Psych 2030 > Chapter 1 > Flashcards
Chapter 1 Flashcards
Psychological disorder
A psychological dysfunction within an individual that is associated with distress or impairment in functioning and a response that is not typical or culturally expected
Involves 3 things:
- psychological dysfunction
- personal distress or impairment
- atypical or not culturally expected
Psychological Dysfunction
Psychological dysfunction refers to a breakdown in cognitive, emotional, or behavioural functioning.
i.e. fearing all dates, abnormal intense fear of blood
Knowing where to draw the line between normal and abnormal dysfunction is often difficult.
- For this reason, these problems are often considered to exist on a continuum or as a dimension, rather than as categories that are either present or absent.
- This is one reason that just having a dysfunction is not enough to meet the criteria for a psychological disorder.
Personal Distress or impairment
The criterion of a psychological disorder is satisfied if the individual is also extremely upset.
On its own, this criterion does not define abnormal behaviour
- normal to be upset in some situations (i.e. death, failure)
- for some disorders, by definition, suffering and distress are absent
Atypical or not culturally expected
Something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is.
Many people are far from the average in their behaviour, but few would be considered disordered. We might call them talented or eccentric.
- In most cases, the more productive you are in the eyes of society, the more eccentricities society will tolerate.
Another view is that your behaviour is abnormal if you are violating social norms in your culture.
- To enter a trance state and believe you are possessed would point to a psychological disorder in most Western cultures, but in many other societies the behaviour is accepted and expected
- neuroscientist Robert Sapolsky (2002) worked closely with the Masai tribe in East Africa and saw cultural differences
A related concept that is also useful when considering the definition of psychological disorder is to determine whether the behaviour is beyond the individual’s control (something he or she doesn’t want to do or feel)
Wakefield’s definition of psychological disorder
According to Wakefield, a psychological disorder is caused by a failure of one or more mechanisms to perform their evolved function and the dysfunction produces harm or distress.
Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains the current listing of criteria for psychological disorders.
The DSM-5 acknowledges that it is difficult to provide a clear and encompassing definition of psychological disorders
The most widely accepted definition used in the DSM-5 describes behavioural, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment.
A prototype
Consider how the apparent disease or disorder matches a “typical” profile of a disorder
We call this typical profile a prototype
The patient may have only some features or symptoms of the disorder (a minimum number) and still meet the criteria for the disorder because his or her set of symptoms is close to the prototype.
Thomas Szasz and George Albee
Some controversial figures, such as Thomas Szasz and George Albee, are highly critical of medical diagnoses being used in the case of psychological disorders.
In 1960, Szasz said that:
- mental illness is a myth
- the practice of labelling mental illnesses should be abolished
- argued that a fundamental difference exists between the use of diagnoses for physical diseases and their use in mental illnesses. The former uses objective criteria (e.g., results of blood tests), but for mental illness, subjective judgments are required.
Albee (1998, 2000)
- has argued that the biggest mistake made by the clinical psychology profession was uncritically accepting the concept of “mental disease” and using the medical model and associated diagnoses (e.g., the DSM system) in conceptualizing abnormal behaviour
Psychopathology
Psychopathology is the scientific study of psychological disorders.
Within this field are specially trained professionals, including clinical and counselling psychologists, psychiatrists, psychiatric social workers, psychiatric nurses, marriage and family therapists, sex therapists, and mental health counsellors.
Clinical psychologists
Clinical psychologists typically receive a Ph.D. (Doctor of Philosophy) following a course of graduate-level study that lasts six to seven years.
- This education prepares them to conduct research into the causes and treatment of psychological disorders and to assess, diagnose, and treat these disorders.
Instead of a Ph.D., clinical psychologists sometimes receive a Psy.D. (Doctor of Psychology) degree for which the training is similar to the Ph.D. but with more emphasis on clinical practice and less on research training.
Regulation of the psychology profession in Canada
In Canada, regulation of the psychology profession is under the jurisdiction of the provinces and territories.
- Depending on the jurisdiction, a psychologist may have either a doctoral or a master’s degree.
In Ontario, professional psychologists are regulated by the College of Psychologists of Ontario
- only those who are licensed or registered with their provincial or territorial board or college are permitted to call themselves psychologists (with the exception of university professors in psychology)
Psychotherapist VS Therapist
The labels psychotherapist and therapist are not regulated in most provinces and territories.
The label of psychologist conveys information about the training and qualifications of the professional, whereas the label of psychotherapist does not always (as of 2015, Ontario has a new College of Registered Psychotherapists).
In addition, the terms therapist and psychotherapist are not specific to a particular profession.
- For example, a social worker, a psychologist, a nurse, and a psychiatrist can all refer to themselves as psychotherapists if they provide therapy services to members of the public around psychological issues.
Psychologists with other specialty training, such as experimental and social psychologists, concentrate on investigating the basic determinants of behaviour but do not assess or treat psychological disorders
Counselling psychologists vs Clinical psychologists
Counselling psychologists (who can receive a Ph.D., Psy.D., or Ed.D.—Doctor of Education, or a master’s degree in education or counselling) tend to study and treat adjustment and vocational issues encountered by relatively healthy individuals
Clinical psychologists usually concentrate on more severe psychological disorders.
Psychiatrists
Psychiatrists first earn an M.D. in medical school and then specialize in psychiatry during a four-year residency training program.
Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view, make diagnoses, and offer treatments.
Many psychiatrists emphasize drugs or other biological treatments, although many use psychosocial treatments as well.
Psychiatric social workers
Psychiatric social workers typically earn a master’s degree in social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a psychological disorder.
Social workers also treat disorders, often concentrating on family problems associated with them.
Psychiatric nurses
Psychiatric nurses have advanced degrees, such as a master’s or a Ph.D., and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a treatment team
Marriage and family therapists and mental health counsellors
Marriage and family therapists and mental health counsellors typically spend one to two years earning a master’s degree and provide clinical services in hospitals or clinics, usually under the supervision of a doctoral-level clinician.
Scientist-practitioners
Many mental health professionals take a scientific approach to their clinical work and are therefore referred to as scientist-practitioners
Mental health practitioners may function as scientist-practitioners at least one of three ways
- They keep up with the latest scientific developments in their field and therefore use the best empirically supported diagnostic and treatment procedures
- This approach is now often called evidence-based practice - Scientist-practitioners evaluate their own assessments or treatment procedures to see whether they work and to generate new knowledge, an approach called practice-based evidence
- Scientist-practitioners might conduct research, often in clinics or hospitals, that produces new information about disorders or their treatment.
Overall:
Scientist-practitioner:
- consumer of science
- evaluator of practice
- creator of science
Studying psychological disorders:
- clinical description
- causation (ethology)
- treatment and outcome
Clinical Description
Presenting problem
- a patient “presents” with a specific problem or set of problems
- it is why the person came to the clinic
Clinical description
- represents the unique combination of behaviours, thoughts, and feelings that make up a specific disorder
- the word clinical refers both to the types of problems or disorders you would find in a clinic or hospital and to the activities connected with assessment and treatment
Prevalence of the disorder
- Statistical data may be relevant
- how many people in the population as a whole have the disorder?
Lifetime prevalence
- How many people in the population have ever had the disorder?
Incidence of the disorder
- Statistics on how many NEW cases occur during a given period, such as a year
Course
- most disorders follow a somewhat individual pattern, or course
- some disorders, such as schizophrenia, follow a CHRONIC course, meaning that they tend to last a long time, sometimes a whole lifetime
- Other disorders, like mood disorders, follow an EPISODIC course in which the individual is likely to recover within a few months, only to have a recurrence of the disorder later
- other disorders may have a TIME-LIMITED course, like some sleep disorders, meaning the disorder will improve without treatment in a relatively short period with little or no risk of recurrence.
Disorders also have differences in onset
- Some disorders have an ACUTE onset, meaning that they begin suddenly
- others develop gradually over an extended time, which is sometimes called an INSIDIOUS onset.
Prognosis
- The anticipated course of a disorder
- saying “the prognosis is good,” meaning the individual will probably recover, or “the prognosis is guarded,” meaning the probable outcome doesn’t look good.
Patient’s age is an important part of the clinical description.
- A specific psychological disorder occurring in childhood may present differently in adulthood or old age
- Because children’s thoughts and feelings are different from those experienced by adults with anxiety and panic, children are often misdiagnosed and treated for a medical disorder
Causation, treatment, and outcomes
Etiology, or the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions.
Treatment is often important to the study of psychological disorders.
- If a new drug or psychosocial treatment is successful in treating a disorder, it may give us some hints about the nature of the disorder and its causes.
