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Abnormal Psychology, Psychopathology & Psychotherapy. What should be labeled deviant? What psychiatrists, clinical psychologists or other trained professionals label deviant? (DSM-IV) Or, Only organically based behavioral disorders (Szaz). Treating Insanity.

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Abnormal psychology psychopathology psychotherapy l.jpg
Abnormal Psychology, Psychopathology & Psychotherapy

What should be labeled deviant?

  • What psychiatrists, clinical psychologists or other trained professionals label deviant? (DSM-IV)

    Or,

  • Only organically based behavioral disorders (Szaz).


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Treating Insanity

  • Hippocrates – recognized depression and epilepsy as medical problem.

  • Middle ages – deviant people were locked up

    • Bedlam (Bethlehem hospital, London)

  • Reform movement

     Pinel (1790)

     Dorothea Dix (1850)

     Medical Model (late 19th century)







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    Medical ModelofMental Illness

    • Psychiatry an offshoot of neurology (Charcot (1860), Breuer & Freud (1896), Bleuler (1911).

    • Freud: Too little was known about the brain; opted for psychoanalysis. Classified mental illness into two major categories: neuroses and psychoses.

    • “General paresis” discovered by Krafft-Ebbing to have a physical cause in 1905 (syphilis).

    • Pavlov (1904). Concept of conditioning and experimental neurosis that was mediated by specific brain circuits.


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    Reactions to the Medical Model

    • Harry Stack Sullivan (broke with psychoanalytic tradition).

    • Clinical (lay) psychologists allowed to treat patients with “mental” disorders.

    • Carl Rogers, Ph.D. Published first transcript of a therapeutic session.

    • Behavior Therapy (Wolpe, Lazarus). Began in 50’s.

    • Cognitive Therapy (Seligman). Began in 60’s.

    • Thomas Szaz: Mental illness should only refer to behavioral deviations that have a well defined organic basis. Other deviant behaviors the product of “problems of living”.

    • DSM-III (1983) & IV (1994)


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    • What is a normal personality?

      • Least deviant?

      • What is deviant?

      • Statistical (does 1/10 of population have mental illness?)

      • Adaptive sublimation?

      • Self-actualization?

      • Quantitative vs. qualitative differences between normal and abnormal.



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    Types of Personality Tests

    • Objective

      MMPI (Minnesota Multi Phasic Inventory)

    • Projective

      TAT (Thematic Apperception Test)

      Rorschach Test




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    Interpretation of Sample MMPI Score

    • Overly self-critical

    • Personality disorder

    • Poor social adjustment

    • Unusual thinking and behavior

    • High level of anxiety




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    Sample Responses On TAT Test

    • (1) My first thought is that it looks like a mother comng to the door.

    • (2) --the doorbell just rang and she’s expecting someone probably pretty dear.

    • (3) maybe it’s her son--that shows I’m homesick.

    • (4) stuff in the room--furniture, flowers, bookshelves and books--looks roughly like the middle-class home I came from

    • (5) she doesn’t look like my mother, but somebody’s mother

    • (6) even if she has one nude leg.


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    TAT STORIES IN RESPONSE TO “BOY LOOKING AT VIOLIN”

    • 45-year old business man:

    • This is a child prodigy dreaming over his violin, thinking more of the music that anything else. But of wonderment that so much music can be in an instrument and in the fingers of his own hand. . . .I would say that possibly he is in reverie about what he can do with his music in the times that lay ahead. He is dreaming of concert halls, tours, and . . . the beauty he will be able to express and even now can express with his own talents.


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    TAT STORY 2

    • 45-Year old clerk:

    • . . . This is the son of a very well-known, a very good musician. . . . The father has probably died. The only thing the son has left is this violin which is undoubtedly a very good one. . . . To the son, the violin is the father and the son sits there daydreaming of the time that he will understand the music and interpret is on the violin that his father had played.






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    DSM III (1983)

    Disorders first evident in childhood (e.g., mental retardation, hyperactivity).

     Organic mental disorders: symptoms directly related to injury to brain or to abnormality (syphilis, Alzheimer’s disease, extreme alcoholism, brain tumor).

     Substance use disorders.

     Schizophrenic disorders.

     Paranoid disorders.

     Affective disorders (manic and/or depressed moods).

    Somatoform disorders (hysteria, hypochodriasis).

    Dissociative disorders (amnesia, multiple personalities).

    Psychosexualdisorders (transsexualism, frigidity, exhibitionism, sexual sadism, homosexuality-but only if individual is unhappy).

    Personality disorders (anti-social behavior, narcissistic personality).

    Anxiety disorders (generalized anxiety or panic, phobias, posttraumatic stress disorder, obsessive-compulsive disorder).

    Leftovers (marital problems, family therapy).


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    DSM-IV (1994)

    • Anxiety disorders.

    • Mood disorders.

    • Somatoform disorders.

    • Dissociative disorders.

    • Schizophrenia and other psychotic disordcrs (delusional).

    • Substance-related disorders

    • Eating disorders (aneroxia nervosa, bulimia nervosa).

    • Sleep disorders.

