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    PsychExchange.co.uk Shared Resource PsychExchange.co.uk Shared Resource Document Transcript

    • Definitions of AbnormalityDefining a person or behaviour as „abnormal‟ implies something undesirable andrequiring changeTherefore, we must be careful how we use the termPsychologists need methods for distinguishing „normal‟ from „abnormal‟Our definition of abnormality must be objective: It must not depend on anyone‟s opinion or point of view It should produce the same results whoever applies itIt must not be under or over-inclusive It must not label as „abnormal‟ or „normal‟ behaviours or traits that aren‟tThree definitions are used to define abnormality: Deviation from social norms Failure to function adequately Deviation from ideal mental health Deviation from social normsUnder this definition, a person‟s thinking or behaviour is classified as abnormal ifit violates the (unwritten) rules about what is expected or acceptable behaviour ina particular social group.Their behaviour may: Be incomprehensible to others Make others feel threatened or uncomfortableWith this definition, it is necessary to consider: The degree to which a norm is violated, the importance of that norm and the value attached by the social group to different sorts of violation. E.g. is the violation rude, eccentric, abnormal or criminal?Abnormality is defined in terms of behavior which goes against societiesaccepted standardsDifferent societies have different standardsStandards change over timeStrengthsShouldbe easy to pick out the deviantAllows for adaptation: As social norms change, so will our ideas about what isnormal / abnormalWeaknessesWhat is deviant in one social group is accepted / expected in another: Acrosssocieties and cultures / across generations and sub-cultures
    • Psychiatric wards used to hold women locked away for „mental insanity‟ ie havingbabies outside of marriage Failure to function adequatelyUnder this definition, a person is considered abnormal if they are unable to copewith the demands of everyday life.They may be unable to perform the behaviours necessary for day-to-day livinge.g. self-care, hold down a job, interact meaningfully with others, makethemselves understood etc.Rosenhan& Seligman (1989) suggest the following characteristics: Suffering Maladaptiveness (danger to self) Vividness & unconventionality (stands out) Unpredictability & loss of control Irrationality/incomprehensibility Causes observer discomfort Violates moral/social standardsAbnormality is defined in terms of an inability to maintain social relationships, orhold down a job. Some people with mental health disorders appear to the outsideworld to cope very well. Sometimes withdrawal from the world is an adaptiveresponseStrengthsThese are what most people refer to when talking about problems with mentalhealth (Sue et al 1994)These are the reasons most people go for help with their mental health (Miller &Marley 1986)WeaknessesWho decides what an acceptable level of functioning is?Context of their behaviourSome people have psychological disorders but still function adequatelySome people may be classified as not functioning adequately but do not have apsychological disorderFunctioning adequately is subject to cultural variation Deviation from ideal mental healthUnder this definition, rather than defining what is abnormal, we define what isnormal/ideal and anything that deviates from this is regarded as abnormalThis requires us to decide on the characteristics we consider necessary to mentalhealthPsychologists vary, but usual characteristics include: Positive view of the self Capability for growth and development Autonomy and independence
    • Accurate perception of reality Positive friendships and relationships Environmental mastery – able to meet the varying demands of day-to-day situations Deviation from ideal mental health continued:Self-actualisation – Becoming all that you are capable of becomingStrengths: Optimistic Focuses on a health not illness model This approach emphasises a positive approach to human behaviour and experience. Has value as a tool for defining normality but as a means of defining abnormality it has severe limitations.Weaknesses: Represents deviation from an ideal mental state. Very few people would match Jahoda‟s criteria and so would be classified as abnormal! The characteristics listed by Jahoda are rooted in Western culture. The goals autonomy and self-actualisation would not be recognised by collectivist cultures. Severely culturally restricted. The difficulty of self-actualisation Very difficult to measure objectively Who defines ideal mental health? Possible benefits of stress
    • Approaches to Psychopathology The Biological Approach All mental disorders have a physical cause (BING - Brain injury, Infection, Neurotransmitters, Genetics) Mental illnesses can be described in terms of clusters of symptoms (syndromes) Symptoms can be identified, leading to the diagnosis of an illness Diagnosis leads to appropriate physical treatmentsOne of the best examples of how brain injury can influence abnormality is the case ofPhineas Gage.Working on a railway in 1848, he had an accident in which a tamping iron went upthrough his face , behind his left eye and out through the top of his head.He survived the accident, but his personality was completely changed, including ahuge increase in aggression.Some months after the accident, probably in about the middle of 1849, Phineas feltstrong enough to resume work. But because his personality had changed so much,the contractors who had employed him would not give him his place again. Beforethe accident he had been their most capable and efficient foreman, one with a well-balanced mind, and who was looked on as a shrewd smart business man. He wasnow fitful, irreverent, and grossly profane, showing little deference for his fellows. Hewas also impatient and obstinate, yet capricious and vacillating, unable to settle onany of the plans he devised for future action. His friends said he was "No longerGage.“Brain Damage • A degeneration or malformation of brain cells can cause memory loss often present in Alzheimer‟s disease. • Korsakoff‟s syndrome occurs when drink and drugs damage part of the brain involved in memory.Korsakoffs syndrome is caused by lack of thiamine (vitamin B1), which affects thebrain and nervous system. Thiamine deficiency is often seen in people who consumeexcessive amounts of alcohol. The main symptom is memory loss - particularly ofevents arising after the onset of the condition. Sometimes, memories of the moredistant past can also be affected.Infection • Syphilis causes short-lived sores followed by general paresis- forgetfulness, mental deterioration and delusions of grandeur and persecution.
