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ABNORMAL PSYCHOLOGY
PSYCHOPATHOLOGY — AN INTEGRATIVE APPROACH TO MENTAL DISORDERS — DAVID H. BARLOW, V. MARK DURAND, STEFAN G. HOFMANN CHAPTER 1 : PSYCHOPATHOLOGY IN HISTORICAL CONTEXT UNDERSTANDING PSYCHOPATHOLOGY PSYCHOLOGICAL DISORDER a psychological dysfunction within an individual associated with distress or impairment in functioning and a response that is not typical or culturally expected. JANELLE: THE GIRL WHO FAINTED AT THE SIGHT OF BLOOD Janelle, a 16-year-old, was referred to our anxiety disorders clinic after increasing episodes of fainting. About 2 years earlier, in Janelle’s first biology class, the teacher had shown a movie of a frog dissection to illustrate various points about anatomy. This was a particularly graphic film, with vivid images of blood, tissue, and muscle. About halfway through, Janelle felt a bit lightheaded and left the room. But the images did not leave her. She continued to be bothered by them and occasionally felt slightly queasy. She began to avoid situations in which she might see blood or injury. She stopped looking at magazines that might have gory pictures. She found it difficult to look at raw meat or even Band-Aids because they brought the feared images to mind. Eventually, anything her friends or parents said that evoked an image of blood or injury caused Janelle to feel lightheaded. It got so bad that if one of her friends exclaimed, “Cut it out!” she felt faint. Beginning about 6 months before her visit to the clinic, Janelle actually fainted when she unavoidably encountered something bloody. Her family physician could find not wrong with her, nor could several other physicians. By the time she was referred to our clinic, she was fainting 5 to 10 times a week, often in class. Clearly, this was problematic for her and disruptive in school; each time Janelle fainted, the other students flocked around her, trying to help, and class was interrupted. Because no one could find anything wrong with her, the principal finally concluded that she was being manipulative and suspended her from school, even though she was an honor student. Janelle was suffering from what we now call blood–injection–injury phobia. Her reaction was quite severe, thereby meeting the criteria for phobia, a psychological disorder characterized by marked and persistent fear of an object or situation. But many people have similar reactions that are not as severe when they receive an injection or see someone who is injured, whether blood is visible or not. For people who react as severely as Janelle, this phobia can be disabling. They may avoid certain careers, such as medicine or nursing, and, if they are so afraid of needles and injections that they avoid them even when they need them, they put their health at risk. WHAT IS A PSYCHOLOGICAL DISORDER? Psychological Disorder or Problematic Abnormal Behavior Definition: It is 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. PSYCHOLOGICAL DYSFUNCTION Definition: Refers to a breakdown in cognitive, emotional, or behavioral functioning. Some problems are often considered to be on a continuum or a dimension rather than to be categories that are either present or absent. Just having a dysfunction is not enough to meet the criteria for a psychological disorder. DISTRESS OR IMPAIRMENT The behavior must be associated with distress to be classified as a disorder adds an important component and seems clear: The criterion is satisfied if the individual is extremely upset. But remember, by itself this criterion does not define problematic abnormal behavior. Furthermore, for some disorders, by definition, suffering and distress are absent. Consider the person who feels extremely elated and may act impulsively as part of a manic episode. Thus, defining psychological disorder by distress alone doesn’t work, although the concept of distress contributes to a good definition. The concept of impairment is useful, although not entirely satisfactory. ATYPICAL OR NOT CULTURALLY EXPECTED At times, something is considered abnormal because it occurs infrequently;
it deviates from the average. The greater the deviation, the more abnormal it is. The criterion that the response be atypical or not culturally expected is important but also insufficient to determine if a disorder is present by itself. Many people are far from the average in their behavior, but few would be considered disordered. We might call them talented or eccentric. Another view is that your behavior is disordered if you are violating social norms, even if a number of people are sympathetic to your point of view. Another possibility is to determine whether the behavior is out of the individual’s control (something the person doesn’t want to do). AN ACCEPTED DEFINITION Behavioral, 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. In conclusion, it is difficult to define what constitutes a psychological disorder and the debate continues. THE SCIENCE OF PSYCHOPATHOLOGY PSYCHOPATHOLOGY is the scientific study of psychological disorders Clinical psychologists and Counseling psychologists receive the Ph.D., doctor of philosophy, degree (or sometimes an Ed.D., doctor of education, or Psy.D., doctor of psychology) and follow a course of graduate-level study lasting approximately 5 years, which prepares them to conduct research into the causes and treatment of psychological disorders and to diagnose, assess, and treat these disorders. Counseling psychologists
- tend to study and treat adjustment and vocational issues encountered by relatively healthy individuals. Clinical psychologists
- usually concentrate on more severe psychological disorders. Psychiatrists
- earn an M.D. degree in medical school and then specialize in psychiatry during residency training that lasts 3 to 4 years.
- Investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments.
- Emphasize drugs or other biological treatments, although most use psychosocial treatments as well. 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.
- Also treat disorders, often concentrating on family problems associated with them. Psychiatric nurses
- have advanced degrees, such as a master’s or even 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 counselors
- typically spend 1 to 2 years earning a master’s degree and are employed to provide clinical services by hospitals or clinics, usually under the supervision of a doctoral-level clinician. THE SCIENTIST—PRACTITIONER Many mental health professionals take a scientific approach to their clinical work and therefore are called scientist-practitioners and may function as scientist-practitioners in one or more of three ways. (1) First, they may keep up with the latest scientific developments in their field and therefore use the most current diagnostic and treatment procedures. (2) Second, scientist-practitioners evaluate their own assessments or treatment procedures to see whether they work. They are accountable not only to their patients but also to the government agencies and insurance companies that pay for the treatments, so they must demonstrate clearly whether their treatments are effective or not. (3) Third, scientist-practitioners might conduct research, often in clinics or hospitals, that produces new information about disorders or their treatment, thus becoming immune to the fads that
hints about the nature of the disorder and its causes. Psychopathology is rarely simple. This is because the effect does not necessarily imply the cause. To use a common example, you might take an aspirin to relieve a tension headache you developed during a grueling day of taking exams. If you then feel better, that does not mean that the headache was caused by a lack of aspirin. HISTORICAL CONCEPTIONS OF ABNORMAL BEHAVIOR Three major models that have guided us date back to the beginnings of civilization. Humans have always supposed that agents outside our bodies and environment influence our behavior, thinking, and emotions. These agents— which might be divinities, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars—are the driving forces behind the supernatural model. Since the era of 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 behavior in one or the other. This split gave rise to two traditions of thought about abnormal behavior, summarized as the biological model and the psychological model. THE SUPERNATURAL TRADITION For much of our recorded history, deviant behavior has been considered a reflection of the battle between good and evil. In fact, in the great Persian empire from 900 to 600 B.C., all physical and mental disorders were considered the work of the devil. Barbara Tuchman
- Ably captures the conflicting tides of opinion on the origins and treatment of insanity during that bleak and tumultuous period. DEMONS AND WITCHES One strong current of opinion put the causes and treatment of psychological disorders squarely in the realm of the supernatural. During the last quarter of the 14th century, religious and lay authorities supported these popular superstitions, and society as a whole began to believe more strongly in the existence and power of demons and witches. The Catholic Church had split. People increasingly turned to magic and sorcery to solve their problems. During these turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen as the work of the devil and witches. Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits. Other approaches included shaving the pattern of a cross in the hair of the victim’s head and securing sufferers to a wall near the front of a church so that they might benefit from hearing Mass. STRESS AND MELANCHOLY An equally strong opinion, even during this period, reflected the enlightened 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. In the 14th^ century, one of the chief advisers to the king of France, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression) was the source of some bizarre behavior, rather than demons. 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. CHARLES VI: THE MAD KING In the summer of 1392, King Charles VI of France was under a great deal of stress, partly because of the division of the Catholic Church. As he rode with his army to the province of Brittany, a nearby aide dropped his lance with a loud clatter, and the king, thinking he was under attack, turned on his own army, killing several prominent knights before being subdued from behind. The army immediately marched back to Paris. The king’s lieutenants and advisers concluded that he was mad. During the following years, at his worst the king hid in a corner of his castle believing he was made of glass or roamed the corridors howling like a wolf. At other times, he couldn’t remember who or what he was. He became fearful and enraged whenever he saw his own
