Chapter 15

Abnormality, Therapy, and Social Issues

Module 15.1

Abnormal Behavior: An Overview

Abnormality, Therapy and Social Issues

What is abnormal?

It seems simple: there is normal and abnormal behavior The distinction between normal and “weird” is clear to

everyone. Isn’t it? Define “abnormal” Behavior must be interpreted in its context.

Normal is a matter of place and time as well as mental state and action.

Defining Abnormal Behavior

No definition of “abnormal” that can’t be questioned. Example: “subjective feelings of distress”

Anyone who thinks they have a problem automatically qualifies.

What about people who behave in bizarre and dangerous ways, but insist they are fine?

Example:“behavior that could result in suffering or death” heroic deeds would be a bona fide symptom.

Example: “behavior that is very different from the usual” very depressed people would be diagnosed, but so would very happy people.

APA definition of abnormal behavior

The American Psychiatric Association characterizes abnormal behavior as "behavior that leads to distress (pain), disability (impaired functioning), or an increased risk of death, pain, or loss of freedom."

Even this definition has problems Heroic behavior sometimes leads to death – does that make it

abnormal? Does everyone who reports psychological distress actually have a

psychological problem? Some people whose behavior appears to be seriously disordered

report no distress at all.

It is safest to reserve official psychiatric diagnoses for people whose mental problems seriously interfere with their daily lives.

Cultural influences on abnormality

Abnormality is culturally defined, to some extent. Each era and society has had its own interpretations of

abnormal behavior. Culture-specific disorders are found all over the planet.

Demonic possession has been a common diagnosis in some societies for thousands of years.

Running amok consists of episodes of indiscriminant violent behavior in young Southeast Asian men.

Social Anxiety: US vs. Japan

Cultural influences on abnormality

Dissociative Identity Disorder (aka: Multiple Personality Disorder, “split personality”)

There is alternation between two or more personalities. Each has its own disposition, behavior, and name, as if

each were a separate person. Very rare disorder until the 1950’s, when a few

cases received widespread publicity.(Three Faces of Eve, Sybil)

By the early 1990s there were many cases of DID reported.

Some observers began to claim that the disorder did not exist at all.

It is most likely that it was being promoted by over eager therapists.

Defining Abnormal Behavior

The biopsychosocial model -- 3 major factors to understanding mental illness Biological roots - include genetic factors, injury,

disease processes, and the like which result in abnormal brain development, damage, imbalances of neurotransmitters and hormones, all of which can result in abnormal behavior.

Psychological roots – an individual’s life history and experiences contribute to his or her ability to cope and degree of vulnerability to stress.

Social and cultural context – people are greatly influenced by how other people act toward them and the expectations people hold for them.

Psychopathology

Most of us feel sad, anxious, or angry occasionally. Our moods change, we have or develop bad habits, and we

have “funny” beliefs. Mental health diagnoses are reserved for people with

problems that seriously interfere with their lives.

Diagnosis

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

describes specific symptoms and diagnostic guidelines for psychological disorders

Provides a common language to label mental disorders

Comprehensive guidelines to help diagnose mental disorders

Background of DSM First published by APA in 1952First published by APA in 1952 Used as a resource by the majority of mental health professionals. Used as a resource by the majority of mental health professionals. In earlier editions, many clinicians considered it merely a tool for In earlier editions, many clinicians considered it merely a tool for

researchers. researchers. Now, in an era of managed care, clinicians often forced to rely on Now, in an era of managed care, clinicians often forced to rely on

standardized criteria in DSM to support insurance claims or legal defenses. standardized criteria in DSM to support insurance claims or legal defenses. While widely used as a resource the DSM is not a substitute for a clinical While widely used as a resource the DSM is not a substitute for a clinical

diagnosisdiagnosis The DSM provides diagnostic categories and criteria for their diagnoses.

The proper use of these requires clinical training, knowledge and skills to apply them.

Classifying Psychological Disorders

The DSM-IV Diagnosis is made along five axes (lists). A person can have one or more diagnoses on a given

axis, or none at all. Clinical disorders are diagnosed on Axis I--mental

disorders that arise after infancy and are viewed as deteriorations in overall mental functioning.

Most common psychological disorders are listed on Axis I.

Table 15.1 Some major categories of psychological disorders according to Axis I of DSM-IV.

Classifying Psychological Disorders

The DSM-IV Axis II is reserved for personality disorders and

mental retardation. These are disorders that persist throughout life. A personality disorder is a maladaptive, inflexible way of

dealing with situations and people.