Psychology is never simple because the effect does not necessarily imply the cause
Three major models that explain behaviour
- Supernatural
- Divinities, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars, are the driving forces behind the supernatural model. - Biological
- Psychological
Since ancient Greece, the mind has often been called the soul or the psyche and considered separate from the body.
- Although many have thought that the mind can influence the body and, in turn, the body can influence the mind, most philosophers looked for causes of abnormal behaviour in one or the other.
- This split gave rise to two traditions of thought about abnormal behaviour, summarized as the biological model and the psychological model.
The Supernatural Tradition
In history, deviant behaviour has been considered a reflection of the battle between good and evil.
- When confronted with unexplainable behaviour and by suffering and upheaval, people perceived it as evil
Demons and Witches
Stress and melancholy
Treatments for Possession
The moon and the stars
Demons and Witches - The Supernatural Tradition
During the last quarter of the 14th century, religious and lay authorities supported these popular supernatural superstitions, and society as a whole began to believe in the reality and power of demons and witches.
The Catholic Church had split, and a second centre, complete with a pope, emerged in the south of France to compete with Rome. In reaction to this schism, the Roman church fought back against the evil in the world that must have been behind this heresy.
People turned increasingly to magic and sorcery to solve their problems. The bizarre behaviour of people with psychological disorders was seen as the work of the devil and witches. It followed that individuals possessed by evil spirits were probably responsible for any misfortune experienced by the townspeople, which inspired drastic action against the possessed.
Treatments included exorcism, in which various religious rituals were performed to rid the victim of evil spirits. Other approaches included shaving the pattern of a cross in the victims’ hair and securing them to a wall near the front of a church so that they might benefit from hearing mass.
The conviction that sorcery and witches were causes of madness and other evils continued into the 15th century. Evil continued to be blamed for unexplainable behaviour, even after the European founding of the New World, as evidenced by the Salem witch trials in the 17th century, which resulted in the hanging deaths of 20 women.
stress and melancholy - the supernatural tradition
An equally strong opinion reflected the
view that insanity was a natural phenomenon, caused by mental or emotional stress, and that it was curable. Mental depression and anxiety were recognized as illnesses, although symptoms such as despair and lethargy were often identified by the church with the sin of acedia, or sloth.
Common treatments were rest, sleep, and a healthy and happy environment. Other treatments included baths, ointments, and various potions.
During the 14th and 15th centuries, people with mental illnesses, along with people who had physical deformities or disabilities, were often moved from house to house in medieval villages, as neighbours took turns caring for them.
One of the chief advisers to the king of France Charles V, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression), rather than demons, was the source of some bizarre behaviour. Oresme pointed out that much of the evidence for the existence of sorcery and witchcraft, particularly among people with psychological disorders, was obtained from people who were tortured and who, quite understandably, would confess to anything.
These conflicting crosscurrents of natural and supernatural explanations for mental disorders are represented more or less strongly in various historical works, depending on the sources consulted by historians. Some assume that demonic influences were the predominant explanations of abnormal behaviour during the Middle Ages; others believe the supernatural had little or no influence. As we see in the handling
of the severe psychological disorder experienced by King Charles VI of France in the late 14th century, both influences were strong, sometimes alternating in the treatment of the same case.
Treatments for possession - the supernatural tradition
It is logical to conclude that the person is largely responsible for his or her own disorder, which might well be a punishment for evil deeds.
The acquired immune deficiency syndrome (AIDS) epidemic reflects a very similar belief among some people. Because the human immunodeficiency virus (HIV) is, in Western societies, most prevalent among gay men, some people believe it is a divine punishment for what they consider abhorrent behaviour. This view is slowly dissipating as the AIDS virus spreads to other “less sinful” segments of the population, but it still persists.
Possession is not always connected with sin and may be seen as involuntary and the possessed individual as blameless. Futhermore, exorcisms have the virtue of being relatively painless. They are sometimes associated with relief
In the Middle Ages, if exorcism failed, some authorities thought that steps were necessary to make the body uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and other forms of torture.
Somewhere along the way, a creative “therapist” decided that hanging people over a pit full of poisonous snakes might scare the evil spirits right out of their bodies. Strangely, this approach sometimes worked; that is, the most disturbed, oddly behaving individuals would suddenly come to their senses and experience relief from their symptoms, if only temporarily. Naturally, this was reinforcing to the therapist, and, so, snake pits were built in many institutions. Many other treatments based on the hypothesized therapeutic element of shock were developed, including dunking people in ice-cold water.
the moon and the stars - the supernatural tradition
Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning. This influential theory inspired the word lunatic, which is derived from the Latin word for moon, luna.
The belief that heavenly bodies affect human behaviour still exists, although no scientific evidence supports it.
Despite much ridicule, millions of people around the world are convinced that their behaviour is influenced by the stages of the moon or the position of the stars. This belief is most noticeable today in followers of astrology, who hold that their behaviour and the major events in their lives can be predicted by their day-to-day relationship to the position of the planets. No serious evidence has ever confirmed such a connection, however.
comments - the supernatural tradition
The supernatural tradition in psychopathology is alive and well, although it is relegated, for the most part, to some cultures outside North America and to small religious sects within North America.
Members of organized religions in most parts of the world look to psychology and medical science for help with major psychological disorders
The Roman Catholic Church requires that all health-care resources be exhausted before spiritual solutions, such as exorcism, be considered.
Nonetheless, miraculous cures are sometimes achieved by exorcism, magic potions, rituals, and other methods that seem to have little connection with modern science.
The BIologIcal Tradition
Physical causes of mental disorders have been sought since early in history. Important to the biological tradition are a man, Hippocrates; a disease, syphilis; and the early consequences of believing that psychological disorders are biologically caused.
- hippocrates and galen
- the 19th century
- the development of Biological treatments
- consequences of the Biological tradition
Hippocrates and galen - the biological tradition
The Greek physician Hippocrates the father of modern medicine. He has a body of work called the Hippocratic Corpus, written between 450 BCE and 350 BCE, in which they suggested that psychological disorders could be treated like any other disease.
They believed that psychological disorders might also be caused by brain pathology or head trauma and could be influenced by heredity (genetics). Hippocrates considered the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore, disorders involving these functions would logically be located in the brain.
Hippocrates also recognized the importance of psychological and interpersonal contributions to psychopathology, such as the sometimes negative effects of family stress; on some occasions, he removed patients from their families.
The Roman physician Galen later adopted the ideas of Hippocrates and developed them further.
One of the more interesting and influential legacies of the Hippocratic- Galenic approach is the humoral theory of disorders. Hippocrates assumed that normal brain functioning was related to four bodily fluids, or humors: blood, black bile, yellow bile, and phlegm. Blood came from the heart, black bile from the spleen, phlegm from the brain, and choler or yellow bile from the liver. Physicians believed that disease resulted from too much or too little of one of the humors; for example, too much black bile was thought to cause melancholia (depression). The humoral theory was, perhaps, the first example of associating psychological disorders with chemical imbalance, an approach that is widespread today.
Terms derived from the four humors are still sometimes applied to personality traits. For example, sanguine (red, like blood) describes someone who is ruddy in complexion—presumably from copious blood flowing through the body—and cheerful and optimistic, though insomnia and delirium were thought to be caused by excessive blood in the brain. Melancholic, of course, refers to a depressive personality (depression was thought to be caused by black bile flooding the brain). A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can also mean being calm under stress. A choleric person (from yellow bile or choler) is hot tempered.
Excesses of one or more humors were treated by regulating the environment to increase or decrease heat, dryness, moisture, or cold, depending on which humor was out of balance.
In addition to rest, good nutrition, and exercise, two treatments were developed. In bleeding or bloodletting, a carefully measured amount of blood was removed from the body, often with leeches. In the other, vomiting was induced. In a well-known treatise on depression published in 1621, Anatomy of Melancholy, Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting
The notion of a lack of balance in energy or other properties of the body as a cause of various symptoms is still quite alive today in alternative therapies, for example in traditional Chinese medicine and Ayurvedic medicine
Hippocrates also coined the word hysteria to describe a concept he learned from the Egyptians, who had identified what we now call the somatic symptom disorders. In these disorders, the physical symptoms appear to be the result of a pathology for which no organic cause can be found, such as paralysis and some kinds of blindness. Because these disorders occurred primarily in women, the Egyptians (and Hippocrates) mistakenly assumed that they were restricted to women. They also presumed a cause: The empty uterus wandered to various parts of the body in search of conception (the Greek for “uterus” is hysteron). Numerous physical symptoms reflected the location of the wandering uterus. The prescribed cure might be marriage or, occasionally, fumigation of the vagina to lure the uterus back to its natural location
the 19th century - the biological tradition
The biological tradition waxed and waned during the centuries after Hippocrates and Galen, but was reinvigorated in the 19th century by two factors: the discovery of the nature and cause of syphilis, and strong support from the well-respected American psychiatrist John P. Grey.
