Chapter 15 Abnormality, Therapy, and Social Issues

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Chapter 15Abnormality, Therapy, and Social Issues
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Abnormality, Therapy and Social Issues

• On the surface it would appear that there is
  normal and abnormal behavior, and the distinction
  between normal and weird is clear to everyone.
• But when we go deeper into the issue of normal
  versus abnormal, we start to see that behavior
  must be interpreted in its context. Normal is a
  matter of place and time as well as mental state
  and action.

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Module 15.1

• Abnormal Behavior An Overview

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Psychopathology

• Most of us feel sad, anxious, or angry
  occasionally.
• Our moods change, we have or develop bad habits,
  and we have funny beliefs.
• Mental health diagnoses are reserved for people
  with problems that seriously interfere with their
  lives.

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Defining Abnormal Behavior

• There is probably no definition of abnormal
  that cant be questioned.
• If we use the standard of subjective feelings
  of distress than anyone who thinks they have a
  problem automatically qualifies.
• And if someone behaves in bizarre and dangerous
  ways, but insists that they are A-OK, many people
  who are in fact suffering from mental illness
  could not be diagnosed and treated.

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Defining Abnormal Behavior

• If we say that behavior that could result in
  suffering or death is a sign of mental illness,
  heroic deeds would be a bona fide symptom.
• If we say that behavior that is very different
  from the usual is a sign of a psychological
  disorder, very depressed people would be
  diagnosed, but so would very happy people.

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Defining Abnormal Behavior

• Cultural Influences on Abnormality
• 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.
• Brain fag syndrome is a frequent complaint of
  West African students.
• Running amok consists of episodes of
  indiscriminant violent behavior in young
  Southeast Asian men.

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Defining Abnormal Behavior

• Cultural Influences on Abnormality
• An American example Multiple Personality
  Disorder
• The split personality syndrome, this is now
  referred to as dissociative identity disorder.
• There is alternation between two or more
  personalities.
• Each has its own disposition, behavior, and name,
  as if each were a separate person.

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Defining Abnormal Behavior

• Cultural Influences on Abnormality
• This was a very rare disorder until the 1950s,
  when a few cases received widespread publicity.
• By the early 1990s there were many cases of DID
  reported.
• Some observers began to claim that the disorder
  did not exist at all.
• It is most likely that it is a real, if rare,
  disorder, and that it was being promoted and
  over-diagnosed by therapists.

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Defining Abnormal Behavior

• The Biopsychosocial model
• The predominant view in Western cultures today
  uses the biopsychosocial model to understand
  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.

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Defining Abnormal Behavior

• The Biopsychosocial model
• Psychological roots an individuals 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.

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Classifying Psychological Disorders

• The DSM-IV
• The Diagnostic and Statistical Manual of Mental
  Disorders
• This manual has been created to establish uniform
  definitions and standards for diagnosis.
• It is now in its fourth edition.
• It lists acceptable labels for all psychological
  disorders.
• It lists symptoms and criteria for making
  diagnoses and contains information on
  differential diagnosis how to distinguish a
  particular disorder from others that are similar
  to it.

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Classifying Psychological Disorders

• The DSM-IV
• Diagnosis is made along five axes (lists).
• A person can have one or more diagnoses on a
  given axis, or none at all.
• Clinical disorders are diagnosed on Axis I. These
  are disorders that involve a deterioration of
  functioning.
• Most common psychological disorders are listed on
  Axis I.

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• Table 15.1
• Some Major Categories of Psychological Disorders
  According to Axis I of DSM-IV

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Classifying Psychological Disorders

• The DSM-IV
• Axis II is reserved for personality disorders and
  mental retardation.
• These are disorders that persist throughout life.
• A personality disorder is a maladaptive,
  inflexible way of dealing with situations and
  people.

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• Table 15.2
• Some Major Categories of Psychological Disorders
  According to Axis II of DSM-IV

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Classifying Psychological Disorders

• The DSM-IV
• Axis III is for general medical conditions that
  may influence the persons mood or behavior.
• Axis IV is for psychosocial and environmental
  problems that may increase the persons 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.

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Classifying Psychological Disorders

• Differential Diagnosis
• As in medicine, diverse mental health disorders
  often have similar or overlapping symptoms.
• Psychologists and psychiatrists are trained to
  make differential diagnoses.
• They look at all the disorders with similar
  symptoms that listed in the DSM-IV as well as
  disorders that are purely medical but affect mood
  and behavior.
• They either rule these disorders out or revise
  their original diagnosis based on the information
  they have gathered.

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Classifying Psychological Disorders

• Criticisms of DSM-IV
• The distinction between normal and abnormal can
  seem arbitrary at times (5 months of a problem is
  not a disorder, but 6 months is.)
• Are criminal behaviors (child molesting) really a
  sign of mental illness, or some other serious
  problem?

