes and improve school performance while decreasing drug use. 2013).

Psychology.EliteCME.com Page 75 The Good Behavior Game A randomized control trial evaluated the GBG program. The trial The Good Behavior Game (GBG) is a program for students in early included first grade students in 42 different classrooms in 19 separate elementary schools. It is based on classroom interactions by building elementary schools over a two-year period. Classrooms and teachers teamwork and fostering behavior management to help children were randomly assigned to the GBG intervention or the control develop. It uses intrinsic self-regulation by rewarding teams that meet group (in this case the standard school program). A total of 1918 the behavior standards set by their teachers. A fundamental goal of study participants completed follow-up interviews over 15 years. The the program is to create a positive classroom environment free from primary outcomes measured suicidal ideation and suicidal attempts. aggression and disruptive behavior where students are supported Individuals who participated in the GBG intervention were half as by their peers and can learn effectively. Students are intentionally likely to experience suicidal ideation compared to the control group separated in to groups, with an equal distribution of those with a and were, therefore, less likely to attempt suicide as compared to the disruptive and aggressive behavior history. The teachers publish the control group. rules of the game with respect to student behavior, and the group with four or fewer infractions of permissible student behavior is rewarded Evidence-based practice! The Good Behavior Game (Katz et al., 2013). has been shown to decrease such key risk factors as drug The Good Behavior Game has been shown to improve such key risk use, tobacco use, and alcohol use in adolescence and factors as drug use, tobacco use, and alcohol use in adolescence and early adulthood. A reduction in the above mentioned risk early adulthood. It works by targeting early aggressive and disruptive factors could potentially positively affect suicide rates by behavior, which is a shared risk among students and thereby prevents preventing suicide-related risk factors and improving the later maladaptive behavioral outcomes. A reduction in the above academic performance. mentioned risk factors has a potential for affecting suicide rates. It is well known that poor academic performance can be linked to an The GBG program was shown to delay the onset of suicide attempts increased propensity for suicidal behaviors, impulse control problems, in females and led to a reduction in relative risk for suicide attempts drug use disorders, and antisocial personality disorder. by up to 30%. The GBG program received a grade of B on reducing suicidal ideations and attempts (Katz et al., 2013).

Assessment of suicide Almost 3% of adults are assumed to experience thoughts of suicide is resolved. The clinician must ask questions until any discrepancies at any specific time. The assumption is that the incidence of suicidal between the assessment and the patient’s responses are addressed. thoughts is much higher among adolescents. Five steps have been In cases where the patient is having suicidal thoughts, the clinician denoted key components of any suicide risk assessment (Kazim, should ask specific questions about the intensity and frequency of the 2017). suicidal thoughts as well as the degree to which the patient is prepared. Step 1, an assessment of risk factors: Risk factors include different Does the patient have a suicide plan? If a specific plan is described, types of life events and circumstances, such as illness. As previously the clinician should document that and document whether the patient noted, the strongest predictor of suicide is the presence of a previous has self-injurious or lethal plans. Additionally, the clinician inquires suicide attempt. Individual risk factors for suicide include major about the method of suicide rehearsals, such as loading a gun, walking physical illness, chronic pain, and the presence of traumatic brain on a bridge to assess the height, or tying a noose. Whenever possible, injury. Mental health disorders are also included in this category. This the clinician should confirm findings with a family member or a close section should also include a family history of suicide and abuse; the friend because patients are more likely to inform close relations of patient’s psychiatric state of mind; the presence of drugs; and other suicidal ideations than they are likely to tell a health care provider confounders, such as insomnia (Kazim, 2017). (Kazim, 2017). Step 2, suicide inquiry, including specific questions about suicidal Step 3, assessment of the protective factors against suicidal thoughts, suicidal ideations, suicidal plans, suicidal intent, and thoughts, such as strong family ties and friendships or the access to means: In general, patients will not spontaneously report presence of a significant other. Additionally, religious belief and suicidal ideations, but it has been shown that up to 70% of patients faith and a sense of belonging can be used as protective factors. It is will report their intentions to commit suicide to their friends and best to explore the patient’s reasons to die versus reasons to live. The family members. To get patients to open up when asking about presence of protective factors can help dampen the suicide risk in suicidal ideations, it is important that the clinician avoid asking people with low or moderate suicide risks. Ideally, protective factors leading questions. An example of a wrong question to ask is, “You can be strengthened and used as part of safety planning in patients are not thinking about committing suicide, are you?” The correct with low to moderate suicide risks (Kazim, 2017). question to pose is, “Have you ever tried to kill yourself or thought Step 4, clinical judgment: The provider should use the above about suicide?” If this inquiry reveals no indications of any suicidal information to form and make a clinical decision on the risk of suicide. ideations, questioning may stop at that time. However, if the clinician Clinical decision making is complex given the medical comorbidities, is highly suspicious that the patient may have suicidal thoughts but mental health diagnoses, and the contextual and environmental factors the patient initially denies any suicidal thoughts, he or she may keep affecting patients with suicidal risk (Kazim, 2017). asking questions as many times as necessary until the incongruence Step 5, the documentation of the above four components in their entirety within the medical record (Kazim, 2017).

