Theoretical Perspectives

By WHITBOURNE, S.K., Halgin, R.P

Edited by Paul Ducham

THEORETICAL PERSPECTIVES IN ABNORMAL PSYCHOLOGY

Underlying theoretical perspectives, orientations to understanding the causes of human behavior and the treatment of abnormality all guide research and clinical work in abnormal psychology.  The article discusses major theoretical perspectives and how the perspectives apply to specific disorders. To facilitate your understanding of these perspectives, we will use Meera’s case as an example to show how clinicians working within each perspective would address her treatment. Although Meera’s plan calls for treatment within the cognitive behavioral perspective, her case has many facets that each of the major theories do address. These warrant discussion.

BIOLOGICAL PERSPECTIVE: THEORIES

The transmission of information throughout the nervous system takes place at synapses, or points of communication between neurons. Electrical signals containing information transmit chemically across the synapse from one neuron to the next. Through this transmission, neurons form complex pathways along which information travels from one part of the nervous system to another. Neurotransmitters are the chemical messengers that travel across the synapse, allowing neurons to communicate with their neighbors. Table 4.1 shows the proposed role of several major neurotransmitters in psychological disorders.
      Apart from disturbances in neurotransmitters, abnormalities in the brain structures themselves can also cause psychological symptoms. Although it’s not always possible to link brain structures that are too large or too small to behavioral impairments, researchers believe that some disturbances in behavior have a connection to abnormally developed or functioning brain structures. Because we cannot directly observe brain structures, researchers have developed sophisticated brain scanning methods to allow them to measure how an individual’s brain is structured and, more importantly, how it performs while it is processing information.
The causes of nervous system dysfunction range from genetic abnormalities to brain damage. Genetic abnormalities can come about through the inheritance of particular combinations of genes, to faulty copying when cells reproduce, or to mutations that a person acquires over the course of life. Cells do possess the ability to repair many of these mutations. If these repair mechanisms fail, however, the mutation can pass along to the altered cell’s future copies.
           Genes contain the instructions for forming proteins, which, in turn, determine how the cell performs. In the case of neurons, genes control the manufacturing of neurotransmitters, as well as the way the neurotransmitters behave in the synapse. Genes also determine, in part, how the brain’s structures develop throughout life. Any factor that can alter the genetic code can also alter how these structures perform.
           Inherited disorders come about when the genes from each parent combine in such a way that the ordinary functioning of a cell is compromised. Your genotype is your genetic makeup, which contains the form of each gene that you inherit, called an allele. Let’s say that Allele A causes a protein to form that leads a neuron to form abnormally. Allele B causes the neuron to be entirely healthy. If you have inherited two genes containing Allele B, then you have no chance of developing that disease. If, on the other hand, you have inherited two genes containing Allele A, you will almost certainly get the disease. If you inherit one Allele A and one Allele B, the situation becomes more complicated. Whether or not you get the disease depends on whether Allele A is “dominant,” meaning that its instructions to code the harmful protein will almost certainly prevail over those of Allele B. If Allele A is “recessive,” then it alone cannot cause the harmful protein to form. However, because you are an AB combination, you are a carrier because should you produce a child with another AB carrier, that child could receive the two AAs, and therefore develop the disorder (Figure 4.1).