Syphilis
Behavioural and cognitive symptoms of advanced syphilis include believing that everyone is plotting against you (delusion of persecution) or that you are God (delu- sion of grandeur), as well as other bizarre behaviours. Although these symptoms are very similar to those of psychosis, researchers recognized that a subgroup of apparently psychotic patients deteriorated steadily, becoming paralyzed and dying within five years of onset. This course of events contrasted with that of most psychotic patients, who remained fairly stable.
In 1825, the condition was designated a disease, general paresis, because it had consistent symptoms (presentation) and a consistent course that resulted in death. The relationship between general paresis and syphilis was only gradually established.
Louis Pasteur’s germ theory of disease, around 1870, facilitated the identification of the specific bacterial micro-organism that caused syphilis. Pasteur stated that all the symptoms of a disease were caused by a germ (bacterium) that had invaded the body.
Of equal importance was the discovery of a cure for general paresis. Physicians observed a surprising recovery in patients who had contracted malaria and deliberately injected others with blood from a soldier who was ill with malaria. Many recovered, because the high fever “burned out” the syphilis bacteria. Ulti- mately, clinical investigators discovered that penicillin cures syphilis, but the malaria cure convinced many for the first time that “madness” and associated behavioural and cognitive symptoms could be traced directly to a curable infection. Many mental health professionals then assumed that comparable causes and cures might be discovered for all psychological disorders.
John P. Grey
The champion of the biological tradition in North America was a very influential psychiatrist named John P. Grey, who was appointed superintendent of a large hospital in New York in 1854. Grey also became editor of the American Journal of Insanity, the precursor of the current American Journal of Psychiatry, and the flagship publication of the American Psychiatric Association.
Grey’s position was that insanity always has physical causes. Therefore, the mentally ill patient should be treated as physically ill. The emphasis was once again on rest, diet, and proper room temperature and ventilation, approaches used for centuries by previous therapists in the biological tradition. Grey even invented the rotary fan to ventilate his large hospital.
Under Grey’s leadership, the conditions in hospitals greatly improved, and they became more humane, livable institutions. But in subsequent years they also became so large and impersonal that individual attention was not possible. In fact, leaders in psychiatry at the end of the 19th century were alarmed at the increasing size and impersonality of mental hospitals and recommended that they be downsized.
the Development of Biological treatments - the biological tradition
In the 1930s, the physical interventions of electric shock and brain surgery were often used. Their effects, and the effects of new drugs, were discovered quite by accident.
Insulin was occasionally given to stimulate appetite in psychotic patients who were not eating, but it also seemed to calm them down. In 1927, a Viennese physician, Manfred Sakel, began using higher and higher dosages until, finally, patients convulsed and became temporarily comatose. Some actually recovered their mental health, much to the surprise of everybody, and their recovery was attributed to the convulsions. The procedure became known as insulin shock therapy, but it was abandoned because it was too dangerous, often resulting in prolonged coma or even death.
In the 1920s, Joseph von Meduna observed that schizophrenia was very rarely found in people suffering from epilepsy (which ultimately did not prove to be true). Some of his followers concluded that induced brain seizures might cure schizophrenia. Following suggestions on the possible benefits of applying electric shock directly to the brain—notably, by two Italian physicians, Cerletti and Bini, in 1938—a surgeon in London treated a depressed patient by sending six small shocks directly through his brain, producing convulsions. The patient recovered. Though greatly modified, shock treatment is still with us today.
During the 1950s, the first effective drugs for severe psychotic disorders were developed in a systematic way, and they were introduced to Canada by psychiatrist Heinz Lehman. Before that time, a number of medicinal substances, including opium (derived from poppies), had been used as sedatives, along with countless herbs and folk remedies. With the discovery of Rauwolfia serpentina (later renamed reserpine) and another class of drugs called neuroleptics (major tranquilizers), for the first time hallucinations and delusions could be diminished; these drugs also reduced agitation and aggressiveness. Other discoveries included benzodiazepines (minor tranquilizers), which seemed to reduce anxiety. By the 1970s, the benzodiazepines (known by such brand names as Valium and Librium) were among the most widely prescribed drugs in the world. As drawbacks and side effects of tranquilizers became apparent, along with their limited effectiveness, the number of prescriptions decreased somewhat.
Throughout the centuries, as Alexander and Selesnick (1966, p. 287) point out, “The general pattern of drug therapy for mental illness has been one of initial enthusiasm followed by disappointment.” For example, bromides, a class of sedating drugs, were used at the end of the 19th and the beginning of the 20th centuries to treat anxiety and other psychological disorders. By the 1920s, they were reported as being effective for many serious psychological and emotional symptoms. By 1928, one of every five prescriptions in the United States was for bromides. When their side effects, including various undesirable physical symptoms, became widely known, and experience began to show that their overall effectiveness was relatively modest, bromides largely disappeared from the scene.
Neuroleptics were also used less when attention focused on their many side effects, such as chronic tremors and shaking.
consequences of the Biological tradition
In the late 19th century, John P. Grey and his colleagues, ironically, reduced or eliminated interest in treating patients with mental illnesses because they thought mental disorders were due to some as yet undiscovered brain pathology and were therefore incurable. The only available course of action was to hospitalize these patients. In fact, around the turn of the 20th century, some nurses documented clinical success in treating mental patients with psychological methods but were prevented from treating others for fear of raising hopes of a cure among family members. In place of treatment, interest centred on diag- nosis, legal questions concerning the responsibility of patients for their actions during periods of insanity, and the study of brain pathology itself.
Emil Kraepelin (1856–1926) was the dominant figure during this period and one of the founding fathers of modern psychiatry. He was extremely influential in advocating the major ideas of the biological tradition, but he was little involved in treatment, reflecting the belief that disorders were due to brain pathology. His lasting contribution was in the area of diagnosis and classification. Kraepelin was one of the first to distinguish among various psychological disorders, seeing that each may have a different age of onset and course, with somewhat different clusters of presenting symptoms and probably a different cause.
By the end of the 19th century, a scientific approach to psychological disorders and their classification had begun with the search for biological causes. Furthermore, treatment was based on humane principles. There were many drawbacks, however, the most unfortunate being that active intervention and treatment were all but eliminated in some settings, despite the fact that some very effective approaches were available
The PsychologIcal Tradition
Plato thought that the two causes of maladaptive behaviour were the social and cultural influences in a person’s life and the learning that took place in that environment. If some- thing was wrong in the environment, such as abusive parents, a person’s impulses and emotions would overcome reason. The best treatment was to re-educate the individual through rational discussion so that the power of reason would predominate. This approach was very much a precursor to modern psychosocial approaches, which focus not only on psychological factors but also on social and cultural ones.
Other well-known early philosophers, including Aristotle, also emphasized the influence of the social environment and early learning on later psychopathology. These philosophers wrote about the importance of fantasies, dreams, and cognitions and thus anticipated, to some extent, later developments in psychoanalytic thought and cognitive science. They also advocated humane and responsible care for people with psychological disturbances.
- Moral therapy
- asylum reform and the decline of moral therapy
- Psychoanalytic theory
- humanistic theory
- the Behavioural model
Moral therapy - the psychological tradition
During the first half of the 18th century, a strong psychosocial approach to mental disorders called moral therapy became influential. The term moral really meant “emotional” or “psychological” rather than a code of conduct. Its basic tenets included treating institutionalized patients as normally as possible in a setting that encouraged and reinforced normal social interaction, thus providing them with many opportunities for appropriate social and interpersonal contact. Relationships were carefully nurtured. Individual attention clearly emphasized positive consequences for appropriate interactions and behaviour; the staff made a point of modelling this behaviour. Lectures on various interesting subjects were provided, and restraint and seclusion were eliminated.
The principles of moral therapy date back to Plato and beyond. But moral therapy as a system originated with the well-known French psychiatrist Philippe Pinel. A former patient, Pussin, long since recovered, was working in the Parisian hospital La Bicêtre when Pinel took over. Pussin had already instituted remarkable reforms. Pussin persuaded Pinel to go along with the changes. He did, first at La Bicêtre and then at the women’s hospital Salpêtrière, where a humane, socially facilitative atmosphere produced “miraculous” results.
After William Tuke followed Pinel’s lead in England, Benjamin Rush (1745–1813), considered the founder of North American psychiatry, introduced moral therapy to the New World. It then became the treatment of choice in the leading hospitals. Asylums had appeared in the 16th century in Europe, with the intent of providing places of refuge for the confinement and care of people with mental illnesses. These early asylums were more like prisons than hospitals, however. Many housed beggars as well as people with a variety of mental illnesses, conditions were often deplorable. It was the rise of moral therapy in Europe and North America that made institutions habitable and even therapeutic.
