Chapter 15 Abnormality, Therapy, and Social Issues 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. 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. Defining Abnormal Behavior There is probably no definition of ?abnormal? that can?t be questioned. If we use the standard of ?subjective feelings of distress? than anyone who thinks they have a problem automatically qualifies. If someone behaves in bizarre and dangerous ways, but insists that they are fine, many people who are in fact suffering from mental illness could not be diagnosed and treated. 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. Cultural influences on abnormality Culture-specific disorders are found everywhere and in every era. Demonic possession has been a common diagnosis 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. 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. Dissociative identity disorder This was a very rare disorder until the 1950?s, 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 was promoted by suggestion of over eager therapists. The biopsychosocial model The predominant view in Western culture today uses the biopsychosocial model to understand mental illness. Biological roots - include genetic factors, injury, disease processes that 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. Classifying Psychological Disorders The DSM-IV The Diagnostic and Statistical Manual of Mental Disorders Establishes uniform definitions and standards for diagnosis. Now in its fourth edition (DSM-IV-TR). Lists acceptable labels for all psychological disorders. Lists symptoms and criteria for making diagnoses and contains information on differential diagnosis ? making distinctions between similar diagnoses. Axis I - Clinical disorders are diagnosed on Axis I. These are disorders that involve deterioration of functioning. Most common psychological disorders are listed on Axis I. 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. Axis III is for general medical conditions that influence the person?s mood or behavior. Axis IV is for psychosocial problems that increase the person?s level of stress. Axis V is a 1-100 scale called the global assessment of functioning. The lower the number assigned by the assessing clinician, the less adaptive the person?s functioning is judged to be at the time. Table 15.1 Table 15.1 Some major categories of psychological disorders according to Axis I of 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. Table 15.2 Table 15.2 Some major categories of psychological disorders according to Axis II of DSM-IV. Figure 15.1 Figure 15.1 In this survey just over a quarter of U.S. adults suffer a psychological disorder in any given year, and nearly half do at some time in life. This figure combines results for men and women of all adult ages. (Based on data of Kessler, Berglund, et al. 2005 Kessler, Chiu, Demler & Walters 2005) There is a stigma associated with receiving a mental health diagnosis. 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, people with psychological disorders are not different from the rest of us. ----------------------------------------------------------------------------- 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. Psychoanalysis The psychodynamic therapies are based on the theories of Sigmund Freud. These methods relate personality to the interplay of conflicting forces in the person. Psychoanalysis The psychodynamic therapies are based on the theories of Sigmund Freud. 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. 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. 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. Transference refers to the client?s experience of feelings previously associated with a parent or other important figure that are ?transferred? to the therapist. Figure 15.2: Figure 15.2: 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.? Schools of Psychotherapy Psychoanalysis The psychodynamic therapies Psychoanalysts and other psychodynamic therapists make active interpretations of the client?s statements. If a client disagrees with the therapist?s interpretations, they may label this as resistance, a continued repression that interferes with therapy. Therapies that focus on thoughts and beliefs Some therapies focus on what current mental processes, not past thoughts and feelings. Cognitive therapy improves functioning by changing people?s thoughts and beliefs about situations. Rational-emotive therapy (RET) assumes that thoughts precede emotions, and that unpleasant feelings result from irrational thoughts. Cognitive-behavior therapy sets clear goals for changing behavior (like a behavioral therapist). The therapist puts more emphasis on also changing the person?s interpretation of thoughts and events (like a cognitive therapist). Humanistic therapists, founded by Abraham Maslow, believe that people naturally strive to achieve their full potentials. The most common humanistic therapy is person-centered (nondirective/client-centered) therapy, which Carl Rogers promoted. Person-centered therapy The therapist listens to the client non-judgmentally and provides unconditional positive regard, an ideal state like 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 client?s thoughts or feelings or offer advice. Table 15.4 Table 15.4 Comparison of five types of psychotherapy Concept Check: In which type of therapy would the therapist be most likely to interpret a thought, feeling or dream? Psychodynamic or psychoanalysis Concept Check: In which therapies are treatment goals stated in clear and specific terms? Behavioral and cognitive-behavior Concept Check: In which therapy is the client viewed as essentially good and wishing to achieve full potential in life? Person-centered (humanistic) Family systems therapy Family systems therapy treats the person in the context of the family. The underlying assumption is that an individual?s problems arise in a family setting. The best way to deal with these is to improve family relationships and communication. Eclectic therapists do not use a single method exclusively, but a combination of approaches. Brief therapy models in which the therapist and client agree to a certain length, number of meetings, expectations and goals for the treatment are becoming more popular. Group therapy involves the treatment of many clients by one or two therapists on an ongoing basis. It?s 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. Psychotherapy How effective is psychotherapy? Evaluating effectiveness of psychotherapeutic treatment is complicated, but there are distinct advantages to seeking professional mental health care. A trained clinician keeps confidentiality, uses methods with some demonstrated level of effectiveness, makes referrals to other professionals if other problems are suspected (for example, additional medical problems). 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 don?t be afraid to ask for your therapist?s input if this doesn?t happen. Be an active participant in your own treatment ? nobody ?fixes? you, rather, you receive help in changing your own life. 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. Deinstitutionalization As a result of this lack of foresight, many former mental hospital patients are now: Homeless Placed in nursing homes Imprisoned Dead 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 M?Naghten rule, from 19th Century British law. 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. 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 various routes to circumventing mental illness or lessening its damaging effects. Preventing Mental Illness Prevention methods are aimed at stopping mental illness before it begins. Intervention involves identifying a disorder in its early stages and relieving it. Maintenance is taking steps to prevent an illness from becoming more serious. ?An ounce of prevention is worth a pound of cure.? -- Old aphorism Preventing Mental Illness Some steps that would help in prevention efforts: Ban use of environmental toxins Promote good prenatal care and education Control smoking in public places and educate the public about the risks of smoking Promote full employment Provide high quality and affordable child care Improve educational opportunities
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