           The dominant-recessive gene inheritance model rarely, if at all, can account for the genetic inheritance of psychological disorders. In some cases, inherited disorders come about through maternal linkages only, meaning that they transmit only through the mother. These disorders occur with defects in the mitochondrial DNA, which is the DNA that controls protein formation in the cell’s mitrochondria (energy-producing structures). Many psychological disorders reflect a polygenic model involving the joint impact of multiple gene combinations.
           To complicate matters further, not only are multiple genes involved in the development of psychological disorders, but the environment plays an important role in contributing to the way our behavior reflects our genetic inheritance. Your phenotype is the observed and measurable characteristic that results from the combination of environmental and genetic influences. Some phenotypes are relatively close to their genotype. For example, your eye color does not reflect environmental influences. Complex organs such as the brain, however, often show a wide disparity between the genotype and phenotype because the environment to which people are exposed heavily influences brain development throughout life. Moreover, there are numerous genes that participate in building the structures in the brain and influencing their changes over time. The study of epigenetics attempts to identify the ways that the environment influences genes to produce phenotypes.
        Reflecting the complexity of the brain’s structures and functions, leading researchers in schizophrenia (Gottesman & Shields, 1972; Gottesman & Shields, 1973) proposed the use of the term “endophenotypes” to characterize the combination of genetic and environmental contributors to complex behaviors. An endophenotype is an internal phenotype, that is, a characteristic that is not outwardly observable. In the case of schizophrenia, for example, there are several possible endophenotypes that may underlie the disease’s outwardly observed symptoms. These include abnormalities in memory, sensory processes, and particular types of nervous system cells. The assumption is that these unobservable characteristics, which heredity and the environment influence, are responsible for the disease’s behavioral expressions. The concept of endophenotypes was probably decades ahead of its time, because in the 1970s, researchers were limited in what they could study both in terms of genetics and the brain. With the development of sophisticated DNA testing and brain imaging methods, the concept is seeing a resurgence (Gottesman & Gould, 2003).
         The relationships between genetic and environmental influences fall into two categories: gene-environment correlations and interactions between genes and the environment (Lau & Eley, 2010). Gene-environment correlations exist when people with a certain genetic predisposition are distributed unequally in particular environments (Scarr & McCartney, 1983). These correlations can come about in three ways. The first way is through passive exposure. Children with certain genetic predispositions can be exposed to environments that their parents create based on their genetic predispositions. For example, a child of two athletically gifted parents who participate in sports inherits genes that give this child athletic prowess. Because the parents themselves are involved in athletic activities, they have created an environment that fosters the child’s own athletic development. This elicits the second gene-environment interaction and can occur when the parents treat the children with certain genetic predispositions in particular ways because their abilities bring out particular responses. Returning to our example, the school coach may recruit the athletically gifted child for sports teams starting in early life, leading the child to become even more athletically talented. We call the third geneenvironment correlation “niche picking.” The athletically gifted child may not wait for recruitment, but instead seeks out opportunities to play sports, and in this process becomes even more talented. In terms of the development of psychological disorders, any three of these situations can occur, heightening the risk that children of parents with genetic predispositions are more likely to develop the disorder because of the environment’s enhancing effect.
              Gene-environment interactions occur when one factor influences the expression of the other. In the case of people with major depressive disorder, for example, researchers have found that people with high genetic risk are more likely to show depressive symptoms when placed under high stress than are people with low genetic risk. Thus, the same stress has different effects on people with different genetic predispositions. Conversely, the genetic risk of people exposed to higher stress levels becomes higher than that of people who live in low-stress environments. In other words, a person may have a latent genetic predisposition or vulnerability that only manifests itself when that individual comes under environmental stress. In these studies, the researchers defined genetic risk in terms of whether or not an individual had a close relative with disorder symptoms. The genetic risk presence did not predict whether or not the person developed major depressive disorder unless that individual was exposed to a high-stress environment (Lau & Eley, 2010).