Sussman (1998) provides a description of the history of the development of asylums in Canada in the 19th century. He notes that institutionalizing people with mental illnesses in Canada began with humane intentions, to relieve the suffering and neglect of these individuals who had previously been placed in jails or poorhouses, or left to care for themselves in the community. The provinces proceeded relatively independently to develop separate and more adequate provisions for people with mental illness in the form of mental hospitals or “asylums”. Asylum development in most provinces was influenced to a great extent by systems and movements in Great Britain and to a lesser extent by those in the United States. The involvement of religious orders in the care of people with mental illnesses in Quebec was influenced by practices occurring in France. According to Sussman, the development of asylums through the moral therapy movement did bring some relief to many people with mental illnesses.
asylum reform and the decline of moral therapy - the psychological tradition
Unfortunately, after the mid-19th century, humane treatment declined because of a convergence of factors.
First
- it was widely recognized that moral therapy worked best when the number of patients in an institution was 200 or fewer, allowing for a great deal of individual attention. However, patient loads in existing hospitals increased to 1000, 2000, and more with the enormous waves of immigrants arriving in North America at the time.
A second reason for the decline of moral therapy
- The great crusader Dorothea Dix campaigned endlessly for reform in the treatment of the insane throughout Canada and the United States. A schoolteacher who had worked in various institutions, she had firsthand knowledge of the deplorable conditions imposed on people with mental disorders, and she made it her life’s work to inform the public and their leaders of these abuses. Her work became known as the mental hygiene movement
- Dix visited Canada in 1843 and 1844 and discovered appalling conditions involving the incarceration of “lunatics” at Beauport in Quebec and in the Toronto Jail. She was involved in the construction of the asylum in St. John’s, Newfoundland and Labrador, in 1854. Probably most notable of her contributions to the mental hygiene movement in Canada was her appeal to the Nova Scotia Legislature in January 1850, when she described the deplorable conditions for people with mental illnesses at the time and argued for the development of an asylum in Nova Scotia
- In addition to improving the standards of care, Dix worked hard to make sure that everyone who needed care received it, including homeless people. Through her efforts, humane treatment became more widely available in North American institutions. As her career drew to a close, she was rightly acknowledged as a hero of the 19th century.
- Unfortunately, an unforeseen consequence of Dix’s heroic efforts was a substantial increase in the number of mental patients. This influx led to a rapid transition from moral therapy to custodial care because hospitals were inadequately staffed. Dix reformed asylums and single-handedly inspired the construction of numerous new institutions. But even her tireless efforts and advocacy could not ensure sufficient staffing to allow the individual attention necessary for effective moral therapy. Unfortunately, institutionalization in Canada eventually “became a synonym for an inhumane response to mentally ill people”, often because resources were insufficient to provide adequate care.
Clarence Hincks, a University of Toronto medical school graduate who cofounded the Canadian Committee for Mental Hygiene in 1918.
- Early in his career, he toured mental institutions throughout Manitoba. In his unpublished autobiography and his report to the Manitoba government, Hincks documented continued appalling conditions for people with mental illnesses in these institutions
- Hincks often found that those working in institutions— including the superintendents—had no special psychiatric training.
- Hincks noted that some of the institutions were not even meant for those with mental illness but had come to house them anyway, despite having no methods for caring for them.
- At another Manitoban institution, he discovered that mentally ill patients were locked into coffin-like boxes at night to sleep, and in another, “mentally defective” children were rolled in long strips of cotton at night, with their arms and legs bound, and then placed on shelves to sleep.
- Hincks had himself experienced and recovered from a bout of major depression while in university. His personal experience in recovering from depression led him to advocate for the idea that mental illness was treatable. Hincks’s position stood in contrast to the prevailing view at the time that mental illness was incurable. In fact, one Manitoba institution that Hincks visited in 1918 in Portage La Prairie was named the “Home for Incurables.”
A final blow to the practice of moral therapy
- was the decision, in the middle of the 19th century, that mental illness was caused by brain pathology and, therefore, was incurable. The psychological tradition lay dormant for a time, only to re-emerge in several very different schools of thought in the 20th century.
- The first major approach was psychoanalysis, based on Sigmund Freud’s (1856–1939) elaborate theory of the structure of the mind and the role of unconscious processes in determining behaviour.
- The second was behaviourism, associated with John B. Watson, Ivan Pavlov, and B. F. Skinner, which focuses on how learning and adaptation
affect the development of
psychopathology.
Psychoanalytic theory - the psychological tradition
Patients of Austrian physician Anton Mesmer and people who have been hypnotized
- feel as if someone had cast a spell on them
- feel mesmerized by a look across the room from attractive people
- Mesmer suggested to his patients that their problem was due to an undetectable fluid found in all living organisms called “animal magnetism” that could become blocked. Mesmer had his patients sit in a dark room around a large vat of chemicals with rods extending from it and touching the patients. Dressed in flowing robes, he might then identify and tap various areas of their bodies where their animal magnetism was blocked while suggesting strongly that they were being cured. Because of his rather unusual techniques, Mesmer was considered an oddity and maybe a charlatan and was strongly opposed by the medical establishment.
Benjamin Franklin put animal magnetism to the test by conducting a brilliant experiment in which patients received either magnetized water or nonmagnetized water with strong suggestions that they would get better. Neither the patient nor the therapist knew which water was which, making it a double-blind experiment.
- When both groups got better, Franklin concluded that animal magnetism, or mesmerism, was nothing more than strong suggestion
- Nevertheless, Mesmer is widely regarded as the father of hypnosis, a state in which suggestible subjects sometimes appear to be in a trance.
Many distinguished scientists and physicians were very interested in Mesmer’s powerful methods of suggestion
- One of the best known, Jean Charcot (1825–1893), was head of the Salpêtriére Hospital in Paris, where Philippe Pinel had introduced psycho- logical treatments several generations earlier.
- A distinguished neurologist, Charcot demonstrated that some of the techniques of mesmerism were effective with several psychological disorders, and he did much to legitimize the fledgling practice of hypnosis while doing away with the flowing robes and chemicals.
- in 1885 a young man named Sigmund Freud came from Vienna to study with Charcot.
After returning from France, Freud teamed up with Josef Breuer (1842–1925), who had experimented with a somewhat different hypnotic procedure.
- While his patients were in the highly suggestible state of hypnosis, Breuer asked them to describe their problems, conflicts, and fears in as much detail as they could. Breuer observed two extremely important phenomena during this process.
- First, patients often became extremely emotional as they talked and felt quite relieved and improved after emerging from the hypnotic state.
- Second, seldom would patients have gained an understanding of the relationship between their emotional problems and their psychological disorder.
- it was difficult or impossible for them to recall some of the details they had described under hypnosis. In other words, the material seemed to be beyond the awareness of the patient. With this observation, Breuer and Freud had “discovered” the unconscious mind and its apparent influence on the production of psychological disorders.
- another discovery was that recalling and reliving emotional trauma that has been made unconscious and releasing the accompanying tension is therapeutic—a process that became known as catharsis
- A fuller understanding of the relationship between current emotions and earlier events is called insight.
Freud and Breuer’s theories were based on systematic case observations.
- An excellent example is Breuer’s classic description of his treatment of “hysterical” symptoms in Anna O. in 1895 (Breuer & Freud, 1957).
- Anna O. was a young woman who was perfectly healthy until she turned 21. Shortly before her problems began, her father developed a serious chronic illness that led to his death. Throughout his illness, Anna O. had cared for him, spending hours at his bedside.
- Five months after her father became ill, Anna noticed that during the day her vision blurred and periodically she had difficulty moving her right arm and both legs. Soon, she began to experience some difficulty speaking, and her behaviour became very erratic. Shortly thereafter, she consulted Breuer.
- In a series of treatment sessions, Breuer dealt with one symptom at a time through hypnosis and subsequent “talking through,” tracing each symptom to its hypothetical causation in circumstances surrounding the death of Anna’s father. One at a time her “hysterical” ailments disappeared, but only after treatment was administered to each respective behaviour.
Freud took these basic observations and
expanded them into the psychoanalytic model, the most comprehensive theory yet constructed on the development and structure of our personalities.
Although most of it remains unproven,
psychoanalytic theory has had a strong influence, and it is important to be familiar with its basic ideas; what follows is a brief outline of the theory. We focus on its three major facets: (1) the structure of the mind and the distinct functions of personality that sometimes clash with one another; (2) the defence mechanisms with which the mind defends itself from these clashes or conflicts; and (3) the stages of early psychosexual development that provide grist for the mill of our inner conflicts.