    • • The influenza virus has been linked to schizophrenia. Brown et al (2004)found that 14% of schizophrenic cases may be linked to the foetus being exposed to the „flu virus in the womb during the first trimester.Neurotransmitter ImbalanceNeurotransmitters have been thought to contribute to many psychological disorders • One of the factors involved in schizophrenia is an excessive amount of dopamine • High levels of serotonin have been thought be involved in the manic state of bi-polar depression.Neurotransmitters have been studied quite a bit in relation to psychology and humanbehavior. What we have found is that several neurotransmitters play a role in theway we behave, learn, the way we feel, and sleep. And, some play a role in mentalillnesses. The following are those neurotransmitters which play a significant role inour mental health. • Dopamine – correlated with movement, attention, and learning Too much dopamine has been associated with schizophrenia, and too little is associated with some forms of depression as well as the muscular rigidity and tremors found in Parkinson‟s disease. • Serotonin – plays a role in mood, sleep, appetite, and impulsive and aggressive behavior Too little serotonin is associated with depression and some anxiety disorders, especially obsessive-compulsive disorder. Some antidepressant medications increase the availability of serotonin at the receptor sites. • GABA (Gamma-Amino Butyric Acid) – inhibits excitation and anxiety Too little GABA is associated with anxiety and anxiety disorders. Some anti- anxiety medication increases GABA at the receptor sites.Genetics • Individuals may inherit a predisposition to certain illnesses. These are carried on genes, through DNA, which pass from one generation to the next. • Concordance rate: measures how often two individuals who are closely related have the same disorder. • Twin Studies: Twins can be • identical (monozygotic,MZ) or • fraternal (dizygotic, DZ).
    • McGuffin et al (1996) Studied twins where one of the pair already suffered from depression. Assessed the co-twin and found… 46% concordance rate for depression (MZ) 20% concordance rate for depression (DZ) Gottesman (1991) Meta-analysis of about 40 twin studies Found concordance rate for schizophrenia of 48% in monozygotic twins and 17% in dizygotic twinsStrengths Evidence from brain scans. No „blame‟ – it‟s an illness. Offers rapid and effective treatment solutions. Brain imaging studies etc show how neurotransmitters can be involved Bipolar disorder, phobias, schizophrenia etc sometimes run in families Depression, for example, can be effectively treated with drugs It focuses upon physical factors in the same way that medicine does for physical disorders. Genes and brain chemistry can be reliably measured and manipulated. Patients may find it reassuring that their „condition‟ can be attributed to a physical deficiency rather than „something wrong with them‟ as a personWeaknesses Reductionist Genetics don‟t provide a complete explanation, e.g.diathesis-stress Stigma of mental illness Pathologising all undesirable behavior Takes only the biological view, when we know that there are also environmental factors. Doesn‟t paint the full picture This component (genetic) must interact with non-genetic environmental factors. E.g. non genetic factor could be stress, which then triggers the genetic vulnerability. This is called diathesis-stress, the interaction between nature (e.g genetic vulnerability) and nurture (stress) = depression. Drug treatments not effective for everyone. And some disorders don‟t respond at all, e.g. phobias and eating disorders. Drugs are like a plaster, they treat the symptoms, but not the underlying causes.
    • The Psychodynamic Approach Much of our behaviour is driven by unconscious motives Childhood is a critical period in development Mental disorders arise from unresolved, unconscious conflicts originating in childhood Resolution occurs through accessing and coming to terms with repressed ideas and conflictsThe key assumption of the psychodynamic approach is that all human behaviour canbe explained in terms of inner conflict of the mindThe Mind: The conscious - The small amount of mental activity we know about. Thoughts & Perceptions The preconscious - Things we could be aware of if we wanted or tried. Memories & Stored knowledge The unconscious - Things we are unaware of and cannot become aware of. Fears, Unacceptable desires, Violent motives, Irrational wishes, Immoral urges, Selfish needs, Shameful experiences & Traumatic experiencesPsyche- the forces in an individual that influence thought, behaviour and personalityId – Instincts - The id is the unorganized part of the personality structure whichcontains the basic drives. The id acts according to the "pleasure principle", seekingto avoid pain or displeasure aroused by increases in instinctual tension.Developmentally, the id precedes the ego. The mind of a newborn child is regarded
    • as completely "id-ridden", in the sense that it is a mass of instinctive drives andimpulses, and needs immediate satisfactionEgo – Reality - The ego acts according to the “reality principle”, i.e. it seeks toplease the id‟s drive in realistic ways that will benefit in the long term rather thanbringing grief. At the same time, the ego "attempts to mediate between id and reality.Superego – Morality - The Super-ego can be thought of as a type of conscience(aka “punishing parent”) that punishes misbehaviour with feelings of guilt. The super-ego works in contradiction to the id. The super-ego strives to act in a sociallyappropriate manner, whereas the id just wants instant self-gratification. The super-ego controls our sense of right and wrong and guilt. It helps us fit into society bygetting us to act in socially acceptable ways.Personality Development Freud believed that the id, ego and super ego were separate and conflicting forces, They need to be balanced for good mental health and normal behaviourExample - There is one cake left on the table:  ID – want the cake, needs to take the cake, isnt concerned about others.  SUPEREGO – I mustn‟t have the cake, I should leave it for someone else, I will let someone else have it, don‟t be greedy.  EGO – I will wait for a few minutes, see if anyone else has it, I am rather hungry, if it is still there in 5 minutes then I‟ll take it.Development of the ID, EGO and SUPEREGO  At birth, personality is ruled by ID (pleasure principle)  Early childhood, EGO starts to develop (reality principle)  Later childhood, the SUPER EGO emerges (Morality principle)Innate drive to seek immediate satisfaction of pleasure through libido (sexualenergy), aggression and/or violence.Reality creeps in, it can‟t always get what it wants, has to accommodate theenvironment. Regulates interactions with the here and now/environment.Balancingdemands of the superego with the drives of the id.Conscience, sense of right and wrong. Personal moral authority, developed throughidentification and influence of parents. Societal norms are internalised.