        Researchers studying psychopathology have long been aware of the joint contributions of genes and the environment to the development of psychological disorders. The diathesis-stress model proposed that people are born with a diathesis (genetic predisposition) or acquire vulnerability early in life due to formative events such as traumas, diseases, birth complications, or harsh family environments (Zubin & Spring, 1977). This vulnerability then places these individuals at risk for the development of a psychological disorder as they grow older (Johnson, Cohen, Kasen, Smailes, & Brook, 2001).
         With advances in genetic science, researchers are now much better able to understand the precise ways in which genes and environmental factors interact. Usually, people inherit two copies of a gene, one from each parent, and both copies actively shape the individual’s development. However, certain genes regulate through a process known as epigenesis, meaning that the environment causes them to turn “off ” or “on.” If the remaining working gene is deleted or severely mutated, then a person can develop an illness. The process of DNA methylation can turn off a gene as a chemical group, methyl, attaches itself to the gene (Figure 4.2) (http://www.nature.com/scitable/topicpage/ the-role-of-methylation-in-gene-expression-1070).
        Through the epigenetic processes of DNA methylation, maternal care, for example, can change gene expression. One study showed that during pregnancy, a mother’s exposure to environmental toxins caused DNA methylation in her unborn child (Furness, Dekker, & Roberts, 2011). Studies on laboratory animals also show that stress can affect DNA in specific ways that alter brain development (Mychasiuk, Ilnytskyy, Kovalchuk, Kolb, & Gibb, 2011). Researchers believe that certain drugs that the mother uses during pregnancy cause DNA methylation, including nicotine, alcohol, and cocaine.
        To understand the contributions of genetics to psychological disorders, researchers use three methods: family inheritance studies, DNA linkage studies, and genomics combined with brain scan technology. In family inheritance studies, researchers compare the disorder rates across relatives who have varying degrees of genetic relatedness. These studies examine disorder rates in different pairs of genetically related individuals. The highest degree of genetic relatedness is between identical or monozygotic (MZ) twins, who share 100 percent of their genotype. Dizygotic (DZ) or fraternal twins share, on the average, 50 percent of their genomes, but both types of twins share the same familial environment. Therefore, although MZ-DZ twin comparisons are useful, they do not allow researchers to rule out the impact of the environment. Similarly, studies of parents and children are confounded by the fact that the parents create the environment in which their children are raised. In order to separate the potential impact of the environment in studies comparing MZ and DZ twins, researchers turned long ago to adoption studies in which different families raised MZ twins, and therefore the twins experienced diff erent environments.
         For decades, family and twin studies were the only methods researchers had at their disposal to quantify the extent of genetic influences on psychological disorders. With the advent of genetic testing, however, researchers became able to examine specific genetic contributions to a variety of traits, including both physical and psychological disorders.
         In a genome-wide linkage study, researchers study the families of people with specific psychological traits disorders. The principle behind a linkage study is that characteristics near to each other on a particular gene are more likely inherited together. With refined genetic testing methods available, researchers can now carry this task out with far greater precision than was true in the past.
       Although useful, linkage studies have limitations primarily because they require the study of large numbers of family members and may produce only limited findings. In genome-wide association studies (GWAS), researchers scan the entire genome of individuals who are not related to find the associated genetic variations with a particular disease. They are looking for a single nucleotide polymorphism (SNP) (pronounced “snip”), which is a small genetic variation that can occur in a person’s DNA sequence. Four nucleotide letters—adenine, guanine, thymine, and cytosine (A, G, T, C)—specify the genetic code. A SNP variation occurs when a single nucleotide, such as an A, replaces one of the other three. For example, a SNP is the alteration of the DNA segment AAGGTTA to ATGGTTA, in which a “T” replaces the second “A” in the first snippet (Figure 4.3). With high-tech genetic testing methods now more readily available, researchers are much better able to find SNPs that occur with particular traits (or diseases) across large numbers of people. Although many SNPs do not produce physical changes in people, researchers believe that other SNPs may predispose people to disease and even influence their response to drug regimens.
        Imaging genomics increasingly augment genetic studies. Researchers can combine linkage or association methods with imaging tools to examine connections between gene variants and activation patterns in the brain.