royal coat of arms and would try to destroy it if it was brought near him. The people of Paris were devastated by their leader’s apparent madness. Some thought it reflected God’s anger because the king failed to take up arms to end the schism in the Catholic Church; others thought it was God’s warning against taking up arms; and still others thought it was divine punishment for heavy taxes (a conclusion some people might make today). But most thought the king’s madness was caused by sorcery, a belief strengthened by a great drought that dried up the ponds and rivers, causing cattle to die of thirst. Merchants claimed their worst losses in 20 years. Naturally, the king was given the best care available at the time. The most famous healer in the land was a 92-year-old physician whose treatment program included moving the king to one of his residences in the country where the air was thought to be the cleanest in the land. The physician prescribed rest, relaxation, and recreation. After some time, the king seemed to recover. The physician recommended that the king not be burdened with the responsibilities of running the kingdom, claiming that if he had few worries or irritations, his mind would gradually strengthen and further improve. Unfortunately, the physician died, and the insanity of King Charles VI returned more seriously than before. This time, however, he came under the influence of the conflicting crosscurrent of supernatural causation. “An unkempt evil-eyed charlatan and pseudo-mystic named Arnaut Guilhem was allowed to treat Charles on his claim of possessing a book given by God to Adam by means of which man could overcome all affliction resulting from original sin” (Tuchman, 1978, p. 514). Guilhem insisted that the king’s malady was caused by sorcery, but his treatments failed to bring about a cure. A variety of remedies and rituals of all kinds were tried, but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished. “On one occasion, two Augustinian friars, after getting no results from magic incantations and a liquid made from powdered pearls, proposed to cut incisions in the King’s head. When this was not allowed by the King’s council, the friars accused those who opposed their recommendation of sorcery” (Tuchman, 1978, p. 514). Even the king himself, during his lucid moments, came to believe that the source of madness was evil and sorcery. “In the name of Jesus Christ,” he cried, weeping in his agony, “if there is any one of you who is an accomplice to this evil I suffer, I beg him to torture me no longer but let me die!”
TREATMENTS FOR POSSESSION
Possession is not always connected with sin but may be seen as involuntary and the possessed individual as blameless. Furthermore, exorcisms at least have the virtue of being relatively painless. They sometimes work, as do other forms of faith healing. 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. This approach sometimes worked only temporarily. MASS HYSTERIA Another fascinating phenomenon is characterized by large-scale outbreaks of bizarre behavior. During the Middle Ages, they lent support to the notion of possession by the devil. In Europe, whole groups of people were simultaneously compelled to run out in the streets, dance, shout, rave, and jump around in patterns as if they were at a particularly wild party late at night. In an attempt to explain the inexplicable, several reasons were offered in addition to possession. One reasonable guess was reaction to insect bites. Another possibility was what we now call mass hysteria. MODERN MASS HYSTERIA Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the experience of an emotion seems to spread to those around us. If one person identifies a “cause” of the problem, others will probably assume that their own reactions have the same source. In popular language, this shared response is sometimes referred to as mob psychology. THE MOON AND THE STARS This influential theory inspired the word lunatic, which is derived from the Latin word luna, meaning “moon.” The belief that heavenly bodies affect human behavior still exists, although there is no scientific evidence to support it. THE BIOLOGICAL TRADITION