Treatment of suicide The treatment and management of suicide is complex, and clinicians Clinical settings must develop a biopsychosocial treatment plan, which is critical for the Patients seen in an emergency room setting must be immediately appropriate management of suicidal ideation. Clinicians must assess referred to a psychiatrist, psychologist, or other qualified health care the willingness and the availability of family members to participate in provider. Clinicians should also use the assistance of law enforcement a treatment plan crafted to address suicidal ideations. and emergency response personnel, when needed, in outpatient

Page 76 Psychology.EliteCME.com cases that necessitate immediate transportation to a medical facility Several studies using randomized controlled trials have shown that the for evaluation. In all states, law enforcement has the right to place treatment of depression using drug therapy, such as antidepressants, individuals into protective custody when there is suspicion that they has been associated with decreased suicidal ideation in individuals may be a danger to themselves or others. 25 years or older. Some studies have suggested that the use of Emergency response and emergency room staff should be selective serotonin reuptake inhibitors (Lexapro, Prozac) results in a appropriately trained to deal with suicidal patients. An empathetic greater reduction of suicide ideation compared to selective serotonin approach is indispensable in this case. Emergency room staff must and norepinephrine reuptake inhibitors (Cymbalta, PRISTIQ) or be aware of any biases toward suicidal patients, including religious norepinephrine-dopamine reuptake inhibitors (Celexa, Zoloft). or philosophic beliefs, lack of formal psychiatric training, inadequate Interestingly, in patients younger than 25 years old, antidepressant staff, and short staff departments. In an emergency setting, the therapy has not been shown to decrease suicidal ideation and behaviors challenge is identifying patients safe enough to go home. Some although it does decrease signs and symptoms of depression (Kazim, emergency departments have mental health professionals on call to 2017). help evaluate suicidal patients and determine those safe enough to go In 2004, the United States Food and Drug Administration issued a home (Kazim, 2017). warning regarding the risk of increased suicidality associated with Patients on suicidal precautions in a treatment setting should be antidepressant use in young people. Since then, the rates of diagnosis closely observed by clinical staff. As it stands, suicides of persons in of depression and prescriptions of antidepressants for people aged 24 a treatment setting is still reported as sentinel events in the clinical or younger has declined. However, the incidence of overdose using setting. In most clinical settings, suicidal patients are assigned a psychotropic drugs and the incidence of suicide in this group have dedicated “sitter” to watch them; this intervention often decreases both increased (Perlis et al., 2016). the need for restraints in most patients. The use of family members Studies have shown that the higher the lithium content in water, is highly discouraged because family members may connive with the lower the suicide rates in that region. Even though the exact patients to make plans for escape, or if they see a patient leaving, they mechanism of action through which lithium works to reduce suicidal may not try to stop him or her (Kazim, 2017). behaviors remains unknown. It has been theorized that it may function Mechanical and chemical restraints should be used judiciously by reducing mood disorder episodes or by decreasing impulsive and in suicidal patients. The use of restraints should be minimized aggressive behaviors. when possible. However, the use of restraints may be essential and Ketamine (Ketalar), a glutamatergic drug used as an anesthetic, has potentially lifesaving in violent and uncooperative patients. All been used to treat suicidal behavior. Trials have demonstrated that restrained patients must be assessed frequently, sometimes hourly. low doses of ketamine used as an antidepressant invoked a positive Often times documentation of the neurovascular status of the response within minutes of administration in patients with major restrained patient must be performed. Finally, a re-evaluation of the depressive bipolar disorders. Given this ability of ketamine to act need for restraints should be performed daily (Kazim, 2017). rapidly, it is quickly becoming a promising treatment for patients with Patients who are eventually discharged from the inpatient setting must suicidal behaviors in emergency settings. The main drawbacks to the have appropriate outpatient follow-up with mental health providers. use of ketamine are its potential for abuse and misuse, the short- Follow-up should be set up as soon as possible within a few days of lived nature of the responses it invokes, and the adverse cardiac and discharge. Given that compliance with follow-up appointments may psychotomimetic side effects it causes (Perlis et al., 2016). be low, the use of family members in helping patients to comply is Psychotherapies greatly encouraged. Family members and friends can also be engaged Strategies of suicide management include nonpharmacologic to help reduce a patient’s access to lethal means of suicide as a interventions, such as individual psychotherapy, behavioral therapy, strategy to mitigate the prevalence of self-injurious behaviors. This family therapy, and cognitive therapy. In cases of moderately to severe includes removing potential means of suicide from the home—guns, suicide risk, the primary concern is immediate safety. medications, or other toxic substances. Special attention should be paid The psychotherapeutic interventions established as the most to the patient’s documented suicide plan, and appropriate interventions efficacious treatments for suicidal behavior share certain common should be implemented. Finally, appropriate documentation of the elements (Perlis et al., 2016): patient’s progress in the inpatient setting will help guide and inform ●● Exploration to understand the etiology of suicidal behaviors. decisions in the outpatient setting (Kazim, 2017). ●● Interventions that encourage positive and discourage negative Treatment of suicidal ideations should be chosen based on the behaviors. patient’s underlying mental illness and manifestation of suicidal ●● Explicitly focusing on suicidal behaviors. behaviors. For example, chronic suicidal behaviors should be treated ●● Having the therapist adopt an active attitude to treatment, with interventions based on psychotherapy, whereas acute suicidal including problem solving. behaviors should be treated with more aggressive interventions ●● Planning for coping with suicidal urges as an outpatient. (Kazim, 2017). ●● Focusing on emotional and cognitive precursors of suicidal Elderly patients who display acute suicidal behaviors typically require behaviors. a plan that guarantees safety, including hospital admission. Dialectic behavior is one of the most commonly used Drug therapies psychotherapeutic techniques for recurrent suicidal behavior. It has Each patient should be individually addressed to evaluate the safety been used mostly in patients with borderline personality disorder. of the environment into which he or she is returning. In these Dialectic behavior therapy promotes the belief in one’s own ability circumstances, pharmacologic interventions are often employed. If to succeed, the ability to emotionally self-regulate, and interpersonal pharmacologic interventions are used in patients discharged to home, effectiveness. It has repeatedly been shown to reduce the recurrence it is imperative that the patient and family members understand the of suicidal behaviors in affected patients when compared to standard possible side effects associated with the drugs being administered, treatment (Perlis et al., 2016). especially the use of antidepressants in patients who are depressed and Dialectic behavior therapy is based on concepts from cognitive suicidal (Kazim, 2017). behavioral therapy. A greater effects has been noted in adults compared to adolescents, especially when suicidality is the explicit focus of treatment.