Table 4.1

Figure 4.1

Figure 4.2

Figure 4.3

BIOLOGICAL PERSPECTIVE: TREATMENT

At the present time, biologically based treatment cannot address the disorder’s cause in terms of fixing genetic problems. Instead, biological therapies either involve medications, surgery, or other direct treatment forms on the brain.
          Psychotherapeutic medications are intended to reduce the individual’s symptoms by altering the levels of neurotransmitters that researchers believe are involved in the disorder medication gained widespread acceptance in the 1960s, and led the way toward the development of a wider range of psychotherapeutic agents.
         Currently, the major categories of psychotherapeutic agents include antipsychotics, antidepressants, mood stabilizers, anticonvulsants, anti-anxiety medications, and stimulants (Table 4.2). As you can see from this table, some medication categories that pharmaceutical companies have designed to treat one disorder, such as antidepressants, also serve to treat other disorders, such as anxiety disorders. That clinicians use the same medications to treat different disorders suggests that abnormalities involving similar neurotransmitter actions may mediate these disorders.
         Each of these medications can have serious side effects, leading patients experiencing these so-called adverse drug reactions to discontinue their use and try a different medication, perhaps from a different category. The Federal Drug Administration maintains a watch list of side effects with monthly updates (http://www.fda.gov/Safety/MedWatch/ default.htm) and patients can sign up for a monthly newsletter by following a link on this website.
        Biological treatments also include a second major category of interventions. Psychosurgery, or psychiatric neurosurgery, is a treatment in which a neurosurgeon operates use of psychosurgery was a prefrontal lobotomy, which the Portuguese neurosurgeon Egas Moniz developed in 1935. By severing the prefrontal lobes from the rest of the brain, Moniz found that he was able to reduce the patient’s symptoms. Unfortunately, the procedure also caused severe changes in the patient’s personality, including loss of motivation. The medical field considered the technique a major breakthrough at the time, leading Moniz to be honored with a Nobel Prize in 1949. In the 1960s, when psychotherapeutic medications became available, psychiatrists had an alternative to prefrontal lobotomies, allowing them to reduce a patient’s symptoms without resorting to this extreme measure.
        Modern psychosurgery relies on targeted interventions designed to reduce symptoms in patients who have proven otherwise unresponsive to less radical treatment (Figure 4.4). Each of these psychiatric neurosurgery forms targets a specific region of the brain that researchers believe are involved as a cause of symptoms. With higher levels of precision that reflect advances in surgical techniques, neurosurgeons can produce a lesion in a specific brain region to provide symptom relief. For individuals with severe obsessive-compulsive or major depressive disorder, the lesions target the cortex, striatum, and thalamus. Deep brain stimulation (DBS), also called neuromodulation, is another form of psychiatric neurosurgery in which permanently implanted electrodes trigger responses in specific brain circuits, as needed (Shah, Pesiridou, Baltuch, Malone, & O’Reardon, 2008).
        In electroconvulsive therapy (ECT), attached electrodes across the head produce an electric shock that produces brief seizures. Ugo Cerletti, an Italian neurologist seeking a treatment for epilepsy, developed this method in 1937. ECT became increasingly popular in the 1940s and 1950s, but, as the movie One Flew over the Cuckoo’s Nest depicts, staff in psychiatric hospitals also misused it as a way to restrain violent patients. Even though ECT had largely fallen into disuse by the mid-1970s, psychiatrists continued to use it to treat a narrow range of disorders. A comprehensive review of controlled studies using ECT for treatment of major depressive disorder showed that, in the short-term, ECT was more eff ective than medications in producing rapid improvement of symptoms. However, there are long-term ECT consequences including memory impairment (UK ECT Review Group, 2003).

Table 4.2

Figure 4.4

 

TRAIT THEORY

As much a theory about normal personality functioning as about psychological disorders, the trait theory approach proposes that abnormality occurs when the individual has maladaptive personality traits. Some assessment methods are focused on measuring the qualities of personality, which we think of as stable, enduring dispositions that persist over time. For many personality trait theorists, these components of psychological functioning are long-standing qualities that are potentially biologically inherited.
        It is easy for most people to relate to trait theory because it fits so closely with the use of the term “personality” in everyday life. When you think about how to describe the personality of someone you know, you will likely come up with a list of qualities that seem to fit the person’s observable behavior. These characteristics typically take the form of adjectives such as “friendly,” or “calm,” or perhaps, “anxious” and “shy.” Trait theories of personality propose that adjectives such as these capture the essence of the individual’s psychological makeup. The fact that people use these adjectives in everyday life to describe themselves and others agrees with the basic principle of trait theory—namely, that personality is equivalent to a set of stable characteristic attributes.
      The predominant trait theory in the field of abnormal psychology is the Five Factor Model, also called the “Big Five” (Figure 4.5) (McCrae & Costa, 1987). According to this theory, each of the basic five dispositions has six facets, which leads to a total of 30 personality components. The Five Factor Model includes the personality traits of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (conveniently, they spell out “OCEAN” or “CANOE”). A complete characterization of an individual on the five factors involves providing scores or ratings on each facet.
        According to trait theory, where they fall on the 30 facets strongly influences the shape of people’s lives. People high on the traits that define the less psychologically healthy end of each continuum may be more likely to experience negative life events because their personalities make them more vulnerable to life stresses. People high on personality traits representing riskiness (thrill-seeking) are more likely to get hurt because their personalities lead them into situations that can land them in trouble. According to the Five Factor Model, although circumstances can change personality, it’s more likely that personality molds circumstances.
       However, according to research using highly sophisticated data analytic designs to follow up on people over time, people can change even their fundamental personality traits. Most of the research is based on samples whose scores fall within the normal range of functioning. For example, as people get older, they are less likely to act impulsively (Terracciano, McCrae, Brant, & Costa, 2005).
       The main value of understanding personality trait theory is that it provides a perspective for examining personality disorders. Research based on the Five Factor Model became the basis for the current attempts to reformulate the personality disorders in the DSM-5. Although the Five Factor Model does not necessarily provide a framework for psychotherapy, it has proven valuable as a basis for personality assessment within the context of understanding an individual’s characteristic behavior patterns (Bastiaansen, Rossi, Schotte, & De Fruyt, 2011).