    • Because the id is present from birth but the ego and super ego develop throughchildhood, Freud thought that early childhood experiences were key tounderstanding adulthood disorders. This is because the immature ego may havestruggled to contain drives of the idand the morals of the superego (once formed).In a healthy psyche, the Ego is in chargeIf the superego dominates, the person may be unable to experience any kind ofpleasurable gratification. The burden of trying to live up to the high moral standardsof Superego (composed of parental and societal code of conduct) could cause hugeanxiety, accompanied by guilt at not being good enough (or still harbouring IDdrives). Neurotic (anxiety) disorders are likely. OCD could be linked into this psyche.Psychosis is a symptom of mental illness characterized by a radical change inpersonality and a distorted or diminished sense of objective realityA dominant IDcould lead to destructive tendencies, pleasure gratification at any cost, uninhibitedbehaviour, including sexual behaviour.Psychopathic psyche is as a result of the SUPER EGO not developing. Pleasureprinciple allowed to reign with no moral compromise, as there are no morals.Oedipus conflict - a boys feelings of desire for his mother and jealously and angertowards his father. Essentially, a boy feels like he is in competition with his father forpossession of his mother. He views his father as a rival for her attentions andaffections.Electra conflict - a girl‟s romantic feelings toward her father and anger towards hermother.During female psychosexual development a young girl is initially attached toher mother. When she discovers that she does not have a penis, she becomesattached to her father and begins to resent her mother who she blames for her"castration." As a result, Freud believed that the girl then begin to identify with andemulate her mother out of fear of losing her love.Thanatos - This postulated death drive allegedly compels humans to engage in riskyand self-destructive acts that could lead to their own death. Behaviours such as thrillseeking and aggression are viewed as actions which stem from this Thanatosinstinct. However, some scientists argue that there is little evidence that most peoplehave a specific drive toward self-destructionEros - also called libido, is the life instinct innate in all humans. It is the desire tocreate life and favours productivity and construction. In early psychoanalytic writings,instincts from the Eros were opposed by forces from the ego. But in laterpsychoanalytic theory, Eros is opposed by the destructive death instinct of ThanatosLibido - the instinct energy or force, contained in what Freud called the id, thelargely unconscious structure of the psyche.
    • Defensive MechanismsThe constant conflict of between Id, Ego and Superego produces anxiety. Tomanage this anxiety, the ego has defence mechanisms; Denial - Extreme form of self-protection where a person refuses to accept that a particular event has happened. eg a terminal cancer patient refusing to accept they are dying. - Survivor of long happy marriage may continue to act as through their husband/wife was still alive Repression - The Ego refuses to allow impulses from the ID to enter into conscious awareness. It does this to protect itself from traumatic experiences or painful experiences in childhood, eg abuse. - Threatening impulses are repressed into the unconscious – not disappeared but no longer known about. Regression -regressing back to earlier childhood behaviour - e.g. a child anxious mother will reject him once new baby bro/sis arrives can revert to tantrums, bed wetting, soiling etc Displacement - Redirecting unacceptable desires and impulses on to a relatively safe target – eghatred towards mother (unacceptable in society) is displaced on to a brother or sister. – egtaking out your anger on someone else e.g. shouting at the dog after having an argument with your mum. Projection - Attributing your own unacceptable desires and impulses onto someone else - i.e. accusing a friend of not liking you when you really don’t like them yourself. In other words, blaming someone else Sublimation - socially unacceptable impulses or idealizations are consciously transformed into socially acceptable actions or behaviour, possibly converting the initial impulse in the long term. Intellectualisation -reasoning is used to block confrontation with an unconscious conflict and its associated emotional stress, by using excessive and abstract ideation to avoid difficult feelings. It involves removing ones self, emotionally, from a stressful event. Reaction Formation -hiding real feelings by acting in the opposite way - e.g. talking loudly when nervousDefence mechanisms can lead to Mental Disorder. Unacceptable desires andimpulses, traumatic events, etc „managed‟ by defence mechanisms can; Re-emerge as symptoms of anxiety or other emotional disorders. Still affect behaviour, leading to distress as person doesn‟t understand why they‟re behaving as they are Be triggered by similar life event, leading them to re-experience original event leading to depression.The Psychodynamic Model assumes that experiences in our earlier years can affectour emotions, attitudes and behaviour in later years without us being aware that it ishappening. Freud suggested that abnormal behaviour is caused by unresolved
    • conflicts in the Unconscious. These conflicts create anxiety, and we use defencemechanisms such as repression and denial to protect our Ego against this anxiety.Psychosexual Stages Oral - The first stage of psychosexual development is the oral stage, spanning from birth until the age of two years, wherein the infants mouth is the focus of libidinal gratification derived from the pleasure of feeding at the mothers breast, and from the oral exploration of his or her environment, i.e. the tendency to place objects in the mouth - too much or too little gratification of desire might lead to an oral-stage fixation, characterised by passivity, gullibility, immaturity, unrealistic optimism Anal - The second stage of psychosexual development is the anal stage, spanning from the age of fifteen months to three years, wherein the infants erogenous zone changes from the mouth (the upper digestive tract) to the anus (the lower digestive tract), while the ego formation continues. Phallic - The third stage of psychosexual development is the phallic stage, spanning the ages of three to six years, wherein the childs genitalia are his or her primary erogenous zone. It is in this third infantile development stage that children become aware of their bodies, the bodies of other children, and the bodies of their parents; they gratify physical curiosity by undressing and exploring each other and their genitals, and so learn the physical (sexual) differences between "male" and "female" and the gender differences between "boy" and "girl". Latency -The fourth stage of psychosexual development is the latency stage that spans from the age of six years until puberty, wherein the child consolidates the character habits he or she developed in the three, earlier stages of psychological and sexual development. Genital -The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychological detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts.This part of Freudian theory is without doubt the most controversial. It is nottotally separate from the theory of personality because to some extent he isexplaining how the three parts of the personality develop in the way that they do.The theory is controversial from the onset seeing the infant as a sexual being .Bythis he means that the child has a desire for sensual pleasure from birth and thatthe child isn‟t divorced from its sexuality until it suddenly arrives in the adultbeing. Many people struggle to see children as sexual beings today so you canimagine the reception Freud got in Victorian times. Nevertheless this theory is acentral part of the psychodynamic perspective. By saying the child is a sexual