involved restoring proper flow of wind through various methods, including acupuncture. Hippocrates also coined the word hysteria to describe a concept he learned about 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 medical problem for which no physical cause can be found. 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 word for “uterus” is hysteron). The prescribed cure might be marriage or, occasionally, fumigation of the vagina to lure the uterus back to its natural location. The tendency to stigmatize dramatic women as hysterical continued unabated well into the 1970s, when mental health professionals became sensitive to the prejudicial stereotype the term implied THE 9 TH^ CENTURY The biological tradition waxed and waned during the centuries after Hippocrates and Galen but was reinvigorated in the 19th century because of two factors: the discovery of the nature and cause of syphilis and strong support from the well- respected American psychiatrist John P. Grey. SYPHILIS ADVANCED SYPHILIS a sexually transmitted disease caused by a bacterial microorganism entering the brain, include believing that everyone is plotting against you (delusion of persecution) or that you are God (delusion of grandeur), as well as other bizarre behaviors. PSYCHOSIS Psychological disorders characterized in part by beliefs that are not based in reality (delusions), perceptions that are not based in reality (hallucinations), or both. Although advanced syphilis' symptoms are similar to those of psychosis, researchers recognized that a subgroup of apparently psychotic patients deteriorated steadily, becoming paralyzed and dying within 5 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, developed in about 1870, facilitated the identification of the specific bacterial microorganism that caused syphilis. Physicians observed a surprising recovery in patients with general paresis who had contracted malaria, so they deliberately injected other patients with blood from a soldier who was ill with malaria. Ultimately, clinical investigators discovered that penicillin cures syphilis, but with the malaria cure, “madness” and associated behavioral and cognitive symptoms for the first time were 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 Grey’s position was that the causes of insanity were always physical. The emphasis was 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. It was almost 100 years before the community mental health movement was successful in reducing the population of mental hospitals with the controversial policy of deinstitutionalization, in which patients were released into their communities. THE DEVELOPMENT OF BIOLOGICAL TREATMENTS 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. For example, insulin was occasionally given to stimulate appetite in psychotic patients who were not eating, but it also seemed to calm them down. 1927
- a Viennese physician, Manfred Sakel , began using increasingly higher dosages until, finally, patients convulsed and became temporarily comatose (Sakel, 1958). 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. Other methods of producing convulsions were needed. Benjamin Franklin
- discovered accidentally, and then confirmed experimentally in the 1750s, that a mild and modest electric shock to the head produced a brief convulsion and memory loss (amnesia) but otherwise did little harm. 1920s
- Hungarian psychiatrist Joseph von Meduna observed that schizophrenia was rarely found in individuals with epilepsy (which ultimately did not prove to be true). Some of his followers concluded that induced brain seizures might cure schizophrenia 1938
- surgeon in London treated a depressed patient by sending six small shocks directly through his brain, producing convulsions (Hunt, 1980). The patient recovered. Although greatly modified, shock treatment is still with us today. 1950s
- the first effective drugs for severe psychotic disorders were developed in a systematic way 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 serpentine (later renamed reserpine ) and another class of drugs called neuroleptics (major tranquilizers), for the first time hallucinatory and delusional thought processes could be diminished in some patients; these drugs also controlled agitation and aggressiveness. Other discoveries included benzodiazepines (minor tranquilizers), which seemed to reduce anxiety. 1970s
- the benzodiazepines (known by such brand names as Valium and Librium) were among the most widely prescribed drugs in the world Alexander and Selesnick point out, “The general pattern of drug therapy for mental illness has been one of initial enthusiasm followed by disappointment” CONSEQUENCES OF THE BIOLOGICAL TRADITION In the late 19th century, Grey and his colleagues ironically reduced or eliminated interest in treating mental patients because they thought that mental disorders were the result of some as-yet- undiscovered brain pathology and were therefore incurable. The only available course of action was to hospitalize these patients. In place of treatment, interest centered on diagnosis, legal questions concerning the responsibility of patients for their actions during periods of insanity, and the study of brain pathology itself. Emil Kraepelin
- German physician
- 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.