Figure 4.5

PSYCHODYNAMIC PERSPECTIVE: FREUD’S THEORY

Emerging out of his interest in the cause of unusual symptoms in his patients, in the late 1800s, Sigmund Freud began to explore the idea that man could scientifically study and explain the causes of and symptoms of psychological disorders. By the time of his death in 1939, Freud had articulated a vision for psychological disorder cause and treatment with the basic tenet that most symptoms had roots buried deep within an individual’s past.
       According to Freud (1923), the mind has three structures: the id, the ego, and the superego. The id is the structure of personality hidden in the unconscious that contains instincts oriented toward fulfilling basic biological drives, including gratification of sexual and aggressive needs. The id follows the pleasure principle, a motivating force that seeks immediate and total gratification of sensual needs and desires. According to Freud, we can only obtain pleasure when the tension of an unmet drive reduces. The way the id attempts to achieve pleasure is not necessarily through the actual gratification of a need with tangible rewards. Instead, the id uses wish fulfillment to achieve its goals. Through wish fulfillment, the id conjures an image of whatever will satisfy the needs of the moment. We call the id’s primal instincts the libido. The center of conscious awareness in personality is the ego, which gives the individual the cognitive powers of judgment, memory, perception, and decision making. Freud (1911) described the ego as being governed by the reality principle, meaning that the ego uses rationality to achieve its goals. In contrast to the id’s illogical primary process thinking, secondary process thinking, logical analytic approaches to problem solving, characterize the ego functions. The third part of the equation in psychodynamic theory is the superego, which is personality’s seat of morality. The superego includes the conscience (sense of right and wrong), and the ego ideal, or aspirations.
          According to Freud (1923), in a healthy individual’s personality, the id achieves instinctual desires through the ego’s ability to navigate in the external world within the confines that the superego places on it. Psychodynamics, or the interplay among the structures of the mind, is thus the basis for both normal and abnormal psychological functioning.
          Freud believed that people need protection from knowing about their own unconscious desires. They do so by using defense mechanisms (Table 4.3). According to Freud, everyone uses defense mechanisms on an ongoing basis to prevent recognizing the existence of these desires. Although everyone uses defense mechanisms to some extent, they become problematic when an individual fails to come to terms completely with his or her true unconscious nature.
         The topic of development forms an important piece of Freud’s theory. In 1905, he proposed that there is a normal sequence of development through a series of what he called psychosexual stages. Freud claimed that children go through these stages in accordance with the development of their libido. At each stage, the libido becomes fixated on a particular “erogenous” or sexually excitable zone of the body. According to Freud, an individual may regress to behavior appropriate to an earlier stage or may become stuck, or fixated, at that stage. For example, the so-called “anal retentive” personality is overly rigid, controlled, and perfectionistic. Freud believed that the adult personality reflects the way in which the individual resolves the psychosexual stages in early life, though some reworking may occur at least up through middle adulthood. Freud also believed that the child’s feelings toward the opposite-sex parent set the stage for later psychological adjustment. The outcome of what he called the “Oedipus Complex” (named aft er a tragic character in ancient Greece), determined whether the individual has a healthy ego or would spend a life marred by anxiety and repressed conflictual feelings.