The Structure of the Mind - Psychoanalytic theory
The mind, according to Freud, has three major parts or functions: the id, ego, and superego
The id is the source of our strong sexual and aggressive energies or our instinctual drives—the “animal” within us. The positive energy or drive within the id is the libido.
- A less important source of energy is the death instinct, or thanatos.
- The id operates according to the pleasure principle, with an overriding goal of maximizing pleasure and eliminating any associated tension or conflicts. The goal of pleasure, which is particularly prominent in childhood, often conflicts with social rules and regulations. The id has its own characteristic way of processing information; referred to as primary process, this type of thinking is very emotional, irrational, illogical, led with fantasies, and preoccupied with sex, aggression, selfishness, and envy.
- the id’s selfish and sometimes dangerous drives do not go unchecked. In fact, only a few months into life, we know we must adapt our basic demands to the real world; we must find ways to meet our basic needs without offending everyone around us.
The part of our mind that ensures we act realistically is called the ego, and it operates according to the reality principle instead of the pleasure principle.
- The cognitive operations or thinking styles of the ego, characterized by logic and reason, are referred to as the secondary process, as opposed to the illogical and irrational primary process of the id.
- The role of the ego is to mediate conflict between the id and the superego, juggling their demands with the realities of the world. The ego is often called the executive or manager of our minds. If it mediates successfully, we can go on to the higher intellectual and creative pursuits of life. If it is unsuccessful, and the id or the superego becomes too strong, conflict will overtake us and psychological disorders will develop.
- Because these conflicts are all within the mind, they are called intrapsychic conflicts.
superego
- the conscience, represents the moral principles instilled in us by our parents and our culture.
- It is the voice
within us that nags at us when we know we’re doing something
wrong.
- Because the purpose of the superego is to counteract the aggressive and sexual drives of the id that are potentially dangerous, the basis for conflict is readily apparent.
Freud believed the id and the superego are almost entirely unconscious.
Defence Mechanisms - psychoanalytic theory
The ego fights a continual battle to stay on top of the warring id and superego. Occasionally, their conflicts produce anxiety that threatens to overwhelm the ego. The anxiety is a signal that alerts the ego to marshal defence mechanisms, unconscious protective processes that keep primitive emotions associated with conflicts in check so the ego can continue its coordinating function. Although Freud first conceptualized defence mechanisms, it was his daughter, Anna Freud, who developed the ideas more fully.
We all use defence mechanisms at times— sometimes they are adaptive and sometimes they are maladaptive.
- Have you ever done poorly on a test because the professor was unfair in the grading? And then when you got home, you yelled at your brother or perhaps at your dog? This is an example of the defence mechanism of displacement.
- The ego adaptively “decides” that expressing primitive anger at your professor might not be in your best interest. Because your brother and your dog don’t have the authority to affect you in an adverse way, your anger is displaced to one of them.
examples of defence mechanisms
■■ Denial: Refuses to acknowledge some aspect of objective reality or subjective experience that is apparent to others (e.g., a person not facing the fact that a romantic relationship is over)
■■ Displacement: Transfers a feeling about, or a response to, an object that causes discomfort onto another, usually less threat- ening, object or person (e.g., kicking the dog when actually angry with a teacher)
■■ Projection: Falsely attributes own unacceptable feelings, impulses, or thoughts to another individual or object (e.g., a man with sexual feelings toward a certain woman thinks that woman is coming on to him)
■■ Rationalization: Conceals the true motivations for actions, thoughts, or feelings through elaborate reassuring or self- serving but incorrect explanations (e.g., after not getting into a certain graduate school, an aspiring graduate student deci- des that school was not really where she wanted to study after all)
■■ Reaction formation: Substitutes behaviour, thoughts, or feel- ings that are the direct opposite of unacceptable ones (e.g., a man with sexual feelings toward children crusades against child pornography)
■■ Repression: Blocks disturbing wishes, thoughts, or experi- ences from conscious awareness (e.g., a person “forgets” about an embarrassing experience)
■■ Sublimation: Directs potentially maladaptive feelings or impulses into socially acceptable behaviour (e.g., redirecting energy from underlying conflict into artistic expression and achievement)
Defence mechanisms have been subjected to scientific study, and there is some evidence that they may be of potential import in the study of psychopathology (Vaillant, 1992, 2012). For example, Perry and Bond (2012, 2014) noted that reduction in unadaptive defence mechanisms, and strengthening of adaptive mechanisms such as humor and sublimation, correlated with psychological health.
Psychosexual Stages of Development - psychoanalytic theory
Freud also theorized that during infancy and early childhood, we pass through several psychosexual stages of development that have a profound and lasting impact, thus providing the first developmental perspective on abnormal behaviour. The stages—oral, anal, phallic, latency, and genital—represent distinctive patterns of gratifying our basic needs and satisfying our drive for physical pleasure.
the oral stage, typically extending for approximately two years from birth, is characterized by a central focus on the need for food. In the act of sucking, necessary for feeding, the lips, tongue, and mouth become the focus of libidinal drives and, therefore, the principal source of pleasure. Freud hypothesized that, if we did not receive appropriate gratification during a specific stage or if a specific stage left a particularly strong impression (which he termed fixation), an individual’s personality would reflect the stage throughout adult life. For example, fixation at the oral stage might result in excessive thumb sucking and emphasis on oral stimulation through eating, chewing pencils, or biting fingernails. Adult personality characteristics theoretically associated with oral fixation include dependency and passivity or, in reaction to these tendencies, rebelliousness and cynicism.
One of the more controversial and frequently mentioned psychosexual conflicts occurs during the phallic stage (from age three to age five or six), which is characterized by early genital self-stimulation.
- This conflict is the subject of the Greek tragedy Oedipus Rex, in which Oedipus is fated to kill his father and, unknowingly, to marry his mother. Freud asserted that all young boys relive this fantasy when genital self-stimulation is accompanied by images of sexual interactions with their mothers.
- These fantasies, in turn, are accompanied by strong feelings of envy and perhaps anger toward their fathers, with whom they identify but whose place they want to take. Furthermore, strong fears develop that the father may punish that lust by removing the son’s penis—thus, the phenomenon of castration anxiety. This fear helps the boy keep his lustful impulses toward his mother in check. The battle of the lustful impulses on the one hand and castration anxiety on the other creates a conflict that is internal, or intrapsychic, called the Oedipus complex.
- The phallic stage passes uneventfully only if several things happen. First, the child must resolve his ambivalent relationship with his parents and reconcile the simultaneous anger and love he has for his father. If this happens, he may go on to channel his libidinal impulses into heterosexual relationships while retaining harmless affection for his mother. Development of the superego is another consequence of successfully resolving this conflict.
The counterpart conflict in girls, called the Electra complex, is even more controversial. Freud viewed the young girl as wanting to replace her mother and possess her father. Central to this possession is the girl’s desire for a penis so as to be more like her father and brothers—hence the term penis envy.
- According to Freud, the conflict is partially resolved when females develop healthy heterosexual relationships and look forward to having a baby, which he viewed as a healthy substitute for having a penis. It is the partial resolution of the Electra complex, resulting in a less highly developed superego, that makes females (in Freud’s theory) less highly developed psychologically than are males
In Freud’s view, all nonpsychotic psychological disorders result from underlying unconscious conflicts, the anxiety that resulted from those conflicts, and the implementation of ego defence mechanisms. Freud called such disorders neuroses, or neurotic disorders, from an old term referring to disorders of the nervous system.
Later Developments in Psychoanalytic Thought - psychoanalytic theory
Freud’s original psychoanalytic theories have been greatly modified and developed in many different directions, mostly by his students or followers.
Anna Freud (1895–1982), Freud’s daughter, concentrated on the way in which the defensive reactions of the ego determine our behaviour.
- In so doing, she was the first proponent of the modern field of ego psychology or self-psychology. Her book Ego and the Mechanisms of Defense (1946) is still influential. According to Anna Freud, the individual slowly accumulates adaptational capacities, skill in reality testing, and defences. Abnormal behaviour develops when the ego is deficient in regulating such functions as delaying and controlling impulses, or in marshalling appropriate normal defences to strong internal conflicts.
Carl Jung (1875–1961) and Alfred Adler (1870–1937) were students of Freud who came to reject his ideas and form their own schools of thought. Unlike Freud, both Jung and Adler believed that the basic quality of human nature is positive and that people have a strong drive toward self-actualization. Jung and Adler believed by removing barriers to both internal and external growth, the individual would naturally improve and flourish.