- As a student of Wilhelm Wundt, his lasting contribution was in the area of diagnosis and classification was one of the first to distinguish among various psychological disorders, seeing that each may have a different age of onset and time course, with somewhat different clusters of presenting symptoms, and probably a different cause By the end of the 1800s, a scientific approach to psychological disorders and their classification had begun with the search for biological causes. Furthermore, treatment was based on humane principles.
further effort to protect the residents, the town passed an ordinance restricting visits only to those who applied in writing and offered a good reason for visiting. Unfortunately, in the winter of February 1844, the structure burned to the ground. Despite heroic efforts of many townspeople, 10 inmates were killed, and the structure was destroyed. Eventually, a new asylum was built, but by this time it housed only the sick and elderly who could no longer care for themselves. By that time, the new state asylum for the insane had opened far from the island, and the removal of people suffering from insanity to this large (and impersonal) state institution was seen as desirable. New policies were adopted for cases of poverty (presumably those not suffering from addiction of some kind) that included maintaining the poor in their dwellings and providing them with sufficient (but minimal) materials and resources to see them through. A new town “poor department” was created for this purpose. Thus did moral therapy rise and fall in a small rural town in New England, reflecting the tenor of the time (Gavin, 2003). ASYLUM REFORM AND THE DECLINE OF MORAL THERAPY Unfortunately, after the mid- 19 th^ century, humane treatment declined because of a convergence of factors. (1) 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. Because immigrant groups were thought not to deserve the same privileges as “native” Americans (whose ancestors had immigrated perhaps only 50 or 100 years earlier!), they were not given moral treatments even when there were sufficient hospital personnel. (2) A second reason for the decline of moral therapy has an unlikely source. The great crusader Dorothea Dix (1802–
- campaigned endlessly for reform in the treatment of insanity. She had firsthand knowledge of the deplorable conditions imposed on patients with insanity, and she made it her life’s work to inform the American public and their leaders of these abuses. Her work became known as the mental hygiene movement. Improving the standards of care, Dix worked hard to make sure that everyone who needed care received it. Through her efforts, humane treatment became more widely available in U.S. institutions. (3) 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 reemerge in several different schools of thought in the 20th^ century. (1) 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 behavior. (2) The second was behaviorism , 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 Franz Anton Mesmer Mesmer suggested to his patients that their problem was caused by an undetectable fluid found in all living organisms called “animal magnetism,” which 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 them. Because of his rather unusual techniques, Mesmer was considered an oddity and maybe a charlatan, strongly opposed by the medical establishment. In fact, none less than 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, HYPNOSIS a state in which extremely suggestible subjects sometimes appear to be in a trance.
Many distinguished scientists and physicians were interested in Mesmer’s powerful methods of suggestion. One of the best known: Jean-Martin Charcot Demonstrated that some techniques of mesmerism were effective with a number of psychological disorders, and he did much to legitimize the fledgling practice of hypnosis. Significantly, 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 some-what 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. In fact, it was difficult or impossible for them to recall some 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 believed that they had “discovered” the unconscious mind and its apparent influence on the production of psychological disorders. This is one of the most important developments in the history of psychopathology and, indeed, of psychology as a whole. A close second was their discovery that it is therapeutic to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension. This release of emotional material became known as catharsis. A fuller understanding of the relationship between current emotions and earlier events is referred to as insight. Freud and Breuer’s ideas were based on case observations , some of which were made in a surprisingly systematic way for those times. An excellent example is Breuer’s classic description of his treatment of “hysterical” symptoms in Anna O. in 1895 Freud took these basic observations and expanded them into the psychoanalytic mode l, the most comprehensive theory yet constructed on the development and structure of our personalities. Although most of it turned out to be incorrect or remains unproven, psychoanalytic theory has had a strong influence, and it is still important to be familiar with its basic ideas. Three major facets: (1) the structure of the mind and the distinct functions of personality that sometimes clash with one another; (2) the defense 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 Three major parts or functions: the id, the ego, and the super-ego The id
- is the source of our strong sexual and aggressive feelings or energies
- The energy or drive within the id is the libido.