Table 15.2 Some major categories of psychological disorders according to Axis II of DSM-IV.

Classifying Psychological Disorders

The DSM-IV Axis III is for general medical conditions that may

influence the person’s mood or behavior. Axis IV is for psychosocial and environmental

problems that may increase the person’s level of stress. Axis V is a 1-90 scale called the global assessment of

functioning. The lower the number assigned by the assessing clinician, the less likely it is that the person being diagnosed is able to function without treatment and support.

Classifying Psychological Disorders

Differential diagnosis disorders often have similar or overlapping symptoms.

Psychologists and psychiatrists are trained to make differential diagnoses.

They look at all the disorders with similar symptoms that listed in the DSM-IV as well as disorders that are purely medical but affect mood and behavior.

They either rule these disorders out or revise their original diagnosis based on the information they have gathered.

This may take place over time.

Classifying Psychological Disorders

Criticisms of DSM-IV

1) distinguishing normal from abnormal behaviors can be pretty arbitrary E.g., having symptom for 5 months vs. 6 months

2) Difficult to judge marginal or very mild cases

3) Some people still do not fit neatly into any diagnostic category.

4) Sometimes DSM treats problems of adjustment (i.e., to a new situation or change in one’s life) as mental health problems. Pressure to make diagnoses - leading to the worry that

normal concerns are being turned into psychiatric conditions.

Criticisms of DSM-IV (continued)

5) Criteria for Mental disorders are influenced by culture and 5) Criteria for Mental disorders are influenced by culture and historyhistory While widely accepted among While widely accepted among psychologistspsychologists and and

psychiatristspsychiatrists, the manual has proved controversial in , the manual has proved controversial in choices for what constitutes a mental disorder. choices for what constitutes a mental disorder.

E.g., DSM-II classified E.g., DSM-II classified homosexualityhomosexuality as a mental as a mental disorder, a classification that was removed by vote of the disorder, a classification that was removed by vote of the APA in APA in 19731973 * *

** Even the definition of what counts as a disorder (I.e. that it causes distress) was influenced by the debate on homosexuality. By defining disorder as something that caused distress, homosexuality itself was removed and Sexual Orientation Disorder was added for homosexuals who were unhappy about being gay.

Figure 15.1 According to one survey, about half the people in the United States will suffer at least one psychological disorder at some time. (Based on data of Kessler et al., 1994

How Common are Psychological Disorders?

How Common are Psychological Disorders?

Approximately 48% of adults experienced symptoms at least once in their lives

Approximately 80% who experienced symptoms in the last year did NOT seek treatment

2 ways of interpreting this There is a stigma associated with receiving a mental health

diagnosis. Many people who could benefit from treatment do not

seek it Most people seem to deal with symptoms without complete

debilitation

Module 15.2

Psychotherapy: An Overview

Psychotherapy

Psychotherapy is a treatment of psychological disorders by methods that include an ongoing relationship between a trained therapist and a client.

Psychotherapy is utilized for a wide variety of disorders.

Types of Therapy

Psychotherapy—use of psychological techniques to treat emotional, behavioral, and interpersonal problems

Based on assumption that psychological factors play a significant role in troubling feelings, behaviors, or relationships

Biomedical—use of medications and other medical therapies to treat the symptoms associated with psychological disorders

Based on assumption that symptoms of many psychological disorders involve biological factors, such as abnormal brain chemistry

Treating psychological disorders with a combination of psychotherapy and biomedical treatments is increasingly common

Overview

Psychotherapy Psychoanalytic/Psychodynamic Humanistic Behavioral Cognitive Other (group, family, couples, etc.)

Psychoanalysis

Developed by Sigmund Freud based on his theory of personality

Freud’s view of the mind

• conscious-- what you’re aware of, can verbalize and think about in a logical fashion.

• preconscious -- ordinary memory. Not conscious, but can be easily brought into conscious.

• unconscious -- not directly accessible. A dump box for urges, feelings and ideas that are tied to anxiety, conflict and pain. These feelings and thoughts still exert influence on our actions and our conscious awareness.