    • being he does not mean that the child desires sexual intercourse, just that thechild desires sensual pleasure and gratification of such desires.Freud says that these desires are focussed on certain erogenous zones atdifferent times in the child‟s psycho-sexual development. In each stage the childmust get enough gratification in order that they are ready to move on, but if theyget too much gratification this can cause problems. And so, too much or too littlegratification in a stage will cause problems of a fairly specific nature later on inlife. When a person gets stuck in a stage they are said to be fixated or arrestedin the stage of psycho-sexual development.Strengths One strength of the Psychodynamic Model is that it reminds us that experiences in childhood can affect us throughout our lives. It accepts that everybody can suffer mental conflicts and neuroses through no fault of their own. The model also suggests there is no need for medical intervention such as drugs, ECT or psychotherapy, and that the patient, with the help of a psychoanalyst, can find a cure through his own resources. (which empowers the individual & discourages helplessness)Weaknesses The main limitation of the Psychodynamic Model is that it cannot be scientifically observed or tested. Abstract concepts. Any evidence recovered from a patient must be analysed and interpreted by a therapist. This leaves open the possibility of serious misinterpretation or bias because two therapists may interpret the same evidence in entirely different ways. Psychoanalysis is time-consuming and expensive. It may not even work: in a comprehensive view of 7000 cases, Eysenck (1952) claimed that psychodynamic therapy does more harm than good. Sexist – unbalanced, Electra Complex for example not thorough / vague in detail. Reflective of Cultural bias of the time Freud worked (women were not considered as equal to men) There is no way of demonstrating if the Unconscious actually exists. There is no way of verifying if a repressed memory is a real or false memory unless independent evidence is available. In other words, most of the theory must be taken on faith.
    • The Cognitive Approach Abnormality is a result of faulty cognition (thinking) It‟s the way you think about the problem, rather than the problem itself, that is the cause of the disorder Mental disorders can be overcome by learning to use more appropriate ways of thinking The aim is to think positively and rationallyKey assumptions: Individuals who suffer from mental disorders have distorted and irrational thinking – which may cause maladaptive behaviour. It is the way you think about the problem rather than the problem itself which causes the mental disorder. Individuals can overcome mental disorders by learning to use more appropriate cognitions. Life events happen, and people in general will have an adaptive response to them. Beck’s Model of Depression (1979) ‘The Cognitive Triad’ Negative view of the self (I am incompetent and undeserving Depression Negative Negative view of the view of the future problems will world not disappear, it is a hostile there will always be emotional place pain
    • Beck built on the idea of maladaptive responses, and suggested that people withdepression become trapped in a cycle of negative thoughts Negative view of the self (I am incompetent and undeserving) Negative view of the world (it is a hostile place) Negative view of the future (problems will not disappear, there will always be emotional pain)Attributions are internal or external - the cause is seen as internal „it‟s my fault‟, ordue to external circumstances beyond their controlAttributions can be specific or global, i.e. The cause may be specific to aparticular event or apply to all eventsAttributions can be stable or unstable (the individual consistently makes the sametypes of attribution, or they can vary over time and situation)In depression attributions for negative events are internal, global and stable.Attributions for positive events are external, specific and unstable.Examples of Cognitive Biases that may be used by people with Depression Cognitive Bias Explanation Minimisation The bias towards minimising success in life The bias towards maximising the importance of Maximisation even trivial failures A bias towards focussing on only the negative Selective Abstraction aspects of life and ignoring the wider picture A tendency to see life in terms of black and white and ignoring the middle ground; you are All or Nothing Thinking a success or a failure, rather than not good at some things but ok at othersDistorted thinking when interpreting situations: eg attributing an excellent exam result to luck on the day. eg failing to complete a difficult suduko puzzle as a sign of general stupidity.
    • Example of Ellis’s ABC Model A: Activating Event Mary and her boyfriend split up. Rational Thoughts Mary tells herself that although it is a sad situation Irrational Thoughts they were not compatible B: Beliefs Mary tells herself that the and she may learn from the break up is her fault and experience (about A) that she is not loveable, and so will always fail at relationships Desirable Emotions Undesirable Mary feels sad, but is Emotions hopeful that she will have C: Consequences Mary feels guilty that she successful relationships in (of B) spoilt the relationship and the future that she is unlovable Undesirable Desirable Behaviour Behaviour Mary looks forward to forming new healthy Mary resolves not to form relationships and tries to new relationships as she learn from her experience will only fail and get hurt again. Cognitive Therapy Cognitive Behaviour Therapy (CBT) Aim – to challenge irrational and dysfunctional thought processesIt is a way of talking about: how you think about yourself, the world and other people how what you do affects your thoughts and feelings.CBT can help people to change how they think (Cognitive) and what they do(Behaviour). These changes can help them to feel better. It focuses on the hereand now problems and difficulties. Instead of focusing on the causes of distressor symptoms in the past, it looks for ways to improve the state of mind now. It hasbeen shown to help with many different types of problems. Anxiety, depression, panic, phobias, stress, bulimia, OCD, Post-Traumatic Stress Disorder, bipolar disorder and psychosis.