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Classifying Psychological Disorders

• Criticisms of DSM-IV
• Is it an adjustment to a life stressor, or is it
  a mental illness?
• Statistics on prevalence of disorders are
  uncertain and at times seem inflated.
• To what extent is the situation the problem,
  rather than the person?

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• Figure 15.4
• According to one extensive survey, about half the
  people in the United States will suffer at least
  one psychological disorder at some time. (The
  figures for the individual conditions do not add
  up to the total percentage for any disorder
  because some people have more than one disorder.)
  However, the exact percentages depend on where
  one draws the dividing line between normal and
  abnormal. (Based on data of Kessler et al., 1994

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Psychological Disorders

• There is a stigma associated with receiving a
  mental health diagnosis.
• Yet it is possible that as many as 50 of the
  population has a diagnosable mental illness at
  some time in their lives (according to the
  standards of the DSM-IV.)
• If this is true, it is evidence that people with
  psychological disorders are not very different
  from the rest of us. In fact, maybe we are those
  people.

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Module 15.2

• Psychotherapy An Overview

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Psychotherapy

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

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Psychotherapy

• Psychotherapy is sought by or prescribed for a
  diverse range of clients, from those with very
  serious emotional disturbance, to the worried
  well and those who are basically well but wish
  to function more effectively.
• There are many techniques of psychotherapy, but
  all of them seem to depend in large part on the
  clients motivation to improve.

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Schools of Psychotherapy

• Psychoanalysis
• The psychodynamic therapies are based on the
  theories of Sigmund Freud.
• These methods try to relate personality to the
  interplay of conflicting forces in the person.
• The individual may be unaware of some of these
  forces and motives.
• Psychoanalysis is the oldest talk therapy. It
  attempts to bring unconscious thoughts and
  emotions to awareness, and help people understand
  their own thoughts and actions.

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Schools of Psychotherapy

• Psychoanalysis
• The psychodynamic therapies
• Psychoanalysis uses free association and
  transference to bring unconscious material to
  consciousness.
• This in turn produces catharsis, the release of
  pent-up emotions associated with unconscious
  thoughts and memories.

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• Figure 15.5
• The goal of psychoanalysis is to resolve
  psychological problems by bringing to awareness
  the unconscious thought processes that created
  the difficulty. Analysis literally means to
  loosen or break up, to look at the parts.

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Schools of Psychotherapy

• Psychoanalysis
• The psychodynamic therapies
• In free association, the client thinks about a
  symptom or problem and then says everything that
  comes to mind related to it.
• This process is supposed to uncover hidden
  thoughts and feelings.

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Schools of Psychotherapy

• Psychoanalysis
• The psychodynamic therapies
• Transference refers to the clients experience of
  feelings previously associated with a parent or
  other important figure that are transferred to
  the therapist.
• Psychoanalysts and other psychodynamic therapists
  make active interpretations of the clients
  statements.
• If a client disagrees with the therapists
  interpretations, they may label this as
  resistance, a continued repression that
  interferes with therapy.

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Schools of Psychotherapy

• Behavior Therapy
• Behaviorists believe that human behavior is
  learned and can be unlearned. Behavioral therapy
  is based on this principle.
• Treatment begins with specific behavioral goals,
  such as stay in seat for entire class period or
  spend a maximum of X dollars a week.
• The treatment plan entails how the client will
  learn to behave in ways that will help him or her
  achieve the goals.

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• Figure 15.7
• A child can be trained not to wet the bed by
  using classical conditioning techniques. At
  first, the sensation of a full bladder (the CS)
  produces no response, and the child wets the bed.
  This causes a vibration or other alarm (the UCS),
  and the child wakes up (the UCR). By associating
  the sensation of a full bladder with a vibration,
  the child soon begins waking up to the sensation
  of a full bladder alone and will not wet the bed.

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Schools of Psychotherapy

• Therapies That Focus on Thoughts and Beliefs
• Some therapies focus on what is in the clients
  mind right now instead on thoughts and feelings
  from the past.
• Cognitive therapy seeks to improve peoples
  functioning by changing how they think and what
  they believe about situations.
• Rational-emotive therapy assumes that thoughts
  precede emotions, and that unpleasant feelings
  are a result of irrational thoughts

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Schools of Psychotherapy

• Therapies That Focus on Thoughts and Beliefs
• Cognitive-behavior therapy sets clear goals for
  changing behavior (like a behavioral therapist.)
• The therapist puts more emphasis on also changing
  the persons interpretation of thoughts and
  events (like a cognitive therapist.)