Defense Mechanisms

Defense mechanisms come into play to prevent undesirable urges or conflicts E.g., repression--pulling into the unconscious For example forgetting sexual abuse from your

childhood due to the trauma and anxiety

Causes of Psychological Problems

Undesirable urges and conflicts are “repressed” or pushed to the unconscious

Unconscious conflicts exert influence on behaviors, emotions, and interpersonal dynamics

Understanding and insight into repressed conflicts leads to recognition and resolution

Goal of Pyschoanalysis--unearth past problems so patient gains insight into real source of problems

How to reveal the unconscious

Unconscious sometimes reveals itself in disguise

Dreams Memory lapses Slips of the tounge Accidents (spilling hot coffee on someone you envy)

Techniques of Psychoanalysis

Free association—spontaneous report of all mental images, thoughts, feelings as a way of revealing unconscious conflicts

Resistance—patient’s unconscious attempt to block revelation of unconscious material; usually sign that patient is close to revealing painful memories

More Psychoanalytic Techniques

Dream interpretation—dreams are the “royal road to the unconscious”; interpretation often reveals unconscious conflicts

Some symbols in dreams and their potential meaningsqueen and king or empress and emperor

father and mother

knives, daggers, lances, sabers, swords, guns, rifles, revolvers, cannons

a phallus

mountains, rocks, sticks, umbrellas, poles, trees

a phallus

shafts, pits, caves, bottles, boxes, suitcases, tins, pockets, closets, stoves, ships

female genitalia

Apples, peaches and fruits in general

breasts

playing instruments, sliding, slipping and breaking branches

masturbation

teeth falling out or getting pulled

castration (as punishment for masturbation)

More Psychoanalytic Techniques

Transference—process where emotions originally associated with a significant person are unconsciously transferred to the therapist

How psychoanalytic techniques work

Goal is to help patient see how past conflicts influence present behavior

Once insight is achieved therapist helps patient work through and resolve conflicts

As conflicts are resolved maladaptive behaviors driven by conflicts can be replaced with more adaptive emotional and behavioral patterns

Other Dynamic Therapies

Traditional psychoanalysis is seldom practiced today Most therapies today are shorter-term (e.g., a few months) Based on goals that are specific and attainable Therapists are more directive than traditional psychoanalysis Therapist still uses interpretations to help patient recognize

hidden feelings and transferences

Interpersonal therapy (IPT)

a particularly influential short-term psychodynamic therapy focuses on current relationships and social interactions and is highly structured. IPT therapy model,

four categories of personal problems: unresolved grief--dealing with death of significant other role disputes--repeating conflicts with significant others role transitions--problems with major life change interpersonal deficits--absent or faulty social skills

phases of treatment,

1 the therapist identifies the interpersonal problem that is causing difficulties;

2 therapist helps the person understand his or her particular interpersonal problem and develop strategies to resolve it.

Humanistic Therapies

Humanistic perspective emphasizes human potential, self-awareness, and free-will

Humanistic therapies focus on self-perception and individual’s conscious thoughts and perceptions

Client-centered (or person-centered) therapy is the most common form of humanistic therapy

Carl Rogers (1902–1987)—developed this technique

Client-Centered Therapy

Therapy is non-directive—therapist does not interpret thoughts, make suggestions, or pass judgment

Therapy focuses on client’s subjective perception of self and environment

Does not speak of “illness” or “cure”

Therapeutic Conditions

Genuineness—therapist openly shares thoughts without defensiveness

Unconditional positive regard for client—no conditions on acceptance of person

Empathic understanding—creates a psychological mirror reflecting clients thoughts and feelings

Behavior Therapy

Behavioristic perspective emphasizes that behavior (normal and abnormal) is learned

Uses principles of classical and operant conditioning to change maladaptive behaviors

Behavior change does not require insight into causes Often called behavior modification

Figure 15.4 A child can be trained not to wet the bed by using classical conditioning techniques. At first, the sensation of a full bladder (the CS) produces no response, and the child wets the bed. This causes a vibration or other alarm (the UCS), and the child wakes up (the UCR). By associating the sensation of a full bladder with a vibration, the child soon begins waking up to the sensation of a full bladder alone and will not wet the bed.