Others took psychoanalytical theorizing in different directions, emphasizing development over the lifespan and the influence of culture and society on personality. Karen Horney (1885–1952), Erich Fromm (1900–1980), and Erik Erikson (1902–1994) are associated with these ideas.
- For example, Horney (1967) reanalyzed Freud’s male-oriented views of women’s psychological development and developed her own feminine psychology in which she recognized the influences of societal factors.
- Erikson’s (1950) greatest contribution was his theory of development across the lifespan, in which he described in some detail the crises and conflicts that accompany eight specific psychosocial stages. For example, in the last of these stages, the mature age, beginning at about age 65, individuals review their lives and attempt to make sense of them, experiencing both the satisfaction of having completed some lifelong goals and despair at having failed at others.
Psychoanalytic Psychotherapy - psychoanalytic theory
Freud developed techniques of free association, in which patients are instructed to say whatever comes to mind without the usual socially mandated censoring. Free association is intended to reveal emotionally charged material that may be repressed because it is too painful or threatening to bring into consciousness. Freud’s patients lay on a couch, and he sat behind them so they would not be distracted. This method is how the couch became the symbol of psychotherapy.
Other techniques include dream analysis (still quite popular today),
in which the content of dreams, supposedly reflecting the primary process thinking of the id, is systematically related to symbolic aspects of unconscious conflicts. The therapist interprets the patient’s thoughts and feelings from free association and the content of dreams and relates them to various uncon- scious conflicts. This procedure is often difficult because the patient may resist the efforts of the therapist to uncover repressed and sensitive conflicts and may deny the interpretations. The goal of this stage of therapy is to help the patient gain insight into the nature of the conflicts.
The relationship between the therapist, called the psychoanalyst, and the patient is very important.
- In the context of this relationship as it evolves, the therapist may discover the nature of the patient’s intrapsychic conflict: In a phenomenon called transference, patients come to relate to the therapist very much as they did toward important figures in their childhood, particularly their parents.
- Patients who resent the therapist but can verbalize no good reason for it may be re-enacting childhood resentment toward a parent. More often, the patient falls deeply in love with the therapist, which reflects strong positive feelings that existed earlier for a parent.
- In the phenomenon of counter- transference, therapists project some of their own personal issues and feelings, often positive, onto the patient. Therapists are trained to deal with their own feelings as well as their patients’, whatever the mode of therapy, and it is strictly against all ethical canons of the mental health professions to accept overtures from patients that might lead to relationships outside therapy.
- The Canadian Code of Ethics for Psychologists (2017), for example, exhorts therapists to “be acutely aware of the power relationship in therapy and, therefore, not encourage or engage in sexual intimacy with therapy clients, neither during therapy, nor for that period of time following therapy during which the power relationship reasonably could be expected to influence the client’s decision making”
Classical psychoanalysis requires therapy four to five times a week for two to five years to analyze unconscious conflicts, resolve them, and restructure the personality to put the ego back in charge. A study by Norman Doidge at the Canadian Institute of Psychoanalysis in Toronto showed that the mean length of treatment for patients undergoing psychoanalysis in Canada is 4.8 years, 5.7 years in the United States, and 6.6 years in Australia
- In a meta-analysis of 14 studies on the effectiveness of psychoanalysis for complex problems, the range of number of therapy sessions was 234 to 971
- In psychoanalysis, reduction of symptoms (overt manifestations of psychological disorders) is seen as relatively inconsequential, because symptoms are only expressions of underlying intrapsychic conflicts that arise from psychosexual developmental stages. Thus, eliminating a phobia or depressive episode would be of little use unless the underlying conflict was dealt with adequately because another set of symptoms would almost certainly emerge (symptom substitution). Because of the extraordinary expense of psychoanalysis, and the lack of evidence that it is effective in alleviating psychological disorders, this approach is seldom used today.
Classical psychoanalysis is still practised, particularly in some large cities, but many psychotherapists employ a loosely related set of approaches referred to as psychodynamic psychotherapy.
- Although conflicts and unconscious processes are still emphasized, and efforts are made to identify trauma and active defence mechanisms, therapists use an eclectic mixture of tactics, with a social and interpersonal focus. It is significantly briefer than classical psychoanalysis—short-term psychodynamic psychotherapies involve around 20 sessions
- Also, psychodynamic therapists de-emphasize the goal of personality reconstruction, focusing instead on relieving the suffering associated with psychological disorders, addressing history of trauma, and dealing with issues of attachment, among other things.
- Some forms of psychodynamic psycho- therapy have strong scientific evidence for their effectiveness, such as interpersonal therapy (IPT) in the treatment of depression, and group psychodynamic interpersonal psychotherapy for eating disorder.
Comments - psychoanalytic theory
Pure psychoanalysis is of historical more than current interest, and classical psychoanalysis as a treatment has been diminishing in popularity for years. In 1980, the term neurosis, which specifically implied a psychoanalytic view of the causes of psychological disorders, was dropped from the DSM, the official diagnostic system of the American Psychiatric Association.
A major criticism of psychoanalysis is that it is basically unscientific, relying on reports by the patient of events that happened years ago. These events have been filtered through the experience of the observer and then interpreted by the psychoana- lyst in ways that certainly could be questioned and might differ from one analyst to the next. Finally, there has been no careful measurement of any of these psychological phenomena and no obvious way to prove or disprove the basic hypotheses of psychoanalysis. This fact is important, because measurement and the ability to prove or disprove a theory are the foundations of the scientific approach.
Nevertheless, psychoanalytic concepts and observations have been very valuable, not only to the study of psychopathology and psychodynamic psychotherapy but also to the history of ideas in Western civilization. Careful scientific studies of psychopathology have supported the observation of unconscious mental processes—that is, the notion that basic emotional responses are often triggered by hidden or symbolic cues and the understanding that memories of events in our lives can be repressed and other-wise avoided in a variety of ingenious ways.
The relationship of the therapist and the patient, called the therapeutic alliance, is an important area of study across most therapeutic strategies. These concepts, along with the importance of various coping styles or defence mechanisms, appear repeatedly throughout this book.
Freud’s revolutionary idea that pathological anxiety emerges in connection with some of our deepest and darkest instincts brought us a long way from witch trials and incurable brain pathology. Before Freud, the source of good and evil and of urges and prohibitions was conceived as external and spiritual, usually in the guise of demons confronting the forces of good. Since Freud, we ourselves have become the battleground for these forces, and we are inexorably caught up in the battle, sometimes for better and sometimes for worse.
humanistic theory
We have already seen that Jung and Adler broke sharply with Freud. Their fundamental disagreement concerned the very nature of humanity. Freud portrayed life as a battleground where we are continually in danger of being overwhelmed by our darkest forces. Jung and Adler, by contrast, emphasized the positive, optimistic side of human nature. Jung talked about setting goals, looking toward the future, and realizing our fullest potential. Adler believed that human nature reaches its fullest potential when we contribute to other individuals and to society as a whole. He believed we all strive to reach superior levels of intellectual and moral development. Nevertheless, both Jung and Adler retained many of the principles of psychodynamic thought. Their general philosophies were adopted in the middle of the 20th century by personality theorists and became known as humanistic psychology.
Self-actualizing was the watchword for this movement. The underlying assumption is that all of us can reach our highest potential, in all areas of functioning, if only we have the freedom to grow. Inevitably, a variety of conditions may block our actualization. Because every person is basically good and whole, most blocks originate outside the individual. Difficult living conditions or stressful life or interpersonal experiences may move you away from your true self.
Self-actualizing was the watchword for this movement. The underlying assumption is that all of us can reach our highest potential, in all areas of functioning, if only we have the freedom to grow. Inevitably, a variety of conditions may block our actualization. Because every person is basically good and whole, most blocks originate outside the individual. Difficult living conditions or stressful life or interpersonal experiences may move you away from your true self.
Carl Rogers (1902–1987) is, from the point of view of therapy, the most influential humanist. Rogers originated client-centred therapy, later known as person-centred therapy (Rogers, 1961). In this approach, the therapist takes a passive role, making as few interpretations as possible. The point is to give the individual a chance to develop during the course of therapy, unfettered by threats to the self. Humanist theorists have great faith in the abil- ity of human relations to foster this growth. Unconditional posi- tive regard, the complete and almost unqualified acceptance of most of the client’s feelings and actions, is critical to the human- istic approach. Empathy is the sympathetic understanding of the individual’s particular view of the world. The hoped-for result of person-centred therapy is that clients will be more straightforward and honest with themselves and will access their innate tendencies toward growth.
Like psychoanalysis, the humanistic approach has had a substantial effect on theories of interpersonal relationships.