Table 4.3

PSYCHODYNAMIC PERSPECTIVE: POST-FREUDIAN PSYCHODYNAMIC VIEWS

Freud developed his theory in the context of his clinical practice, but he also encouraged like-minded neurologists and psychiatrists to work together to develop a new theory of abnormality. Over a period of years, they spent many hours comparing notes about their clinical cases and trying to come to a joint understanding of the cause of abnormality. Although they shared many of the same views when they began their discussions, several went on to develop their own unique brand of psychodynamic theory and now have their own schools of thought.
       The most notable departure from Freud’s school of thought came when Swiss psychiatrist Carl Jung (1875–1961) revamped the definition of the unconscious. According to Jung (1961), the unconscious is formed at its very root around a set of images common to all human experience, which he called archetypes. Jung believed that people respond to events in their daily lives on the basis of these archetypes, because they are part of our genetic makeup. For example, Jung asserted that archetypal characters (such as today’s Batman and Superman) are popular because they activate the “hero” archetype. In addition, Jung (1916) believed that abnormality resulted from an imbalance within the mind, especially when people fail to pay proper attention to their unconscious needs.
       For Alfred Adler (1870–1937) and Karen Horney (1885–1952), the ego was the most important aspect of personality. Although their theories represented distinct contributions, and each associated with it a particular type of therapy, they both gave great emphasis to the role of a healthy self-concept in normal psychological functioning. Adler talked about the negative consequences of an “inferiority complex,” and Horney proposed that unhappiness comes from trying to live up to a false self. Both Adler and Horney also emphasized social concerns and interpersonal relations in the development of personality. They saw close relationships with family and friends and an interest in the life of the community as gratifying in their own right, not because a sexual or an aggressive desire is indirectly satisfied in the process (as Freud might say).
      Perhaps the only psychodynamic theorist to give attention to the whole of life, not just childhood, was Erik Erikson (1902–1994). Like Adler and Horney, Erikson gave greatest attention to the ego, or what he called “ego identity.” For this reason, we refer to the theories of Adler, Horney, and Erikson as the ego psychology group. In fact, we associate Erikson with the term “identity crisis,” a task that he believed was central to development in adolescence. Erikson believed that the ego goes through a series of transformations throughout life in which a new strength or ability can mature. He also believed that each stage builds on the one that precedes it, and in turn, influences all following stages. However, Erikson proposed that any stage could become a major focus at any age—identity issues can resurface at any point in adulthood, even aft er a person’s identity is relatively set. For example, a middle-aged woman who is laid off from her job may once again question her occupational identity as she seeks to find a new position for herself in the workforce.
      Yet another group of psychodynamically oriented theorists focused on what became object relations, namely, the relationships that people have with the others (“objects”) in their lives. In particular, the object relations theorists believed that the individual’s relationship with the caregiver (usually the mother) becomes a model for all close adult relationships. These theorists included John Bowlby (1907–1990), Melanie Klein (1882– 1960), D. W. Winnicott (1896–1971), Heinz Kohut (1913–1981), and Margaret Mahler (1897–1995). As with the ego psychologists, the object relations theorists each have a particular model of therapy that we associate with their theories. However, they all agree that early childhood relationships are at the root of abnormality.
      The work of object relations theorists led to the development of what is now a widely recognized framework for understanding adult personality, particularly as applied to romantic relationships. Canadian psychologist Mary Salter Ainsworth (1913–1999) and her associates (1978) studied diff erences among infants in attachment style, or the way of relating to a caregiver figure. She developed the “strange situation,” an experimental setting in which researchers separated infants from and then reunited them with their mothers.
          Although designed as a theory of child development, later researchers have adapted the concept of attachment style to apply to adult romantic relationships. Most children develop secure attachment styles, and later in life relate to their close romantic partners without undue anxiety about whether or not their partners will care about them. Those who are insecurely attached in childhood, however, may show a pattern in adulthood of anxious attachment in which they feel they cannot rely on their partner’s love and support. Alternatively, insecurely attached adults may show a dismissive or avoidant attachment style in which they fear rejection from others, and therefore try to protect themselves by remaining distant.
          An individual’s attachment style may also influence how he or she responds to psychotherapy. Across 19 separate studies involving nearly 1,500 clients, researchers found that attachment security was positively related to therapy outcome. Individuals with a secure attachment style, these researchers maintain, are better able establish a positive working relationship with their therapists, which, in turn, predicts positive therapy outcomes (Levy, Ellison, Scott, & Bernecker, 2011).