    • CBT can help to break the vicious circle of maladaptive thinking, feelings andbehaviour.When the parts of the sequence are clearly outlined and understood, they can bechanged.CBT aims to get the person to a point where they can „DIY, and work out theirown ways of tackling their problems. The Sessions Meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes. CBT is effective in reducing symptoms of depression and in preventing relapse (Kuyken et al, 2007) It is the most effective psychological treatment for moderate and severe depression. It is as effective as antidepressants for many types of depression (Fava et al, 1994). Keller et al (2000) Recovery rates (from depression) 55% drugs alone 52% CBT alone 85% when used together. Strengths Weaknesses  Client is actively involved in their  Clients can become dependant recovery on their therapist, or non-  CBT is not physically invasive cooperative  Client learns to help themselves,  CBT is not effective for people and can use the skills in new with rigid attitudes or resistance situations. to change,  CBT works (e.g. Kuyken, Fava)  or for people who have high  Particularly when combined with stress levels in response to drug treatment (Keller) genuinely difficult life circumstances (depressive realism)  CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages - but cannot do it for the client.
    • REBTThe task of the Rational-Emotive Therapist or CounselorThe amount of emotionaland often physical energy expended in clinging to irrationalassumptions canusually be put to more productive and happier use. Helping peopleto ridthemselves of their self-defeating philosophies and irrational assumptions isaprimary goal of the rational-emotive therapist or educator.Unlike other therapeutic techniques, the rational-emotive system does notfocusintensely on events of the past. Such a focus too often serves people aconvenientexcuse for continuing to blame others, especially parents, and thus topreserve self-defeating patterns. Rather, the rational-emotive therapist isconcerned with showingindividuals that they are maintaining the irrationalassumptions they hold, that theystill believe them, and they are currentlydisturbed by them. Because of its emphasison deep philosophic change andscientific thinking, the rational-emotive systemfocuses on the steps towardphilosophic change which can only take place ifindividuals are helped to observeexactly what they are telling themselves in thepresent and then encouraged tocontradict, re-think, challenge, and take positiveaction. Rational Emotive Behavior Therapy (REBT) is a form of psychotherapy created by Albert Ellis in the 1950s. REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc. The ABC ModelThe Three Basic „Musts‟ (Self-defeating Philosophies) I must do well and win the approval of others for my performances or else I am no good. anxiety, depression, shame, and guilt Other people must treat me considerately, fairly and kindly, and in exactly the way I want them to treat me. If they dont, they are no good and they deserve to be condemned and punished. rage, passive-aggression and acts of violence I must get what I want, when I want it; and I must not get what I dont want. Its terrible if I dont get what I want, and I cant stand it. self-pity and procrastinationDisputing is the D of the ABC ModelThe goal of REBT is to help people change their irrational beliefs into rationalbeliefs. Changing beliefs is the real work of therapy.Changing beliefs is the real work of therapy and is achieved by the therapistdisputing the clients irrational beliefs. For example, the therapist might ask, "Why
    • must you win everyones approval?" "Where is it written that other people musttreat you fairly?" "Just because you want something, why must you have it?"Disputing is the D of the ABC model. When the client tries to answer thetherapists questions, s/he sees that there is no reason why s/he absolutely musthave approval, fair treatment, or anything else that s/he wants.InsightAlbert Ellis and REBT contend that although we all think irrationally from time totime, we can work at eliminating the tendency. The only way to get better is towork hard at changing our beliefs. It takes practice, practice, practice.AcceptanceEmotionally healthy human beings develop an acceptance of reality, even whenreality is highly unfortunate and unpleasant. REBT therapists strive to help theirclients develop three types of acceptance and each of these types of acceptanceis based on three core beliefs:1)Unconditional self-acceptance: I am a fallible human being; I have my good points and my bad points. There is no reason why I must not have flaws. Despite my good points and my bad points, I am no more worthy and no less worthy than any other human being.2) Unconditional other-acceptance: Other people will treat me unfairly from time to time. There is no reason why they must treat me fairly. The people who treat me unfairly are no more worthy and no less worthy than any other human being.3) Unconditional life-acceptance: Life doesnt always work out the way that Id like it to. There is no reason why life must go the way I want it to Life is not necessarily pleasant but it is never awful and it is nearly always bearable.CHANGE VIEW – Ten key facts about CBTChange: your thoughts and actions View: events from another angleHomework: practice makes perfect I can do it: self-help approachAction: Don‟t just talk, do! Experience: test our your beliefsNeed: pinpoint the problem Write it down: to remember progressGoals: move towards themEvidence: shows CBT can work
    • The Behavioural Approach All behaviour is learned – including „abnormal‟ behaviour This learning can be understood in terms of conditioning and modelling What was learned can be unlearned, using the same principles The same „laws‟ apply to human and non-human animal behaviour Basic Philosophy: That which has been learned can be unlearned. Learning occurring through a process of classical or operant conditioning Classical conditioning is learning via association Operant conditioning is learning via reinforcement. Stimulus and responseOperant Conditioning Classical Conditioning Social LearningReward (positive Association Observation Role Modelreinforcement) Prior – US UR ImitationNegative reinforcement During – US + CS UR Reinforcement - VicariousPunishment After – CS CR Secondary Gain Social Learning theory; an extension of behaviourism, believes that we learn by modelling and coping the behaviours we witness around us. At birth we are born with a tabula rasa (like a blank sheet) and consequently all behaviour is learned in same way. For behaviourists Abnormal behaviour is the consequence of abnormal learning from the environment. There is no difference, in the learning, between normal and abnormal behaviours – they are learned in the same ways. This is by:- Classical conditioning, Operant conditioning &Social learning This is carried out via Stimulus and response training Behavioural Therapy Based on principles of Classical Conditioning CC involves automatic reflexive responses or feelings (UnConditionedResponse) Most common UCR to situations of danger is fear/anxiety Through association can lead to fear of specific thing/situation Anxiety disorder, e.g. phobia Aim of Behavioural Therapy is to remove the association between fear and the object/situation
    • Systematic Desensitisation (Wolfe, 1958)Functional analysis The therapist sits down with the client and they construct ahierarchy of fearful situations.This means coming up with a range of situations (e.g. looking at a picture of adog, having a dog in the same room, having a dog jump up at you) and arrangingthem in order from the least fearful to the most fearful.Relaxation trainingThe client is then trained in methods of relaxation. This mightinvolve releasing muscular tension, control of breathing and visualizationtechniques.Graduated exposureThe client is then brought gradually into contact with thephobic stimulus, following the hierarchy established with the therapist. At eachstage of exposure, the client uses the techniques they have learned to produce astate of relaxation. Only when full relaxation has been achieved does thetreatment move on to a more intense exposure. This can be done using a visualisation technique – imagining the fearful stimulus through the hierarchy, Or using real examples, eg starting with picture of spider, then toy spider and gradually handling real spiders.They can stop at any time and re-start at a lower level.Eventually they can cope with the most feared situation at the top of thehierarchy. Counter Conditioning replacing fear response with an alternative and harmless response. Functional analysis construct a hierarchy of fearful situations Relaxation training The client is then trained in methods of relaxation Graduated exposure The client is then brought gradually into contact with the phobic stimulus, following the hierarchy.FloodingAim: to remove the learned association between the stimulus and responseProcedure: Inescapable exposure to the feared object or situation Lasts until the fear response disappears. Assumes that very high levels of fear/anxiety cannot be sustained and will eventually fall.