Systematic Desensitization

Based on classical conditioning Uses three steps:

Progressive relaxation Development of anxiety hierarchy and control scene Combination of progressive relaxation with anxiety

hierarchy

Sample Anxiety Hierarchy

Token Economy

Based on operant conditioning Use for behavior modification in group settings (prisons,

classrooms, hospitals) Has been successful with severely disturbed people Difficult to implement and administer—esp. in outpatient

situations

Therapies That Focus on Thoughts and BeliefsCognitive Therapy

Based on the assumption that psychological problems are due to maladaptive patterns of thinking

Therapy focuses on recognition and alteration of unhealthy thinking patterns

Rational Emotive Therapy (RET)

Developed by Albert Ellis ABC model

Activating Event Beliefs Consequences

Identification and elimination of core irrational beliefs

Cognitive Behavioral Therapy

Integrates cognitive and behavioral techniques. Based on the assumption that thoughts, moods, and behaviors are

interrelated

Prevalence of Cognitive Therapy

Half of all faculty in accredited clinical psychology doctoral programs now align themselves with a cognitive or cognitive-behavior therapy orientation. (Data from Mayne & others, 1994. Note: Some faculty identify with more than one perspective.)

Concept Check:

In which type of therapy would the therapist be most likely to interpret a thought, feeling or dream?

Concept Check:

In which therapies are treatment goals stated in clear and specific terms?

Behavioral and cognitive-behavioral

Concept Check:

In which therapy is the client viewed as essentially good and wishing to achieve full potential in life?

Person-centered (humanistic)

Other Trends: Group and Family Therapy

One limitation of individual therapies is that client is seen in isolation rather than in context of interactions with others

Therapist must rely on clients interpretation of reality Group and Family Therapies (Family Systems Therapies) address this

limitation Types

Group therapy—One or more therapists working with several people at the same time.

Family therapy—based on the assumption that the family is a system and treats the family as a unit.

Couple therapy—relationship therapy that helps with difficulty in marriage or other committed relationships

Group Therapy

Group can be as small as 3 or 4 or as large as 10 or more Any approach can be used Advantages

Cost effective Therapist observes interactions with others Support and encouragement from others (success often

hinges on group’s sense of cohesion) Advice from group members Safe environment to try out new behaviors

Group vs. self-help/support groups Typically conducted by nonprofessionals

Family Therapy

Assumption: family is a system-- treat the family as a unit Psychologically healthier family leads to healthier individuals

Every family has certain unspoken “rules” of interaction and communication (e.g., who asserts power and how, who makes decisions, who is the peacemaker)

Unhealthy patterns of family interaction can be identified and replaced with new “rules” that promote the psychological health of the family.

Often used to enhance individual therapies E.g., schizophrenics are less likely to relapse when family is involved

in therapy

Couple Therapy

Many different types Most share common goals:

improving communication and problem-solving skills and increasing intimacy between the pair

Effectiveness of Psychotherapy

Most people do not seek help with problems Some cope with help of family and friends Many people report spontaneous remission--improving

with the passage of time Meta-analyses show that psychotherapy is more effective

than no treatment On average person who completes therapy is better off

than 80% of those who do not Gains tend to last long after therapy has ended

• Improvement for people in weekly psychotherapy and people who did not receive psychotherapy.

• After 8 weekly sessions more than 50% receiving therapy were significantly improved compared to 4% of those not receiving therapy

• Clearly, psychotherapy accelerates both the rate and the degree of improvement for those experiencing psychological problems. SOURCE: McNeilly & Howard, 1991.

Is one form of psychotherapy better?Answer 1: No -- in general there is little or no difference in the effectiveness of different empirically supported psychotherapies

Answer 2: Yes -- in some cases one type of therapy is more effective than another for treating a particular problem

E.g., Depression --

cognitive therapy Panic disorder, OCD, phobias

cognitive, behaviorist, CBT > insight oriented therapies Disorders with severe psychotic symptoms (e.g., schizophrenia)

insight oriented therapies < other therapies

What might explain similarities in overall positive results across approaches?

Common Factors in Successful Therapy Therapeutic relationship—caring and mutually respectful Therapist characteristics—caring attitude, ability to listen

empathetically, sensitive, committed to patient’s welfare Client characteristics—motivated, actively involved, emotionally and

socially mature External circumstances -- stable living situation, supportive family

Eclecticism

A good match between person and type of therapy is important Current trend in psychotherapy is Eclecticism--pragmatic and integrated

use of techniques from different psychotherapies. Today therapists identify themselves as eclectic more than any other

orientation Eclectic psychotherapists carefully tailor the therapy approach to the

problems and characteristics of the person seeking help.

Finding the Best Therapy

Research suggests that the various methods of therapy and professionals who provide services are about equally effective. There is no “best” type of therapist or best method.

But no one way of doing psychotherapy is right for every client. You need to use your knowledge to “shop” for the therapist who will work best with you.