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Schools of Psychotherapy

• Humanistic Therapy
• Humanistic therapists believe that people
  naturally strive to achieve their full
  potentials.
• The source of psychological distress is perceived
  incongruence between the way an individuals
  self-concept and his or her ideal image of self.
• The most common humanistic therapy is
  person-centered (nondirective/client-centered)
  therapy.

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Schools of Psychotherapy

• Humanistic Therapy
• Person-centered therapy
• The therapist listens to the client
  non-judgmentally.
• The therapist also provides unconditional
  positive regard.
• Unconditional positive regard is an ideal state,
  similar to the regard that a loving parent has
  for a child.
• The therapist tries to be genuine, empathetic and
  caring, and tries not to interpret the clients
  thoughts or feelings or offer advice.

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• Table 15.3
• Comparison of Five Types of Psychotherapy

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Concept Check

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

Psychodynamic or psychoanalysis
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• In which therapies are treatment goals stated in
  clear and specific terms?

Behavioral and cognitive-behavioral
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• In which therapy is the client viewed as
  essentially good and wishing to achieve full
  potential in life?

Person-centered (humanistic)
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Schools of Psychotherapy

• Family Systems Therapy
• Family systems therapy treats the person in the
  context of the family
• The underlying assumption of family systems is
  that an individuals problems arise in a family
  setting.
• Therefore the best way to deal with them is to
  change and improve family relationships and
  communication.

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Schools of Psychotherapy

• Other Trends in Psychotherapy
• Eclectic therapists do not use any single method
  exclusively, but a combination of approaches.
• Brief therapy models are gaining in popularity.
• In brief or time-limited therapy, the therapist
  and client agree to a certain length, number of
  meetings and expectations and goals for the
  treatment.

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Schools of Psychotherapy

• Other Trends in Psychotherapy
• Group therapy involves the treatment of many
  clients by one or two therapists on an ongoing
  basis.
• Group therapy is less expensive and allows the
  clients to help each other with advice and
  feedback.
• Self-help groups work in a similar way but there
  is no therapist involved.

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Psychotherapy

• How effective is psychotherapy?
• According to some research studies, many people
  start to feel better anyway without psychotherapy
  (spontaneous remission.)
• Meta-analysis of many studies of psychotherapy
  suggests that a majority of people do show
  improvements after therapy.
• Keep in mind the file-drawer effect when
  considering the results of meta-analyses.

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Psychotherapy

• How effective is psychotherapy?
• A recent study by Consumer Reports of mental
  health treatment and psychotherapy supported the
  conclusion that most mental health treatment is
  helpful in improving the psychological and
  emotional well being of clients.
• No one method of therapy stands out as better
  than the others.

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Psychotherapy

• How effective is psychotherapy?
• Although it is a complex and tricky business to
  evaluate the effectiveness of psychotherapeutic
  treatment, there are distinct advantages to
  seeking professional mental health care.
• A trained clinician keeps confidentiality, uses
  methods with some demonstrated level of
  effectiveness, and can make referrals to other
  professionals if he or she suspects that this may
  be warranted (for example, if a medical problem
  may exist.)

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Psychotherapy

• How effective is psychotherapy?
• Similarities Among Psychotherapeutic Methods
• The creation of a therapeutic alliance that
  offers social support for the client.
• The opportunity for the client to engage in
  self-examination (this is not an advantage
  cross-culturally, though.)
• The opportunity to receive encouragement from the
  therapist on a regular basis.
• There is an affirmation of the clients desire to
  change and improve.

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Psychotherapy

• How effective is psychotherapy?
• Advice for Potential Clients
• Ask the local Mental Health Association for some
  recommendations.
• You may feel most comfortable with a therapist
  from a cultural background that is similar to
  yours.
• If spirituality or religion is important to you,
  you may want to find a therapist who sympathizes
  with your beliefs.

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Psychotherapy

• How effective is psychotherapy?
• As with any other remedy be skeptical of
  overconfidence and claims of amazing results.
• Expect at least some small improvement within a
  couple of months of starting, and dont be afraid
  to ask for your therapists input if this doesnt
  happen.
• Be an active participant in your own treatment
  nobody fixes you, rather, you receive help in
  changing your own life.

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Finding the Best Therapy

• Research suggests that the various methods of
  therapy and professionals who provide services
  are about equally effective. There is no best
  type of therapist or best method.
• But no one way of doing psychotherapy is right
  for every client. You need to use your knowledge
  to shop for the therapist who will work best
  with you.

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Module 15.3

• Social and Legal Aspects of Treatment

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Deinstitutionalization

• Deinstitutionalization refers to the trend over
  the second part of the twentieth century of
  removing patients from mental hospitals.
• There are alternatives to long-term inpatient
  care. Unfortunately, many patients were
  discharged without the benefit of adequate
  planning for their future care.

