Chapter 15 Abnormality, Therapy, and Social Issues

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Transcript Chapter 15 Abnormality, Therapy, and Social Issues

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
 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
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
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
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.
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.
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 1952
Used as a resource by the majority of mental health professionals.
In earlier editions, many clinicians considered it merely a tool for
Now, in an era of managed care, clinicians often forced to rely on
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
 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
 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
Classifying Psychological Disorders
 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
Classifying Psychological Disorders
 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
 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
4) Sometimes DSM treats problems of adjustment (i.e., to a
new situation or change in one’s life) as mental health
 Pressure to make diagnoses - leading to the worry that
normal concerns are being turned into psychiatric
Criticisms of DSM-IV (continued)
5) Criteria for Mental disorders are influenced by culture and
 While widely accepted among psychologists and
psychiatrists, the manual has proved controversial in
choices for what constitutes a mental disorder.
 E.g., DSM-II classified homosexuality as a mental
disorder, a classification that was removed by vote of the
APA in 1973 *
* 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.
How Common are Psychological Disorders?
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?
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
 Many people who could benefit from treatment do not
seek it
 Most people seem to deal with symptoms without complete
Module 15.2
Psychotherapy: An Overview
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
 Psychoanalytic/Psychodynamic
 Humanistic
 Behavioral
 Cognitive
 Other (group, family, couples, etc.)
Developed by Sigmund Freud based on his theory of
Freud’s view of the mind
conscious-- what you’re
aware of, can verbalize and
think about in a logical
preconscious -- ordinary
memory. Not conscious, but
can be easily brought into
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
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 meanings
queen 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
playing instruments, sliding, slipping and breaking branches
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
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
Systematic Desensitization
Based on classical conditioning
Uses three steps:
 Progressive relaxation
 Development of anxiety hierarchy and control scene
 Combination of progressive relaxation with anxiety
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
Therapies That Focus on Thoughts and Beliefs
Cognitive 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
Prevalence of Cognitive Therapy
Half of all faculty in
accredited clinical
psychology doctoral
programs now align
themselves with a
cognitive or cognitivebehavior 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
 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
 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
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
• After 8 weekly sessions more
than 50% receiving therapy were
significantly improved compared
to 4% of those not receiving
• 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
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
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
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
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.