- A less important source of energy, not as well conceptualized by Freud, 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 id has its own characteristic way of processing information; referred to as the primary process, this type of thinking is emotional, irrational, illogical, filled with fantasies, and preoccupied with sex, aggression, selfishness, and envy. The Ego
- The part of our mind that ensures that we act realistically
- it operates according to the reality principle instead of the pleasure principle.
- The cognitive operations or thinking styles of the ego are characterized by logic and reason and are referred to as the secondary process, as opposed to the illogical and irrational primary process of the id.
Anna Freud
- Concentrated on the way in which the defensive reactions of the ego determine our behavior.
- The first proponent of the modern field of ego psychology. According to Anna Freud, the individual slowly accumulates adaptational capacities, skill in reality testing, and defenses. Abnormal behavior develops when the ego is deficient in regulating such functions as delaying and controlling impulses or in marshaling appropriate normal defenses to strong internal conflicts. Heinz Kohut
- focused on a theory of the formation of self-concept and the crucial attributes of the self that allow an individual to progress toward health, or conversely, to develop neurosis. This psychoanalytic approach became known as self-psychology OBJECT RELATIONS Is the study of how children incorporate the images, the memories, and sometimes the values of a person who was important to them and to whom they were (or are) emotionally. Object in this sense refers to these important people, and the process of incorporation is called introjection. According to object relations theory, you tend to see the world through the eyes of the person incorporated into your self. Carl Jung
- rejected many of the sexual aspects of Freud’s theory
- introduced the concept of the collective unconscious , which is a wisdom accumulated by society and culture that is stored deep in individual memories and passed down from generation to generation.
- emphasized the importance of enduring personality traits such as introversion (the tendency to be shy and withdrawn) and extroversion (the tendency to be friendly and outgoing). Adler
- focused on feelings of inferiority and the striving for superiority; he created the term inferiority complex. Jung and Adler also believed that the basic quality of human nature is positive and that there is a strong drive toward self-actualization (realizing one’s full potential). Others took psychoanalytical theorizing in different directions, emphasizing development over the life span and the influence of culture and society on personality. Scientific developments have borne out the wisdom of considering psychopathology from a developmental point of view. PSYCHOANALYTIC PSYCHOTHERAPY Many techniques of psychoanalytic psychotherapy, or psychoanalysis, are designed to reveal the nature of unconscious mental processes and conflicts through catharsis and insight. Freud developed techniques of free association , in which patients are instructed to say whatever comes to mind without the usual socially required censoring. Dream analysis (still quite popular today), in which the therapist interprets the content of dreams, supposedly reflecting the primary- process thinking of the id, and systematically relates the dreams to symbolic aspects of unconscious conflicts. The relationship between the therapist, called the psychoanalyst , and the patient is important. In the context of this relationship as it evolves, the therapist may discover the nature of the patient’s intrapsychic conflict. This is because, in a phenomenon called transference , patients come to relate to the therapist much as they did to important figures in their childhood, particularly their parents. In the phenomenon of countertransference , therapists project some of their own personal issues and feelings, usually positive, onto the patient. Classical psychoanalysis requires therapy four to five times a week for 2 to 5 years to analyze unconscious conflicts, resolve them, and restructure the personality to put the ego back in charge. Because of the high cost of classical psychoanalysis and the lack of evidence that it is effective in alleviating psychological disorders, this approach is seldom used today.
Psychoanalysis is still practiced, particularly in some large cities, but many psychotherapists employ a loosely related set of approaches referred to as psychodynamic psychotherapy. Seven tactics that characterize psychodynamic psychotherapy include (1) a focus on affect and the expression of patients’ emotions; (2) an exploration of patients’ attempts to avoid topics or engage in activities that hinder the progress of therapy; (3) the identification of patterns in patients’ actions, thoughts, feelings, experiences, and relationships; (4) an emphasis on past experiences; (5) a focus on patients’ interpersonal experiences; (6) an emphasis on the therapeu-tic relationship; and (7) an exploration of patients’ wishes, dreams, or fantasies Two additional features characterize psychodynamic psychotherapy. (1) is significantly briefer than classical psychoanalysis. (2) psychodynamic therapists deemphasize the goal of personality reconstruction, focusing instead on relieving the suffering associated with psychological disorders. COMMENTS In 1980, the term neurosis, which specifically implied a psychoanalytic view of the causes of psychological disorders, was dropped from the DSM. A major criticism of psychoanalysis is that it is basically unscientific, relying on reports by the patient of events that happened years ago. Careful scientific studies of psychopathology have supported the observation of unconscious mental processes, 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 otherwise 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.