    • Impulse control disorders (kleptomania, pyromania, pathological gambling)

    • Personality disorders (anti-social behavior, narcissistic personality).

    • Disorders first evident in childhood (e.g., mental retardation, hyperactivity).

    • Delerium, dementia, amnestic and other cognitive disorders.

    • Adjustment disorder (Maladaptive, excessive emotional reaction to a stressful event within previous 6 months).


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    Psychoanalysis

    • Based on Freud’s theory of personality

      Many varieties, e.g., Jung, Adler, Sullivan

    • M.D. usually required; Ph.D. in clinical psychology now acceptable (lay analysts)

    • Training performed by certified institutes in three stages:

      -formal courses

      -personal analysis with an institute analyst

      -control analyses supervised by a training analyst.

    • Patients: usually brighter than average; in most cases neurotic. Typically excluded are homosexuals, alcoholics, psychotics, patients with character disorders.


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    Conditions for Psychoanalysis

    • MD originally required

    • No psychotics, alcoholics, homosexuals, sociopaths

    • Time commitment: ~ 5 years

    • Financial commitment: $150 x 4; $600/week; $27,000/year.

    • Life decisions placed on hold. No marriage, divorce,

      moving, changing jobs without consulting analyst.



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    Psychoanalytic Method

    • Treatment consists of three to five 50 minute sessions per week .

    • Patient is instructed to free associate. He does this while lying on a couch that is facing away from the analyst.

      - less fatiguing to the analyst than face-to-face relationships

      -facilitated free association.

    • Basic goal is to have awareness of one’s motives and memories.

    • Dream interpretation

    • Transference


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    Goals of Psychoanalysis

    • Genetic progression - bring the patient from his point of fixation in the psychosexual development to the genital stage.

    • Structural - the ego should be strengthened in satisfactory relationships with the super ego.

    • Dynamic - direct energy from the defense mechanism to more productive outlets.

    • Topographic- makes the unconscious conscious - specifically, the defense mechanisms.


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    Client-centered Therapy

    • Does not assume medical model (client vs. patient; counsellor vs. therapist/doctor

    • Brief duration (~ 10 vsits)

    • Non-directive

      • Counselor “reflects” rather than “interprets”

      • No dream analysis

      • No specific retracing of psychosexual history


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    PROCESS OF CLIENT-CENTERED THERAPY

    1. Rigidity - little desire to change. Little recognition of feelings.

    2. Perception of problems, externally dispassionate display of feeling. Little recognition of contradictory feelings...

    3. Free expression of feelings. Source of feelings considered. Increased awareness of the “real me.” Awareness of contradictions.

    4. Immediacy of feelings. Real direct experience. High self-regard. Less intellectualization about self.

    5. Acceptance of self and problem.


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    EXCERPTS FROM THE FIRST INTERVIEW IN ROGERIAN THERAPY

    • P (patient): I hesitate to meet people - I hesitate to canvas for my photographic business. I feel a terrific aversion to any kind of activity, even dancing. I normally enjoy dancing very much. But when my inhibition, or whatever you wish to cal it, is on me powerfully, it is an ordeal for me to dance. I notice a difference in my musical ability. On my good days I can harmonize with other people singing.

    • C (counselor): M-hm.


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    EXCERPTS FROM THE FIRST INTERVIEW IN ROGERIAN THERAPY (cont’d.)

    • P: I have a good ear for harmony then. But when I’m blocked, I seem to lose that, as well as my dancing ability. I feel very awkward and stiff.

    • C: M-hm. So that both in your work and in your recreation you feel blocked.

    • P: I don’t want to do anything. I just lie around. I get no gusto for any activity at all.

    • C: You just feel rather unable to do things, is that it?

    • ************************


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    EXCERPTS FROM THE FIRST INTERVIEW IN ROGERIAN THERAPY (cont’d.)

    • P: Well, it’s just reached the point where it becomes unbearable. I’d rather be dead than alive as I am now.

    • C: You’d rather be dead than alive as you are now? Can you tell me a little more about that?

    • P: Well, I hope. Of course, we always live on hope.

    • C: Yes.


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    EXCERPT FROM THE EIGHTH AND FINAL INTERVIEW IN ROGERIAN THERAPY

    • P: Well, I’ve been noticing something decidedly new. Rather than have fluctuations, I’ve been noticing a very gradual and steady improvement. It’s just as if I have become more stabilized and my growth had been one of the hard way and the sure way rather than the wavering and the fluctuating way.

    • C: M-hm.


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    EXCERPT FROM THE EIGHTH AND FINAL INTERVIEW IN ROGERIAN THERAPY

    • P: I go into situations, and even though it’s an effort, why, I go ahead and make progress, and I find that when you sort of seize the bull by the horns, as it were, why it isn’t so bad as if you deliberate and perhaps - well, think too long about it, like I used to. I sort of say to myself, “Well, I know absolutely that avoiding the situation will leave me in the same rut I’ve been talking,” and I realize that I don’t want to be in the same old rut, so I go ahead and go into the situation, and even when I have disappointments in the situation, I find that they don’t bring me down as much as they used to.