    • The person is immersed in the fear reflex until the fear itself fades away. The keyis keeping the patients in the feared situation long enough that they can see thatnone of the dreaded consequences they fear actually come to pass.Pros: very fast (if it works)Cons: if session ends too soon and anxiety levels still high, it may have theopposite to intended effect, i.e. reinforces the phobia rather than extinguishing it.Highly threatening and stressful procedure. Ideally it should only be carried outbe trained therapists and with medical supervision available.Aversion TherapyPrevious two techniques focus on removal of an undesirable association.This one aims to create an undesirable association!The aim is to remove from the individual any undesirable habits by pairing themwith an unpleasant stimulus.Controversial history – used in the 50‟s to try and „cure‟ homosexuality by pairingelectric shocks with pictures of naked men. It was assumed that homosexualswould learn the association between the fear of the shock and the pictures. Itdidn‟t work, was unethical and scientifically unsound.Mainly used with addictions (e.g smoking or alcoholism).Usually a nausea inducing substance is paired with the alcohol (for example)which when paired sufficiently will leave the person wanting to avoid the smell ortaste of alcohol.Evaluation of Behavioural Therapies Focus on symptoms, not deeper underlying causes of behaviour. Systematic desensitisation can be extremely effective in treatment of simple phobias (60-90% success rate, Barlow et al, 2002) Ethical issues in flooding and aversion therapy. Intense fear and anxiety. Even systematic desensitisation causes client to visualise or experience feared situations. Needs careful monitoring to ensure no long term ill-effects. Ignores any genetic or biological factors in psychological disorders. Behaviour Modification Based on principles of Operant Conditioning. Attempt to change voluntary controlled behaviour, rather than reflexive behaviours involved in classical conditioning.
    • Token EconomyToken economy modifies behaviour, but doesn‟t address symptoms. E.g. in wardof schizophrenic patients, behaviour and management of patients may improve,but specific psychotic symptoms not being addressed.Clinical relevance: Eating disorders.Hospitalised patients - if they gain weight get rewards, e.g. have visitors, leavethe hospital. Of course, once they leave hospital they may revert to weight lossbehaviours.Increasing desired behaviour by positive reinforcement.Mostly used in institutions, e.g. psychiatric hospitals.Aim is to reduce levels of anti-social behaviour Tokens given as reward for improved behaviour. Tokens can be exchanged for sweets, cigarettes etc.Social Learning TheoryCognitive element (not just Stimulus Response)Observation, vicarious reinforcement etc play a role.Modelling the patient observes others (the “model(s)”) in the presence of the phobic stimulus who are responding with relaxation rather that fear to the phobic stimulus. In this way, the patient is encouraged to imitate the model(s) and thereby relieve their phobia.Evaluation of Behaviour Modification Token Economy can improve behaviour/reduce anti-social behaviour But, is this replicated once patient back in community? Reductionist approach to complex behaviour, seeing people as stimulus- response „machines‟. Social Learning Theory takes more complex view of human behaviour, including cognitive processes of observation and imitation. Ignores any genetic or biological factors in psychological disorders.