Psychology.EliteCME.com Page 77 Metallization-based therapy focuses on teaching patients how to think with electroconvulsive therapy had no suicidal ideations or suicidal about how their underlying thought and emotions are secondary to intentions after nine sessions. their own and other people’s actions. This, then, enables their ability to Some preliminary evidence has suggested that high doses of repetitive understand their own and other people’s perceptions and thus proves transcranial magnetic stimulation applied to the left prefrontal cortex effective in reducing suicidal behaviors. might rapidly decrease suicide ideation and suicidal behaviors. This Other therapies intervention is potentially useful in emergencies where suicidal Nonpharmacological interventions for the treatment of suicide include ideations and intent must be dealt with expeditiously (Perlis et al., electroconvulsive therapy. A study of patients with depression at 2016). high suicidal risk demonstrated that up to 75% of the patients treated

Suicide prevention The first National Strategy for Suicide Prevention was put forth in of specialists (psychiatrists and psychologists) has been shown to 1999 by then-surgeon general David Satcher, MD. It was a landmark correlate with increased suicide rates (Shrivastava et al., 2015). document that helped officially organize the strategies to prevent Access to health care within communities in general can affect the suicide across the country (U.S. Department of Health and Human incidence of suicide, especially in circumstances where primary care Services, 2012). services are integrated with mental health services. This allows for Research has shown that suicides are preventable with early and timely better resource utilization and better outreach. low-cost interventions. Any efforts to thwart the daunting number The use of the media to increase awareness about suicide and to of suicides worldwide must be thorough and multifaceted; suicide decrease the stigma associated with suicide is beneficial in educating is complex and multifactorial in its etiology. Given that the etiology the public and creating opportunities for open conversation about of suicide is multifactorial, an equally multisector intervention is mental illness and disease (Shrivastava et al., 2015). necessary often involving education, labor, agriculture, business, justice, politics, law, and media. No single approach is impactful Using community-based research to obtain useful knowledge about enough to decrease the incidence of suicide. which groups are at increased risk for suicide is critical. Also proper monitoring by health care providers, law enforcement, and public For any suicide prevention strategy to succeed, it is critical to fully health officials should be carried out to ensure accurate and complete understand the methods used to commit suicide. That way suicide suicide estimates (Shrivastava et al., 2015). prevention interventions are appropriately tailored to address them. All suicides are potentially preventable. Appropriately implemented Interventions interventions at the population and individual levels can help prevent Many school-based, workplace-based, and community-based suicides and suicide attempts. Some of these interventions include interventions and multicomponent primary care interventions can reporting by media outlets in a responsible way and introducing an reduce the incidence of suicide and suicidal behavior. It has also been alcohol policy to reduce the irresponsible consumption of alcohol. shown that the organization of primary care resources and access to care can reduce the access to means of suicide (Perlis et al., 2016). Early identification of mental health disorders and substance abuse disorders is critical to any suicide prevention strategy. Additionally, A multicomponent preventative intervention program in the U.S. Air training nonspecialized health care workers in the identification, Force included leadership and gatekeeper training, increased access to assessment, and management of suicide has been shown to be an mental health resources, coordination of care for high-risk individuals, effective strategy in the prevention of suicide. and a higher level of confidentiality for those who disclosed suicidality. In this population, suicide rates were reduced by 35%. In many societies, mental illness is still considered a taboo, and many people thinking about taking their lives are too afraid to seek help for It is well known that a substantial number of patients access primary fear of being ostracized. Worldwide today, only about 28 countries care resources within one month of suicide, but they rarely receive a have a suicide-prevention program. The lack of awareness by the diagnosis of a mental disorder. There are some education programs for general public with respect to suicide in particular and mental illness primary care doctors intended to help them identify and treat patients as a whole only potentiates the problem (World Health Organization, with depression. This can, in turn, decrease regional suicide rates, 2014; World Health Organization, 2016). especially suicide rates in women. However, there is a continued need for education and additional physician training and support to improve Suicide-prevention strategies should be unique to the target population patient outcomes. Specific needs include websites to provide support and should address differences in patient characteristics, methods of for physicians, increasing liaison between providers and psychiatric suicide, socioeconomic status, age, and gender. facilities, the implementation of suicide hotlines, and public education Given that suicide is a complex issue, multiple professionals must campaigns to train key community facilitators in the recognition of be involved in any strategies put forth. These stakeholders include depression and suicide risk. These might all be important aspects of policymakers, professionals in health education and law, the media, suicide prevention strategies (Perlis et al., 2016). and community members. Any successful strategies must incorporate The integration of primary care with mental health resources has been elements of suicide prevention, including screening for suicidal and shown to provide significantly more benefits compared to the usual homicidal ideations. In lower income settings, integrating suicide- primary care separate from mental health services when addressing prevention programs with the primary care field has been shown outcomes for depression and anxiety. This has been shown to improve beneficial (Shrivastava et al., 2015). suicide ideation in older patients with depression. It is also important to train nonspecialized workers—such as nurses, There is a theory of means restriction based on certain assumptions, paramedics, nurses’ aides, and medical assistants—in identifying such as many suicides are impulsive by nature, and the belief is that patients at risk for suicides and appropriate reporting of suicidal restricting access to lethal methods might prevent a suicidal crisis. If thoughts for ideal follow-up. the patient decides to substitute a lethal method for a less lethal one, Making sure that a psychiatrist is available in communities at risk for the hope is that even if the patient still decides to commit suicide, he or suicide is effective in reducing the incidence of suicide. A shortage she will choose a potentially nonfatal means of suicide attempt (Perlis et al., 2016).