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    EXCERPT FROM THE EIGHTH AND FINAL INTERVIEW IN ROGERIAN THERAPY (cont’d.)

    • C: That sounds like very real progress.

    • P: And what pleases me is that my feelings are on an even keel, steadily improving, which gives me much more of a feeling of security than if I had fluctuations. You see, fluctuations lead you from the peaks to the valleys, and you can’t get as much self-confidence as when you’re having gradual improvement.

    • C: M-hm.

    • P: So that the harder way is really the more satisfactory way.

    • C: Then you’re really finding a step-by-step type of improvement that you hadn’t found before.


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    Phobia THERAPY (cont’d.)DescripionPhobiaDescription


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    Relative Frequency of Phobias THERAPY (cont’d.)


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    How Phobias Vary With Age THERAPY (cont’d.)


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    BEHAVIOR THERAPIST’S INSTRUCTIONS THERAPY (cont’d.)

    “Let all your muscles go loose and heavy. Just settle back quietly and comfortably. Wrinkle up your forehead now; wrinkle it tighter....And now stop wrinkling your forehead, relax and smooth it out. Picture the entire forehead and scalp becoming smoother as the relaxation increases....


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    BEHAVIOR THERAPIST’S INSTRUCTIONS THERAPY (cont’d.)(cont’d.)

    Now frown and crease your brows and study the tension....Let go of the tension again. Smooth out the forehead once more....Now, close your eyes tighter and tighter...feel the tension...and relax your eyes. Keep your eyes closed, gently, comfortably, and notice the relaxation .... Now clench your jaws, bite your teeth together; study the tension throughout the jaws....Relax your jaws now. Let your lips part slightly....Appreciate the relaxation....


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    BEHAVIOR THERAPIST’S INSTRUCTIONS THERAPY (cont’d.)(cont’d.)

    Now press your tongue hard against the roof of your mouth. Look for the tension....All right, let your tongue return to a comfortable and relaxed position .... Now purse your lips, press your lips together tighter and tighter....Relax your lips. Note the contrast between tension and relaxation. Feel the relaxation all over your face, all over your forehead and scalp, eyes, jaws, lips, tongue and throat. The relaxation progresses further and further...”. [from Wolpe and Lazarus (1966), p. 178]


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    Behavioral THERAPY (cont’d.)

    Therapy

    Treatment of

    A Phobia

    (Sensitization)


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    BEHAVIOR THERAPY TRANSCRIPT THERAPY (cont’d.)

    “The patient, a 14-year-old boy, suffered from an intense fear of dogs which lasted for two and one-half to three years. He would take two buses on a roundabout route to school rather than risk exposure to dogs on a direct 300-yard walk. He was rather a dull (IQ = 93), sluggish person, very large for his age, trying to be cooperative, but sadly unresponsive---especially to attempts at training in relaxation.


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    BEHAVIOR THERAPY TRANSCRIPT THERAPY (cont’d.)(cont’d.)

    In his desire to please, he would state that he had been perfectly relaxed even though he had betrayed himself by his intense fidgetiness. Training in relaxation was eventually abandoned, and an attempt was made to establish the nature of his aspirations and goals. By dint of much questioning and after following many false trails because of his inarticulateness, a topic was eventually tracked down that was absorbing enough to form the subject of his fantasies, namely, racing motor-cars.


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    BEHAVIOR THERAPY TRANSCRIPT THERAPY (cont’d.)(cont’d.)

    He had a burning ambition to own a certain Alfa Romeo sports car and race it at the Indianapolis 500. Emotive imagery was induced as follows: “Close your eyes. I want you to imagine, clearly and vividly, that your wish has come true. The Alfa Romeo is now in your possession. It is your car. It is standing in the street outside your house. You are looking at it now. Notice the beautiful, sleek lines. You decide to go for a drive with some friends of yours. You sit down at the wheel, and you feel a thrill of pride as you realize that you own this magnificent machine.


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    BEHAVIOR THERAPY TRANSCRIPT (cont’d.) THERAPY (cont’d.)

    You start up and listen to the wonderful roar of the exhaust. You let the clutch in and the car streaks off. You are out in a clear open road now; the car is performing like a pedigree; the speedometer is climbing into the nineties; you have a wonderful feeling of being in perfect control; you look at trees whizzing by and you see a little dog standing next to one of them-- if you feel any anxiety, just raise your finger....” An item fairly high up on the hierarchy was: “You stop at a cafe in a little town, and dozens of people crowd around to look enviously at this magnificent car and its lucky owner; you swell with pride; and at this moment a large boxer comes up and sniffs at your heels. If you feel any anxiety....” [from Lazarus and Abramovitz (1962)].


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    Comparisons of Different Approaches to Psychotherapy THERAPY (cont’d.)

    Behavior Modification Psychoanalysis

    What is to be modified? Learned behavior Symptoms

    Role of therapist: Deliberate None - minimal

    Active Indirect

    Direct Passive

    Philosophy of treatment: Scientific Intuitive

    Interpretation

    of behavior: Real Symbolic

    Aim: Goal directed General

    restructuring

    Basis of change: Training Insight

    What is dealt with: Present behavior Past behavior


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