    • Treating Abnormality Biological TherapiesDrugsDrugs are often used in the treatment of psychological disorders. They are used todirectly treat the symptoms of a particular disorder. There are four main types ofdrugs used to treat mental illness; Anti-depressants, Anti-Anxiety drugs, Anti-Manicsand Anti-Psychotics.Anti-Depressants include Selective Serotonin Reuptake Inhibiters such as Prozac.They are most commonly used to treat depression. They are also used to treatagoraphobia and other social phobias. They work by raising the levels of serotonin inthe brain (as low levels of Serotonin have been linked with an increased likelihood ofdepression). In „normal‟ brains, Serotonin is constantly being released from nerveendings, stimulating the adjacent neurons. However, sometimes the mechanism failsand serotonin is reabsorbed into the nerve ending before it can stimulate theneighbouring neron. Prozac works by reducing the rate of re-absorption meaningthat serotonin levels don‟t drop and the patient‟s mood can remain constant. Prozacis usually taken over the course of weeks, months or even years and as well asbeing successful in treating depression it can also be used to treat obsessive-compulsive disorder. Side effects can include Nausea, Nervousness, Anxiety,Insomnia, Sexual Dysfunction and Suicidal Morbidity.Anti-Anxiety drugs include Benzodiazepines (BZ‟s). Often referred to as minortranquilisers, Benzodiazepines include Librium, Vallium and Diazepam. These drugsare used to treat a range of anxiety disorders, specific phobias, panic attacks andsleep disorders. They are also prescribed for extreme or prolonged stress. Gamma-Amino Butyric acid (GABA) is a neurotransmitter that is the body‟s natural form ofanxiety relief and has a general „quietening‟ effect on many of the neurons in thebrain. BZ‟s work by enhancing the activity of GABA, which reduces levels ofserotonin to reduce anxiety. They are sedatives and they act to decrease heart andrespiration rate and therefore reduce feelings of tension and nervousness. Theyhave a calming effect. Possible side effects are dependency, addiction, drowsiness,lethargy, and possible overdose.Strengths of drug treatments are that they are effective in the treatment of mentalillness (Kahn et al 1986) They may be useful in the short term for either acute illnessor to enable the patient to seek alternative therapy. Weaknesses are that drugs canhave harmful side effects, they treat the symptoms and not the cause of the problem,Anti-depressants are not useful when taken on a long term basis (NIMH 1987) andcontrolled studies suggest that the effectiveness of anti-depressants is no greaterthan psychotherapy and cognitive therapy (NIMH 1987).ECTElectro-Convulsive Therapy is a medical treatment used to treat drug resistantdepression. Is is used for severely depressed patients for whom medication and
    • psychotherapy have not worked. It is also used when there is a risk of suicidebecause it acts more quickly than anti-depressants. NICE (2003) suggested that itshould only be used when all other treatments have failed. It involves passing asmall electric current through the brain which causes the equivalent of a seizuresimilar to an epileptic seizure. The patient is given a general anaesthetic and musclerelaxant drugs so that they don‟t convulse or feel any pain during the procedure. Thepatient‟s brain is then „stimulated‟ by placing electrodes on their head. Bilateral ECTis when the electrodes are placed on both sides on their head. Unilateral ECT iswhen the electrodes are placed on one side of the head. The electrodes are placedon the non-dominant hemisphere, i.e. on the right hemisphere for right handedpeople. There are less memory problems reported after having unilateral ECT asopposed to Bilateral ECT. A small amount of electrical current of 70 – 150 volts isthen passed through the brain for 0.04 – 1 second. This produces a seizure withinthe brain which lasts up to a minute. This process is usually repeated approximately3 times per week for up to 4 weeks. There are many suggestions as to how ECTworks. The most plausible explanation is Biochemical Change – ECT produces avariety of biochemical changes which are greater than those produced by drugs. Ithas been suggested that ECT causes sensitivity to serotonin as well as an increasein the release of dopamine (Sasa 1999). Another theory is that electric shockproduces Brain Damage, causing memory loss and disorientation that creates atemporary illusion that any problems have gone. Abrams (1997) makes the criticismof ECT in that after 50 years of use and research, scientists are no closer tounderstanding how and why it works. Physiological side effects include impairedmemory, heart problems, headaches (Datto 2000), one third of patients complain ofpersistent memory loss after ECT (Rose et al 2003) Brain examination techniqueshave shown there is a general slowing of the brain following ECT which may takeweeks to disappear (Weiner 1980). Psychological side effects are that 30% ofpatients who had ECT in the previous 2 years reported that they now havepermanent fear and anxiety (Department of Health 1999). As time has passed, ECThas been the subject or much controversy and is now recommended only for themost severe forms of depression. Taylor and Carroll (1987) found that in many casesof severe depression that have been resistant to other therapies, ECT can beeffective.Strengths of ECT are that it can be effective (specifically for treating people withsevere depression and in particular, people who are at risk of suicide), Variousstudies show that 60 – 70% of patients improve with ECT and therefore it doesappear to work for some people (Comer 2002), Mukherjee et al (1994) found ECTeffective in 80% of cases of acute mania where people had not responded tomedication. Weaknesses include the ethical issues – ECT can be given underSection 3 of the 1983 Mental Health Act, without the person‟s consent. It can causeextremely negative side effects and it is still unknown how it works (Abrams 1997)
    • Psychological TherapiesCognitive Behavioural TherapyCBT is a way of talking about how you think about yourself, the world and otherpeople and how what you do affects your thoughts and feelings. It can help peopleto change how they think (Cognitive) and what they do (Behaviour). Thesechanges can help them to feel better. It focuses on the here and now problems anddifficulties. Instead of focusing on the causes of distress or symptoms in the past, itlooks for ways to improve the state of mind now. CBT has been shown to help withmany different types of problems; Anxiety, depression, panic, phobias, stress,bulimia, OCD, Post-Traumatic Stress Disorder, bipolar disorder and psychosis. CBTcan help to break the vicious circle of maladaptive thinking, feelings and behaviour.When the parts of the sequence are clearly outlined and understood, they can bechanged. CBT aims to get the person to a point where they can „DIY, and work outtheir own ways of tackling their problems. CBT is effective in reducing symptoms ofdepression and in preventing relapse (Kuyken et al, 2007) It is the most effectivepsychological treatment for moderate and severe depression. It is as effective asantidepressants for many types of depression (Fava et al, 1994). Keller et al (2000)looked at the recovery rates from depression and found a success rate of 55% usingjust drugs, 52% using just CBT but 85% when used together.The strengths of CBT are; Client is actively involved in their recovery, CBT is notphysically invasive, Client learns to help themselves, and can use the skills in newsituations, CBT works (e.g. Kuyken, Fava) Particularly when combined with drugtreatment (Keller) The weaknesses are; Clients can become dependent on theirtherapist, or non-cooperative, CBT is not