Page 78 Psychology.EliteCME.com The rate of suicide is regulated by the ease of access to certain The supportive and collaborative approaches when combined methods whether firearms; natural gas; car exhaust; Tylenol; less with empathy and respect were most related to positive outcomes. toxic drugs, such as selective serotonin reuptake inhibitors or tricyclic Interestingly, active listening was not significantly related to positive antidepressants; pesticides; or jumping from bridges. outcomes. The study design was set up as silent listening to the The implementations of laws to impede access to a method—whether participants’ conversation and recorded only their demographic data firearms control laws, detoxification of domestic gas or car exhaust, based on their perception or if the participants revealed it. limitation of access to certain drugs, lockboxes for pesticides, or bridge Of the chats recorded, the average chat was 54 minutes. Most chat barriers, along with the installation of telephones and a hotline for visitors appeared to be female—up to 78%. Clearly identified males, crisis intervention—may lead to a reduction in the number of suicides. about 18.4%. The rest of the participants’ gender could not be clearly Also, there are individual-level interventions that could decrease determined. On average, approximately 22.2% of the visitors appeared access to lethal methods of suicides. For example, the safe storage to be 18 years or younger; 53.6% were between 18 and 34 years; of hazardous items, such as firearms or poisons, could be effective and 17.7% were between 35 and 54 years. A small minority (1.7%) in preventing suicide. However, the effect of these interventions on appeared to be older than 55 years. The apparent age category could morbidity or mortality has not been established (Perlis et al., 2016). not be determined for 4.8% of the chat visitors. In participants younger Appropriately following up patients who present to an emergency than age 18, the male-to-female ratio was approximately 1:8 and department after a suicide attempt can potentially reduce the risk of eventually evened out in male and female visitors older than age 55 subsequent suicide attempts in the following 12 months. (Mokkenstorm et al., 2016). Patients at risk of suicide can be identified by several means, such as Most participants were in a suicidal crisis (86.1%), with 61.1% the fact that they often contact health care services. It has been clearly expressing suicidal intent without plans, 21.2% expressing both shown that people who attempt and complete suicide will often seek suicidal intent and plans, and 3.8% contacting 113Online during or just medical help within 12 months of their suicide attempt and often after a suicide attempt. times are seen by primary care providers, thereby giving them an Callers presented with an average of two problems. Mental health opportunity to reach individuals contemplating suicide before they act. problems (defined as having psychological problems or receiving It is important to note that adolescents are less likely than adults to treatment for psychiatric disorders, such as depression, anxiety, seek help in the last year and month before attempting or committing psychosis, or post-traumatic stress disorder) were mentioned most suicide. Despite the fact that patients who attempt suicide have a frequently by 59.7% of the visitors, followed by problems with family high prevalence of emotional or substance-related difficulties, fewer or partners (23.4%) and rumination (18.6%). Females were more often than 20% of these patients use medical services within a year after in suicidal crisis and mentioned mental health problems, death of a the initiation of suicidal thoughts and suicidal behaviors (Perlis et al., person close to them, or physical violence significantly more often 2016). than males did. Males mentioned relationship problems and being a Effectiveness of crisis hotlines and online programs in preventing perpetrator of physical or verbal violence significantly more often than suicide females did. Crisis telephone helplines, or crisis hotlines, are a valuable resource in Visitors aged under 18 mentioned family problems with parents community suicide prevention. There is substantial information that or children, school/professional problems, and being a victim of helplines reduce distress and suicidal behaviors in many callers. verbal violence significantly more often than visitors aged over 18 It is important to recognize the importance and the influence of did. Visitors aged over 18 mentioned mental health problems and digital communication in health care. Currently, major crisis helpline relationship problems significantly more often than visitors aged under organizations offer online help services through chat, instant 18 did (Mokkenstorm et al., 2016). messaging, and email (Mokkenstorm, Eikelenboom, Huisman, The 113Online crisis chat service reached a predominantly female Wiebenga, Gilissen, Kerkhof, & Smit, 2016). and relatively young population, of which a significant proportion Mokkenstorm et al. (2016) evaluated the effectiveness of online was return visitors. The ability to engage with young people is an services for people in the middle of a suicidal crisis. Services included asset of chat services, as telephone hotlines are shown to be relatively volunteer-run helplines, online self-help courses, self-assessment tests, underused by youths. Given their elevated risk, it is also paramount and brief online psychotherapy sessions. These services could all be to reach middle-aged and male suicidal individuals who were accessed online by participants anonymously and for free. underrepresented in the sample. Online chat service: Report of a study Compared to the other studies, 113Online chat visitors seemed to be One program evaluated in the report by Mishara et al. (2007) was experiencing a suicidal crisis more than twice as often, 86.1% versus called 113 Online crisis chat service. Their study observed crisis 35.2%. They had to cope with more types of problems (average 2 vs. telephone helpline services during the years 2003 and 2004, with a 1.3) and suffer from mental health problems twice as often (59.7% vs. total of 1431 crisis calls, including 503 suicidal calls, to more than 28.4%). 14 centers of the United States National Lifeline Centers. They rated These findings indicate that the outcomes of the 113Online crisis chats the callers’ and visitors’ emotional states and ambivalence regarding in 2013 were generally comparable to the outcomes of crisis telephone suicide in the first and last two minutes of their calls. If a change calls of U.S. Lifeline centers in 2003 and 2004 ( Mokkenstorm, et al., in the caller’s attitude did occur, it was much more likely to be an 2016; Mishara, et al., 2007). improvement rather than a deterioration. Overall, Mishara et al. Comparing the other emotional state variables, more improvement and reported a small positive effect of telephone crisis calls, with most less deterioration were observed for the variables desperate, depressive variables not changing significantly from the beginning to the end of mood, sad/happy, apprehensive/confident, and hopeless/hopeful. Less the call (Mokkenstorm et al., 2016). improvement and more deterioration were observed for helpless/ The researchers observed four helper styles based on the analysis of resourceful and confused/decided. helper’s behaviors during hotline calls: 1) the supportive approach and Given the general notion that more positive styles and attitudes lead good contact; 2) the collaborative problem-solving approach; 3) the to better outcomes, the question remains as to which elements in active-listening approach; 4) the negative approach (Mokkenstorm et these styles and attitudes need to be further developed or strengthened al., 2016). to improve chat outcomes. Here, negative observations regarding