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Deinstitutionalization

• As a result of this lack of foresight, many
  former mental hospital patients are now
• Homeless
• Placed in nursing homes
• Imprisoned
• Dead

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Involuntary Commitment and Treatment

• In the case of people with severe mental health
  problems, the right to live freely among others
  can come into conflict with the rights of others.
• If a persons mental state represents a serious
  danger to self, others or causes the individual
  to be completely unable to care for him or
  herself, serious ethical issues are raised.

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Involuntary Commitment and Treatment

• There are many potential problems in the process
  of involuntary commitment
• Not all seriously mentally ill patients realize
  that they are ill,
• People have been committed to mental hospitals
  just to be put out of the way.
• It is extremely difficult to determine which
  patients should be committed.

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Involuntary Commitment and Treatment

• Usually the opinion of one or more trained
  professionals plus court action must be obtained
  in order to commit a person with a mental
  illness.
• Even after commitment, the patient is always
  given the right to refuse specific treatments.

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• Figure 15.11
• People with schizophrenia who refuse drug therapy
  impress their physicians as being seriously
  disturbed. Patients who refuse drugs rate
  themselves as dissatisfied with their physicians
  and their treatments. (a) Physicians ratings of
  their patients. High scores indicate greater
  disturbance. Those refusing treatment showed
  greater indications of disturbance on most scales.

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• Figure 15.11 (cont.)
• People with schizophrenia who refuse drug therapy
  impress their physicians as being seriously
  disturbed. Patients who refuse drugs rate
  themselves as dissatisfied with their physicians
  and their treatments. (b) Patients self-ratings.
  The higher scores of patients who agreed to drug
  treatment indicate their higher levels of
  satisfaction with their treatment. (Based on data
  from Marder et al., 1983)

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The Duty to Protect

• The Tarasoff Case
• The Tarasoff case established that a therapist
  who knows that a client has harmful intent
  towards an identified person or persons has a
  duty to break confidentiality with the client to
  protect the endangered person.
• Judging dangerousness is not a clear-cut matter
  and the therapist must often weigh carefully the
  factors. Breach of confidentiality is a serious
  violation of the patients rights.

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The Duty to Protect

• The Insanity Defense
• Insanity is a legal term, not a psychological or
  medical one.
• Its definition is more judicial than scientific.
• Bizarre crimes in and of themselves do not
  demonstrate insanity.
• The most famous definition of insanity is based
  on the MNaghten rule, from 19th Century British
  law.

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The Duty to Protect

• The Insanity Defense
• The MNaghten Rule
• The gist of the law states that in order to be
  judged insane at the time of a crime, a people
  must be so disordered that they cannot understand
  what they are doing.
• Some legal authorities felt that this rule was
  too narrow and rigid.

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The Duty to Protect

• The Insanity Defense
• The Durham Rule
• Under the Durham rule (1954) a person was not
  held criminally responsible if the deed was a
  product of mental disease or defect.
• However, this rule was used so broadly it began
  to confuse the issue.

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The Duty to Protect

• The Insanity Defense
• The Moral Penal Code
• The Moral Penal Code, created by the American Law
  Institute in the 1950s is a middle ground
  between the MNaghten and the Durham.
• It states that one is not responsible for
  criminal conduct if a mental disease or defect
  caused the person to lose the capacity to
  understand that the act was not lawful.

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The Duty to Protect

• The Insanity Defense
• Under 1 of accused felons plead insanity.
• The insanity defense is extremely rare.
• These cases receive a great deal of media
  attention.
• If the person is found not guilty by reason of
  insanity, they will likely be institutionalized
  for a very long time.

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Preventing Mental Illness

• Some psychologists, especially community
  psychologists have started to create movement
  towards preventing mental illness.
• Community psychologists focus on the needs of
  groups rather than individuals.
• They look at two routes towards prevention.

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Preventing Mental Illness

• Primary prevention methods are aimed at stopping
  mental illness before it begins.
• Secondary prevention involves identifying a
  disorder in its early stages and treating it
  before it becomes serious.
• An ounce of prevention is worth a pound of
  cure.
• -- Old aphorism

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Preventing Mental Illness

• Some steps that would help in prevention efforts
• Ban use of environmental toxins
• Promote good prenatal care and education
• Promote full employment
• Provide high quality and affordable child care
• Improve educational opportunities

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Concept Check

• Can you think of some other steps that would
  promote good mental health and improve
  psychological functioning overall in our society?

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Mental Illness Science and Society

• The issues we have examined in this module are
  complex and involve scientific, social and
  ethical dimensions.
• Even if you do not grow up to be a psychologist,
  as a citizen of our country it is in your best
  interest to be informed about the social and
  legal aspects of mental illness and the benefits
  to society of promoting good mental health.