HUMANISTIC THEORY
Jung and Adler broke sharply with Freud. Their fundamental disagreement concerned the very nature of humanity. They emphasized the positive, optimistic side of human nature. Nevertheless, both Jung and Adler retained many of the principles of psychodynamic thought. Their general philosophies were adopted in the middle of the 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 could reach our highest potential, in all areas of functioning, if only we had the freedom to grow. Abraham Maslow
- was most systematic in describing the structure of personality.
- Postulated a hierarchy of needs, beginning with our most basic physical needs for food and sex and ranging upward to our needs for self- actualization, love, and self-esteem. Carl Rogers
- from the point of view of therapy, the most influential humanist. PERSON-CENTERED THERAPY 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. UNCONDITIONAL POSITIVE REGARD The complete and almost unqualified acceptance of most of the client’s feelings and actions, is critical to the humanistic approach. EMPATHY The sympathetic understanding of the individual’s particular view of the world. Like psychoanalysis, the humanistic approach has had a substantial effect on theories of interpersonal relationships. Rather than seeing the relationship as a means to an end (transference), humanistic therapists believed that relationships, including the therapeutic relationship, were the single most positive influence in facilitating human growth.
He pointed out that all of our behavior is governed to some degree by reinforcement, which can be arranged in an endless variety of ways, in schedules of reinforcement. Using his new principles, Skinner and his disciples 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 behavior or set of behaviors. Pavlov, Watson, and Skinner contributed significantly to behavior therapy in which scientific principles of psychology are applied to clinical problems. COMMENTS The behavioral model has contributed greatly to the understanding and treatment of psychopathology, as is apparent in the chapters that follow. Nevertheless, this model is incomplete and inadequate to account for what we now know about psychopathology. The model also fails to account for development of psychopathology across the life span. Recent advances in our knowledge of how information is processed, both consciously and subconsciously, have added a layer of complexity. Integrating all these dimensions requires a new model of psychopathology. THE PRESENT: THE SCIENTIFIC METHOD AND AN INTEGRATIVE APPROACH We have just reviewed three 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 behavioral). Supernatural explanations of psychopathology are still with us. This tradition has little influence on scientists and other professionals, however. Each tradition has failed in important ways. (1) 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 disprove the theories and treatments had not been developed. (2) Second, health professionals tend to look at psychological disorders narrowly, from their own point of view alone. 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, behavioral, cognitive, emotional, or social—ever occurs in isolation. Our behavior, both normal and abnormal, is the product of a continual interaction of psychological, biological, and social influences. The view that psychopathology is multiply determined had its early adherents Adolf Meyer
- often considered the dean of American psychiatry
- steadfastly emphasized the equal contributions of biological, psycho- logical, and sociocultural determinism By 2000, a veritable explosion of knowledge about psychopathology was occurring. 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. It was clear that a new model was needed that would consider biological, psychological, and social influences on behavior. 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. This development is in line with the Strategic Plan for Research of the National Institute of Mental Health (NIMH), the main funding agency for research on mental health (NIMH, 2020). This plan specifically states four goals: (1) to define the brain mechanisms underlying complex behaviors, (2) to examine mental illness trajectories across the lifespan, (3) to strive for prevention and cures, and (4) to strengthen the public health impact of research.
The goal of this previous NIMH initiative was to offer an alternative to the DSM by utilizing brain circuits and basic biology processes to describe and understand mental disorders. This approach did not turn out to be practically feasible. COGNITION Sample text. Note: SAMPLE TEXT VIDEO
SUBTOPIC 2
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