Psychology.EliteCME.com Page 79 individual items, mood states, and missing values provide valuable time without observing time limits in a forced manner (Mokkenstorm clues for improvement (Mokkenstorm et al., 2016). et al., 2016). Because of the online disinhibition effect, ambivalent or negative In response to the preliminary findings of the study, 113Online has attitudes may be expressed online in a heightened and sometimes adapted practice policies in line with U.S. Lifeline best practices. provocative manner resulting in a less productive dialogue. On Helpers are now instructed to more proactively explore with visitors the other hand, visitors’ criticism may have reflected genuine their reasons to live and reasons to die, to assess suicidal behaviors dissatisfaction with the quality and outcome of the exchange with at the beginning of chats and returning to this issue at the end, and volunteers. to work with visitors toward safety planning and links to care. During the period observed in this study, volunteers were specifically In volunteers’ training and supervision, due emphasis is given to trained in the use of solution-focused therapy principle, which is a structuring the chat within reasonable but flexible time limits with a fruitful way to work with suicidal individuals. pragmatic rather than principal use of solution-focused counseling techniques. To optimize this collaboration and to avoid harm resulting From reading the chat logs, it became evident that this approach from a disappointing dialogue, volunteers were made aware of could have drawbacks in its application by volunteers. For example, a the pitfalls of online communication, in particular with visitors volunteer’s one-sided focus on “what’s strong” rather than on “what’s who display ambivalent, incongruent, or provocative help-seeking wrong,” steering attention away from the exploration of problems may behaviors (Mokkenstorm et al., 2016). evoke a sense of lack of validation and disorientation in the visitor. This could explain why 12.4% of the 113Online visitors felt more The 113Online website look and feel has been adapted to be more helpless and 13.4% more confused at the end of their calls. inviting and accessible for males and for middle-aged or older help seekers. Policies have been implemented to guide frequent visitors Some studies have pointed out that it is important to be transparent exploring with them potentially effective alternatives to regulate mood about the focus and the purpose of the chat at the beginning and and to link them to other forms of care. To further engage the highly throughout. As this study showed, chat duration is almost 3 times volatile and vulnerable group of young visitors, 113Online is piloting longer than call length. While chat is a slow medium, it is important simple therapeutic e-learning modules specifically tailored to problem for helpers to be patient yet assertive in the process and, if needed, areas this group frequently presents with (Mokkenstorm et al., 2016). gently remind the visitor to focus on critical issues within the available