- For example, the human potential movements so popular in the 1960s and 1970s were a direct result of humanistic theorizing. This approach also emphasized the importance of the therapeutic relationship in a way quite different from Freud’s.
- Rather than seeing the relationship as a means to an end (transference), humanistic therapists believed relationships, including the therapeutic relationship, were the single most positive influence in facilitating human growth.
- In fact, Rogers made substantial contributions to the scientific study of therapist–client relationships.
- Research by W. H. Coons and colleagues at the Ontario Hospital in Hamilton provided evidence for the importance of the humanistic concept of empathy or “the opportunity for interpersonal interaction in a consistently warm and accepting social environment” in explaining the success of psychotherapy.
- Proponents of the humanistic model stress the unique, nonquantifiable experiences of the individual, emphasizing that people are more different than alike. Thus, it does not come as a surprise that many humanistic model proponents have not been much interested in doing research that would discover or create new knowledge. A major exception is Carl Rogers himself, who conducted important work on understanding how psychotherapy works, an area known today as psychotherapy process research.
Frederich (Fritz) Perls developed a therapy known as Gestalt therapy that has humanistic elements (Levitsky & Perls, 1970; Perls, 1969).
- Like the person-centred therapy approach, Gestalt therapy focuses on people’s positive and creative potentials.
- It helps clients develop an awareness of their desires and needs, and understand how they might be blocking themselves from reaching their potential.
- Unlike psychoanalytic therapy, Gestalt therapy does not involve delving into past experiences—instead, it is very focused on the present. Relative to person-centred therapy, which does not emphasize technique, Gestalt therapists are trained in the use of specific techniques.
- These include “I language,” in which the therapist encourages the client to refer to “I” rather than to “it” to take more responsibility for emotions and behaviour, and the use of metaphor, in which the therapist uses stories or scenarios to illustrate and make a problem clearer to a client.
As Maslow noted, traditional person-centred therapy found its greatest applicationamongindividualswithoutpsychologicaldisorders. The application of person-centred therapy to more severe psychological disorders has decreased substantially over the decades, although certain variations have periodically arisen in some areas of psychopathology.
the Behavioural model
As psychoanalysis swept the world at the beginning of the 20th century, events in Russia and North America eventually provided an alternative psychological model that was just as powerful. The behavioural model brought the systematic development of a more scientific approach to psychological aspects of psychopathology.
The behavioural model is more commonly referred to today as the cognitive-behavioural (e.g., Meichenbaum, 1995) or social learning model (e.g., Bandura, 1973, 1986), given the greater emphasis today on cognitive and social factors involved in learning.
- Pavlov and Classical Conditioning
- Watson and the Rise of Behaviourism
- The Beginnings of Behaviour Therapy
- B. F. Skinner and Operant Conditioning
Pavlov and Classical Conditioning - the Behavioural model
In his classic study of the salivation response in dogs, physiologist Ivan Petrovich Pavlov (1849–1936) of St. Petersburg, Russia, learned why dogs salivate before the presentation of food.
This classic experiment initiated the study of classical conditioning, a type of learning in which a neutral stimulus is paired with a response until it elicits that response. The word conditioning (or conditioned response) resulted from an accident in translation from the original Russian.
Pavlov was really talking about a response that occurred only on the “condition” of the presence of a particular event or situation (stimulus)—in this case, the footsteps of the laboratory assistant at feeding time. Thus, “conditional response” would have been more accurate. Conditioning is one way we acquire new information, particularly information that is somewhat emotional in nature. This process is not as simple as it first seems, and we continue to uncover many more facts about its complexity
Psychologists working in oncology units have studied a phenomenon well known to many cancer patients, their nurses and physicians, and their families. Chemotherapy, a common treatment for some forms of cancer, has side effects that include severe nausea and vomiting.
- But as documented a long time ago in the research of Patricia Dobkin at McGill University, these patients often experience severe nausea and, occasionally, vomiting, when they merely see the medical personnel who administer the chemotherapy or any equipment associated with the treatment itself, even on days when their treatment is not delivered
- For some patients, this reaction becomes associated with a wide variety of stimuli that evoke people or things present during chemotherapy—anybody in a nurse’s uniform or even the sight of the hospital itself
The strength of the response to similar objects or people is usually a function of how similar these objects or people are. This phenomenon is called stimulus generalization because the response generalizes to similar stimuli. In any case, this particular reaction, obviously, is very distressing and uncomfortable, particularly if it is associated with a wide variety of objects or situations. Psychologists have had to develop specific treatments to overcome this response.
Whether the stimulus is food, as in Pavlov’s laboratory, or chemotherapy, the classical conditioning process begins with a stimulus that elicits a response in almost anyone and requires no learning; no conditions must be present for the response to occur. For these reasons, the food or chemotherapy is called the uncon- ditioned stimulus (UCS). The natural or unlearned response to this stimulus—in these cases, salivation or nausea—is called the unconditioned response (UCR). Now the learning comes in. As we have already seen, a person or an object associated with the unconditioned stimulus (food or chemotherapy) acquire the power to elicit the same response, but now the response, because it was elicited by the conditional or conditioned stimuli (CS), is termed a conditioned response (CR). Thus, the nurse associated with the chemotherapy becomes a conditioned stimulus. The nausea, which is almost the same as that experienced during chemotherapy, becomes the conditioned response.
With unconditioned stimuli as powerful as chemotherapy, a conditioned response can be learned in one trial. However, most learning of this type requires repeated pairing of the uncondi- tioned stimulus (e.g., chemotherapy) and the conditioned stimu- lus (e.g., nurses’ uniforms or hospital equipment). When Pavlov began to investigate this phenomenon, he substituted a metro- nome for the footsteps of his laboratory assistants so he could quantify the stimulus more accurately and, therefore, study the approach more precisely. What he also learned is that presentation of the CS (e.g., the metronome) without the food for a long enough period would eventually eliminate the conditioned response to the food. In other words, the dog learned that the metronome no longer meant that a meal was on the way. This process was called extinction.
Because Pavlov was a physiologist, it was quite natural for him to study these processes in a laboratory and to be quite scientific about it. This method required precision in measuring and observing relationships and in ruling out alternative explanations. Although this approach is common in biology, it was not at all common in psychology at that time. For example, it was impossible for psychoanalysts to measure unconscious conflicts precisely or even to observe them. Early experimental psychologists such as Edward Titchener (1867–1927) emphasized the study of introspection. Subjects simply reported on their inner thoughts and feelings after experiencing certain stimuli, but the
results were inconsistent and discouraging to many experimental psychologists.
Watson and the Rise of Behaviourism - the Behavioural model
An early American psychologist, John B. Watson (1878–1958), is considered the founder of behaviourism. Strongly influenced by the work of Pavlov, Watson decided that to base psychology on introspection was to head in the wrong direction, that psychology could be made as scientific as physiology, and that psychology no more needed introspection or other nonquantifiable methods than did chemistry and physics (Watson, 1913). This point of view is reflected in a famous quotation from a seminal article published by Watson in 1913: “Psychology, as the behaviorist views it, is a purely objective experimental branch of natural science. Its theoretical goal is the prediction and control of behavior. Introspection forms no essential part of its methods” (p. 158). This, then, was the beginning of behaviourism and, like most revolutionaries, Watson took his cause to extremes. For example, he wrote that “thinking,” for purposes of science, could be equated with subvocal talking and that one need only measure movements around the larynx to study this process objectively.
Most of Watson’s time was spent developing behavioural psychology as an empirical science, but he did dabble briefly in the study of psychopathology. In 1920, he and a student, Rosalie Rayner, presented an 11-month-old boy named Albert with a harmless fluffy white rat to play with. Albert was not afraid of the small animal and enjoyed playing with it. Every time Albert reached for the rat, however, the experimenters made a loud noise behind him. After only five trials, Albert showed the first signs of fear if the white rat came near. The experimenters then determined that Albert displayed mild fear of any similar white furry object, even a Santa Claus mask with a white fuzzy beard. You may not think this is surprising, but keep in mind that this was one of the first examples ever recorded in a laboratory of actually producing fear of an object not previously feared. Of course, this experiment would be considered unethical by today’s standards. For example, Watson and Rayner’s failure to remove Albert’s fear before the end of the experiment, and their insufficient follow-up of the child’s fears after the experiment, would be criticized on ethical grounds today.
Another student of Watson’s, Mary Cover Jones, thought that if fear could be learned or classically conditioned in this way, perhaps it could also be unlearned or extinguished. She worked with a boy named Peter, who at two years, ten months old was already quite afraid of furry objects. Jones decided to bring a white rabbit into the room where Peter was playing for a short time each day. She also arranged for other children, whom she knew did not fear rabbits, to be in the same room. She noted that Peter’s fear gradually diminished. Each time it diminished, she brought the rabbit closer. Eventually, Peter was touching and even playing with the rabbit (Jones, 1924a, 1924b), and years later the fear had not returned.