effective for people with rigid attitudes orresistance to change, or for people who have high stress levels in response togenuinely difficult life circumstances (depressive realism) and it is not a quick fix. Atherapist is like a personal trainer that advises and encourages - but cannot do it forthe client.Systematic de-sensitisationSystematic desensitisation (SD) was first developed by Wolpe (1958) and is used inthe treatment of phobias. Often when people have phobias, they will avoid the thingthat they are scared of. For example, someone with a phobia of dogs may cross theroad every time they see a dog, therefore receiving negative reinforcement which willmaintain the phobia. However, if a person is exposed to the thing that they arescared of, they may learn that the thing is not so fearful after all, and over time thephobia will be unlearned. While forcing someone into a inescapable situation wherethey have to face their fears, such as locking a dog phobic in a room full of dogs untilthey stop being scared (this therapy is known as flooding) can be effective, SDintroduces the feared stimulus to the person gradually, and so could be seen to bemore ethical and less stressful. This therapy aims to extinguish a phobia byeradicating an undesirable behaviour (fear) and replacing it with a more desirable
    • one (relaxation). The behaviourist approach assumes that all behaviour is learnedfrom the environment. Therefore, we can unlearn conditioned responses bymanipulating the environment. The process of SD has a number of stages. (1) Thesubject is given training in deep muscle relaxation techniques. (2) The therapist andthe client work together to construct a hierarchy of fear. This is a series of imaginedscenes, each one causing a little more anxiety than the previous one. For example,a hierarchy of fear for a phobia of spiders might look like this: Think about spider,See the word “spider”, See picture of spider, Be in same room as spider in glasstank, Sit next to glass tank with the lid closed, Sit next to glass tank with the lidopen, Put hand in tank, Hold spider in hands. (3) The patient gradually works his/herway through the hierarchy, starting with the least fearful stimuli. They visualise eachanxiety provoking situation while utilising the relaxation techniques. Due to reciprocalinhibition, they should after a while be able to visualise the stressful situation whileremaining relaxed. This event no longer causes them stress. (4) The client thenmoves on to the next step in the hierarchy, again remaining relaxed while theyvisualise the stressful situation. Once this is mastered they move on again and soon. The therapy moves at the pace decided by the client. If they feel that they areunable to proceed, they can move back a stage until they feel more confident. (5)Eventually, the client will reach the top of the hierarchy, and will have mastered thefearful situation which caused them to seek help in the first place. There are twosubtypes of SD. In vivo desensitisation is when the client has to relax while directlyexperiencing the feared stimuli; for example, they have to relax while a real dog is inthe room. In vitro desensitisation is when the client has to visualise the fearedstimuli; for example by imagining that a dog is in the room. Research has found thatin vivo techniques are more successful than in vitro (Menzies and Clarke 1993).However, there may be practical reasons why in vitro may be used.The strengths of SD include that it can be effective for specific phobias (Barlow et al2002), it is the most effective treatment for animal phobias (Rachman and Wilson1980), Capafons et al (1998) successfully treated 20 patients with SD for a fear offlying, Albaucher et al (1998) found 60 – 90% of adults improve considerably,McGrath (1990) found that SD is successful for a wide range of anxiety disorders,with 75% of patients with phobias responding to treatment. The weaknesses includethat it is not effective for complex anxieties (Ohman et al 1975), Spontaneousrecovery from phobia has been found to be as high as 50 – 60% so SD may actuallycontribute very little (McMorran et al 2001), Sue et al (1990) found only a 50%success rate for OCD and there are ethical issues with this treatment.PsychoanalysisThis therapy aims to uncover repressed memories to help the client come to anunderstanding of the origins of their problems. Traditional psychoanalysis involvesseveral sessions a week over a period of several years. Psychoanalysis is expensiveand not offered on the NHS. There are several techniques available:
    • Free Association - The client is encouraged to express anything that comes into theirmind. Each situation they mention may, through free association, lead to other ideasand thoughts and memories perhaps extending back to childhood. The client mustnot censor the material at all, and in this freewheeling way the ego defences may belowered and repressed material accessed. The role of the therapist is to interveneoccasionally, perhaps to encourage some reflection on a particular experience. Thetherapist will also identify key themes and associations throughout the process.Word Association – The client is read a list of words one at a time and asked to replywith whatever comes instantly to mind. The analyst pays particular attention tounusual responses, hesitation and mental blanks, which may indicate that repressionhas taken place in the past.Dream analysis - Freud referred to dreams as the „royal road to the unconscious‟. Hefelt that during dreams the normal barriers to unconscious material were lifted andthe symbolic imagery of dreams was a reflection of this. Therefore by analysing thecontent of dreams the therapist might be able to identify significant conflictsrepressed into the unconscious. For Freud, dreams were essentially wish fulfilment,but wishes from the id that were too threatening to be consciously acknowledged.They were therefore distorted and reflected in the imagery of the dream. In order tounderstand the underlying meaning, Freud made assumptions: Dreams have anobvious content that the client can recall. This is manifest content. Beneath thismanifest content lies the actual meaning of the dream that could only be revealedthrough the therapists interpretation, Freud referred to this as latent content. Thedream work was the process by which the latent content was distorted into themanifest content. The therapist‟s role is to use this understanding of how the dreamwork operates to interpret the symbolism of the dream. After putting together thethemes that gradually emerge through the continuing processes of free associationand dream analysis, regular anxieties and conflicts emerge for the therapist tointerpret. The client can then work through these issues with the therapist, identifyingand hopefully resolving the source of their current anxieties.Projective tests - Shown shapes and ink blot tests (Rorschah ink blot test) and theclient must interpret this image. They are asked what the shape means to them.Anxieties may then emerge from this image.Strengths of Psychoanalysis include that it can be effective for some patients (Bergin1971), Smith et al (1980) conducted a meta-analysis of 475 case studies and foundthat psychoanalysis was effective, but not as effective as CBT. Weaknesses includethat it is too deterministic (abnormality is caused through our early childhoodexperiences), it is difficult to scientifically validate Freud‟s theory of psychoanalysis,as most of the concepts are not measurable. There is mixed support for theeffectiveness of Psychoanalytic therapy – some research shows that it is no moreeffective than leaving patients to recover on their own (Eysenck 1952). Ethical issues– control of the psychotherapist over the patient and the possibility of planting falsememories (Loftus 1975).