Case studies Case study 1 is that communication among providers can be extremely challenging, Mrs. B.—35 years old, married, two kids—presents for an annual and often times providers have to rely on patients for accurate checkup at her primary care doctor. She appears uncomfortable and communication of updates and pertinent findings. refuses to make eye contact with the front desk nurse with whom she In retrospect, her son—who was aware that his mother had a history is usually friendly. She has been seeing Dr. Duke, but she is scheduled of a prior suicide attempt—also was aware that she had contacted the to see his partner, Dr. Cook, this afternoon because Dr. Duke is on suicide hotline before her attempt, but he did not want to betray her vacation. Dr. Cook’s nurse, Joan, notices that Mrs. B. is not her usual confidence by reporting his suspicion to the public. self and appears “out of it” today. Mrs. B. has a remote history of depression, which was diagnosed as postpartum depression when her Clearly, there is a need for continued education regarding mental second child was born. Her second child is now 10 years old, and illness and how it affects families. Also, patients with children who are she has had no depressive symptoms since then. Of note, during the old enough should be encouraged to share their diagnosis with families postpartum period, she had an episode of a suicide attempt. Dr. Cook and encourage their families to use a support system as much as they is extremely busy today, and when Joan brings up Mrs. B.’s apparent feel comfortable. depressed mood to his attention, he is extremely dismissive and Lastly, the nurse Joan should have been more proactive and should remarks that her history of depression and prior suicide attempt was have screened Mrs. B. for suicidal ideation and intent during her last a thing of the past. Two weeks later, Mrs. B. is found by her older son visit given that she had some context and a better understanding of after attempting to hang herself. She was admitted to the intensive care Mrs. B.’s history than did the physician who was filling in. She chose unit at the local hospital. to defer to Dr. Cook’s authority and failed to act on her intuitive Discussion for case study 1 nursing judgment. In addition, she should have at least reported her Upon review of Mrs. B.’s history, the admitting physician noted that suspicious to Dr. Duke when he returned from his vacation four days three months earlier she noted that her husband had been unfaithful. after her visit. She tried to cope with this stressor on her own, and although she saw Case study 2 a counselor monthly, she intentionally kept that information from Ella is a 16-year-old high school student. She requests to see a school the counselor at her last visit two months prior. Also, she cancelled therapist after a bad breakup with her boyfriend of three months. her last two counseling sessions but did call a suicide hotline three During her initial consultation with the school therapist, she reports weeks before her attempted suicide. The suicide hotline attempted to that she has had suicidal ideations as well as intent and a plan. She follow up and check in with her, but she was dismissive and ended up reports that she has a plan to swallow a bottle of Tylenol to “make the refusing to take their calls. In addition to her primary care physician, pain go away.” When asked if she had access to Tylenol, she reports she saw her gynecologist four weeks before her suicide attempt. Her that she bought a bottle a few days ago and was just waiting to find gynecologist did notice that she was not her usual self, but when she the right time. The school counselor promptly contacts Ella’s parents pressed her, Mrs. B. reported that her antidepressant dose was being who come in to meet with her. Ella’s mom reports that Ella tended to adjusted by her therapist and so she would be fine in a few weeks. be dramatic