The Beginnings of Behaviour Therapy - the Behavioural model
The implications of Jones’s research were largely ignored for two decades, given the fervour associated with more psychoanalytic conceptions of the development of fear. But in the late 1940s and early 1950s, Joseph Wolpe (1915–1997), a pioneering psychiatrist from South Africa, became dissatisfied with prevailing psychoanalytic interpretations of psychopathology and began looking for something else. He turned to the work of Pavlov and became familiar with the wider field of behavioural psychology. He developed a variety of behavioural procedures for treating his patients, many of whom had phobias.
His best-known technique was termed systematic desensitization. In principle, it was really very similar to Jones’s treatment of little Peter. Individuals were gradually introduced to the objects or situations they feared so their fear could extinguish; that is, they could test reality and see that nothing bad really happened in the presence of the phobic object or scene.
Wolpe added another element by having his patients do something that was incompatible with fear while they were in the presence of the dreaded object or situation. Because he could not always reproduce the phobic object in his office, Wolpe had his patients carefully and systematically imagine the phobic scene, and the response he chose was relaxation, because it was convenient. For example, Wolpe treated a young man with a phobia of dogs by training him first to relax deeply and then imagine he was looking at a dog across the park. Gradually, he could imagine the dog across the park and remain relaxed, expe- riencing little or no fear, and Wolpe then had him imagine he was closer to the dog. Eventually, the young man imagined he was actually touching the dog while maintaining a very relaxed, almost trance-like state.
Wolpe (1958) reported success with systematic desensitization, one of the first wide-scale applications of the new science of behaviourism to psychopathology. Wolpe, working with fellow pioneers Hans Eysenck and Stanley J. Rachman in London, called this approach behaviour therapy. Wolpe eventually moved to the United States and Rachman to Canada, while Eysenck remained in the United Kingdom, which contributed to the dissemination of behaviour therapy knowledge and techniques throughout North America and Europe.
B. F. Skinner and Operant Conditioning - the Behavioural model
Burrhus Frederic (B. F.) Skinner (1904–1990).
- In 1938, he published The Behavior of Organisms, in which he laid out the principles of operant conditioning, which is a type of learning in which behaviour changes as a function of what follows the behaviour
- Skinner observed early on that a large part of our behaviour is not automatically elicited by an unconditioned stimulus and we must account for this
Some of the best-known examples of his ideas are in the novel Walden Two (Skinner, 1948), which depicts a fictional society run on the principles of operant conditioning. In another well-known work, Beyond Freedom and Dignity (1971), Skinner lays out a broader statement of the problems facing our culture and suggests solutions based on his own view of a science of behaviour.
Skinner was strongly influenced by Watson’s conviction that a science of human behaviour must be based on observable events and relationships among those events. The work of psychologist Edward L. Thorndike (1874–1949) also influenced Skinner. Thorndike is best known for the law of effect, which states that behaviour is either strengthened (likely to be repeated more frequently) or weakened (likely to occur less frequently) depending on the consequences of that behaviour. Skinner took the very simple notions that Thorndike had tested in the animal laboratories, using food as a reinforcer, and developed them in a variety of complex ways that apply to much of our behaviour. For example, if a five-year-old boy starts shouting at the top of his lungs in McDonald’s, much to the annoyance of the people around him, it is unlikely his behaviour was automatically elicited by an unconditioned stimulus. Also, he will be less likely to do it in the future if his parents scold him, take him out to the car to sit for a bit, or consistently reinforce more appropriate behaviour. Then again, if the parents think his behaviour is cute and laugh, chances are he will do it again.
Skinner coined the term operant conditioning because behaviour operates on the environment and changes it in some way. For example, the boy’s behaviour affects his parents’ behaviour and probably the behaviour of other customers as well. Therefore, he changes his environment. Most things we do socially provide the context for other people to respond to us in one way or another, thereby providing consequences for our behaviour. The same is true of our physical environment, although the consequences may be long term (polluting the air eventually will poison us). Skinner preferred the term reinforcement to reward because it connotes the effect on the behaviour. Skinner once said that he found himself a bit embarrassed to be talking continually about reinforcement, much as Marxists used to see class struggle everywhere. But he pointed out that all our behaviour is governed to some degree by reinforcement, which can be arranged in an endless variety of ways, in schedules of reinforcement. Skinner wrote a book on different schedules of reinforcement (Ferster & Skinner, 1957). He also believed that using punishment as a consequence is relatively ineffective in the long run and that the primary way to develop new behaviour is to positively reinforce desired behaviour. Much like Watson, Skinner did not see the need to go beyond the observable and quantifiable to establish a satisfactory science of behaviour. He did not deny the existence of subjective states of emotion or cognition; he simply explained these phenomena as relatively inconsequential side effects of a particular history of reinforcement.
The subjects of Skinner’s laboratory research were usually animals, mostly pigeons and rats. Using his new principles, Skinner and his disciples actually taught the animals a variety of tricks, including dancing, playing Ping-Pong, and playing a toy piano. To do this, he used a procedure called shaping, a process of reinforcing successive approximations to a final behaviour or set of behaviours. If you want a pigeon to play Ping-Pong, first you provide it with a pellet of food every time it moves its head slightly toward a Ping-Pong ball tossed in its direction. Gradually, you require the pigeon to move its head ever closer to the Ping-Pong ball until it touches it. Finally, receiving the food pellet is contingent on the pigeon’s actually hitting the ball back with its head.
Pavlov, Watson, and Skinner contributed significantly to behaviour therapy, in which scientific principles of psychology are applied to clinical problems. Many psychologists and other mental health professionals quickly embraced behaviour therapy techniques and began applying them with their patients in the 1950s and 1960s.
The scientific method and integrative approach
We have just reviewed three different traditions or ways of thinking about causes of psychopathology: the supernatural, the biological, and the psychological (further subdivided into two major historical components: psychoanalytic and behavioural).
Despite the fact that the biological, psychoanalytic, and behavioural models continue to improve our understanding of the various forms of psychopathology, each tradition has failed in at least one important way. First, scientific methods were not often applied to the theories and treatments within a tradition, mostly because methods that would have produced the evidence necessary to confirm or disconfirm the theories and treatments had not been developed. Lacking such evidence, various fads and superstitions were widely accepted that ultimately proved untrue or useless. New fads often superseded truly useful theories and treat- ment procedures. This trend was at work in the so-called discov- ery of the drug reserpine, which, in fact, had been around for thousands of years. King Charles VI was subjected to a variety of procedures, some of which have since been proved useful and others that were mere fads or even harmful.
Second, health professionals tend to look at psychological disorders very narrowly, from their own point of view alone. John Grey assumed psychological disorders are the result of brain disease and that other factors have no influence whatsoever. John Watson assumed that all behaviours, including disordered behaviour, are the result of psychological and social influences and that the contribution of biological factors is inconsequential.
In the 1990s, two developments came together as never before to shed light on the nature of psychopathology: (1) the increasing sophistication of scientific tools and methodology, and (2) the realization that no one influence—biological, behavioural, cogni- tive, emotional, or social—ever occurs in isolation. Every time we think, feel, or do something, the brain and the rest of the body are hard at work. Perhaps not as obvious, however, is the fact that our thoughts, feelings, and actions inevitably influence the function and even the structure of the brain, sometimes permanently. In other words, our behaviour, both normal and abnormal, is the product of the continual interaction of psychological, biological, and social influence
The view that psychopathology is multiply determined had its early adherents. Perhaps the most notable was psychiatrist Adolf Meyer (1866–1950). Whereas most professionals during the first half of the 20th century held narrow views of the cause of psychopathology, Meyer steadfastly emphasized the equal contributions of biological, psychological, and sociocultural determinants. Although Meyer had some proponents, it was a century before the wisdom of his advice was fully recognized in the field
By the turn of the 21st century, a veritable explosion of knowledge about psychopathology had occurred. The young fields of cognitive science and neuroscience began to grow exponentially as we learned more about the brain and about how we process, remember, and use information. At the same time, startling new findings from behavioural science revealed the importance of early experience in determining later development. It was clear that a new model was needed that would consider biological, psychological, and social influences on behaviour. This approach to psychopathology would combine findings from all areas with our rapidly growing understanding of how we experience life during different developmental periods, from infancy to old age. In 2010, the National Institute of Mental Health instituted a strategic plan to support research and development on the inter-relationship of these factors with the aim of translating research findings to front-line treatment settings