and that she had made such threats after her previous In conclusion, Mrs. B. had four interactions with health care three breakups and all Ella needed to do was to stop being distracted professionals within a three-month period before her suicide attempt. by boys and focus on her future. At the counselor’s insistence, the mom Although two of those providers suspected something was off, promised to report the counselor’s findings to her pediatrician. The they did not fully appreciate the gravity of the situation. Part of the next week Ella was found dead by her best friend on her bathroom challenge with caring for patients who are seeing multiple providers floor.

Page 80 Psychology.EliteCME.com Discussion for case study 2 The counselor should have tried to contact Ella’s father and tried Managing and treating suicidal ideations can be challenging, especially to convey her sense of urgency regarding the immediacy of Ella’s in children whose parents are dismissive of the warning signs in their needs. This was especially important given that her mother was being children. The counselor in this case reacted appropriately by promptly so resistant to getting Ella the help she needed. In the aftermath of reporting her findings and suspicions to Ella’s parents. However, Ella’s death, her friends and classmates should receive counseling. Ella’s mom’s denial regarding the challenges her daughter faced was a Additionally, Ella’s parents should receive grief counseling to help particular hindrance in securing the right help for Ella. them cope with the loss of their daughter.

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L., Miller, T. R., Nelson, L. S., & Caine, E. D. (2016). work-loss costs of emergency department-treated nonfatal injuries—United States, 2013. Morbidity Self-injury mortality in the United States in the early 21st century. JAMA Psychiatry, 73(10), and Mortality Weekly Report, 64(38), 1077–1082. Retrieved from http://www.cdc.gov/mmwr/ 1072–1081. doi:10.1001/jamapsychiatry.2016.1870 preview/mmwrhtml/mm6438a5.htm ŠŠ Rothberg, B., & Schneck, C. D. (2016). Anxiety and depression. In R. E. Rakel & D. P. Rakel ŠŠ Florence, C., Simon, T., Haegerich, T., Luo, F., & Zhou, C. (2015). Estimated lifetime medical and (Authors), Textbook of family medicine, 9th ed., (pp. 1090–1107). Philadelphia: Elsevier. work-loss costs of fatal injuries—United States, 2013. Morbidity and Mortality Weekly Report, ŠŠ Shepard, D. S., Gurewich, D., Lwin, A. K., Reed, G. A., Jr., & Silverman, M. M. (2015). Suicide and 64(38), 1074–1077. 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(2012). 2012 national strategy for suicide and the Edinburgh Postnatal Depression Scale: Protocol for the Born and Bred in Yorkshire: prevention: Goals and objectives for action: A report of the U.S. Surgeon General and of the PeriNatal Depression Diagnostic Accuracy (BABY PANDA) study. BMJ Open, 6(6). doi:10.1136/ National Action Alliance for Suicide Prevention. Washington, DC: U.S. Dept. of Health and Human bmjopen-2016-011223 Services, Office of the Surgeon General, National Action Alliance for Suicide Prevention. ŠŠ McCarthy, J. F., Valenstein, M., Kim, H. M., Ilgen, M., Zivin, K., & Blow, F. C. (2009). Suicide ŠŠ Washington State Department of Health. (2014). Washington State injury and violence prevention mortality among patients receiving care in the Veterans Health Administration Health System. guide. Olympia: Washington State Department of Health. American Journal of Epidemiology, 169(8), 1033–1038. doi:10.1093/aje/kwp010 ŠŠ World Health Organization. (2014). 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Psychology.EliteCME.com Page 81 SUICIDE ASSESSMENT AND PREVENTION FOR HEALTH PROFESSIONALS Final Examination Questions Select the best answer for questions 31 through 50 and mark your answers on the Final Examination Answer Sheet found on page 85 or take your test online at Psychology.EliteCME.com.

31. WHO also reported that suicide is the ______most common 38. The NVDRS defines a(n) ______as a “death resulting cause of death among young people between ages 15 and 29 years. from the intentional use of physical force or power against oneself, a. Third. another person, or a group or community.” b. Second. a. Suicide. c. First. b. Violent death. d. Fifth. c. Accident. d. Hate crime. 32. Although suicide rates are lower among younger age groups than older adult groups, suicide remains one of the top _____ causes of 39. What is defined as “death resulting from the use of physical force death among people ages 44 and younger. or power, threatened or actual, against another person, group, or a. Four. community when a preponderance of evidence indicates that the b. Six. use of force was intentional.” c. Ten. a. Homicide. d. Two. b. Suicide. c. Hate crime. 33. The availability of data about suicide rates worldwide is very d. Accident. sparse. Why is this? a. Most suicides occur in countries that do not have adequate 40. Which of these is one of these specific variables analyzed by means of communication. NVDRS? b. Suicide and suicidal behavior is considered illegal in many a. The mechanism of injury. countries. b. Whether the person who died was a victim of a violence- c. People don’t care. related injury. d. The data has not yet been collected. c. Whether the person who died was a suspect who inflected a fatal injury on a victim. 34. Identified variables that could affect the incidence of suicide in d. All of these are variables analyzed by NVDRS. communities include: a. Gender ratio and age distribution. 41. The magnitude of the economic burden associated with b. Urbanization rate. injury-associated deaths only underscores the imperative need for c. Poverty rate and region. ______. d. All of these variables are those that have been identified to a. Better legislation. affect the incidence of suicide in communities. b. More money. c. Effective prevention. 35. Compared to medical examiner systems, ______are d. Drug enforcement. disproportionately located in more rural and less affluent areas of the country. 42. Nonsuicidal self-injury is defined as self-injurious behaviors with a. County health systems. no intent to ______. b. Volunteer-led healthcare. a. Die. c. County coroner systems. b. Harm. d. Charity-based systems. c. Get help. d. Follow through. 36. Despite multiple suicide prevention efforts, the suicide rate in the United done what in the last 100 years? 43. Nonsuicidal self-injury does NOT include: a. Improved a little. a. Repetitive cutting. b. Improved dramatically. b. Burning. c. Changed relatively little. c. Rubbing. d. Gotten higher. d. Firearms.

37. The status of progress toward the Healthy People 2020 objective 44. Studies have shown that 9 out of 10 suicide victims suffered from to reduce the suicide rate can also be directly measured using data at least one ______. from the ______. a. Severe psychological problem. a. National Health Institute. b. Health condition. b. Department of Health and Human Services. c. Economic or career setback. c. Centers for Disease Control’s National Violent Death d. Comorbidity. Reporting System (NVDRS). d. Department of State.

Page 82 Psychology.EliteCME.com 45. The most common means of suicide in the United States is 49. What is defined as any type of self-injurious behavior, including ______. suicide attempts and nonsuicidal self-injury? a. A knife. a. Deliberate self-harm. b. A bridge. b. Suicide. c. A firearm. c. Homocide. d. Asphyxiation. d. Mental illness.

46. Among females, what age groups has the highest rate of suicide? 50. Suicide warning signs do NOT include: a. 15-22. a. Talking about feeling hopeless or having no purpose. b. 25-30. b. Increasing use of drugs or alcohol. c. 35-64. c. Excitement about a future event. d. 64-88. d. Sleeping too little or too much.

47. It has been well established that ______is a distinct class of depression with specific and special recommendations for the identification and clinical management of this medical condition. a. Childhood depression. b. Perinatal depression. c. Bi-polar depression. d. Seasonal-affective disorder.

48. Blow et al. (2012) noted that ______were at the highest risk for suicide. a. Adolescents. b. Women. c. Elderly. d. Middle-aged men.

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