PSYCHODYNAMIC PERSPECTIVE: TREATMENT

The main goal of traditional psychoanalytic treatment as developed by Freud (1913– 14/1963) was to bring repressed, unconscious material into conscious awareness. To accomplish this task, he developed the therapeutic method of free association, in which the client literally says whatever comes to mind. Freud believed that clients needed to work through their unconscious conflicts, bringing them gradually into conscious awareness.
         Current psychodynamic treatment is focused on helping clients explore aspects of the self that are “unconscious” in the sense that the client does not recognize them. Therapists focus in particular on how clients reveal and influence these aspects of the self in their relationship with the therapist. The key elements of psychodynamic therapy involve exploring the client’s emotional experiences, use of defense mechanisms, close relationships with others, past experiences, and exploration of fantasy life in dreams, daydreams, and fantasies (Shedler, 2010).
         Unlike the stereotyped portrayal that you might see in movies or on television, clinicians need not conduct psychodynamic therapy on a couch, for years at a time, or with a silent therapist. However, given the impracticality of maintaining such a long-term and intense form of treatment, psychotherapists began developing briefer forms of psychodynamic therapy. Instead of attempting to revamp a client’s entire psychic structure, psychotherapists using these methods focus their work on a specific symptom or set of symptoms for which the client is seeking help. The number of sessions can vary, but rarely exceeds 25. Unlike traditional psychodynamic therapy, the therapist takes a relatively active approach in maintaining the focus of treatment on the client’s presenting problem or issues immediately relevant to that problem (Lewis, Dennerstein, & Gibbs, 2008).
         In one version of brief psychodynamic therapy, the clinician identifies the client’s “Core Conflictual Relationship Theme (CCRT).” The clinician assesses the client’s wishes, expected responses from others, and client responses either to the responses of others or to the wish. Clients describe specific instances in their relationships with others that allow the clinician to make the CCRT assessment. The clinician then works with the clients in a supportive way to help them recognize and eventually work through these patterns (Jarry, 2010).

BEHAVIORAL PERSPECTIVE: THEORIES

Classical conditioning accounts for the learning of emotional, automatic responses. For example, if you were trapped in a smokefilled room with no immediate escape, you might experience fear every time you hear a loud buzzing noise that sounds like the fire alarm that blared in the background while you awaited rescue. Much of the classical conditioning that behavioral clinicians focus on involves this type of aversive conditioning in which the individual associates a maladaptive response with a stimulus that could not itself cause harm.

         By contrast, in operant conditioning an individual acquires a maladaptive response by learning to pair a behavior with its consequences. The behavior’s consequences are its reinforcement—the condition that makes the individual more likely to repeat the behavior in the future. Reinforcement can take many forms. For example, through positive reinforcement, your friends may laugh when you express outrageous opinions, making you more likely to express those opinions in the future. You might also learn through negative reinforcement to take an over-the-counter sleep medication if you find that it helps alleviate your insomnia. Both negative and positive reinforcement increase the frequency of the behaviors that precede them. In these examples, the behaviors that increase are speaking outrageous opinions and taking sleep medication.
      According to the behavioral perspective, you don’t have to directly experience reinforcement in order for it to modify your behavior. Psychologists who study social learning theory believe that people can learn by watching others. Through vicarious reinforcement, you become more likely to engage in these observed behaviors. You can also develop ideas about your own abilities, or sense of self-efficacy, by watching the results of your own actions or those of other people with whom you identify. For example, you may wonder whether you have the ability to overcome your fear of public speaking, but if you see a fellow student present successfully in class, this will build your feelings of self-efficacy, and you do well when it’s your turn to get up and speak.

BEHAVIORAL PERSPECTIVE: TREATMENT

Behavior therapists focus their therapeutic efforts on helping their clients unlearn maladaptive behaviors and replacing them with healthy, adaptive behaviors. In counterconditioning, clients learn to pair a new response to a stimulus that formerly provoked the maladaptive response. The new response is, in fact, incompatible with the old (undesirable) response. For example, you cannot be physically anxious and relaxed at the same time. Through counterconditioning, as developed by physician Joseph Wolpe (1915–1997), clients learn to associate the response of relaxation to the stimulus that formerly caused them to feel anxious. Clinicians teach clients to relax through a series of progressive steps; for example, by first relaxing the head and neck muscles, then the shoulders, arms, and so forth.
       Counterconditioning often occurs in gradual stages using the systematic desensitization method. The therapist breaks down the maladaptive response into its smallest steps rather than exposing the client all at once to the feared stimulus. The client provides the therapist with a hierarchy, or list, of images associated with the feared stimulus. Starting with the least fearful situation in the hierarchy, the clinician asks the client to imagine that image and relax at the same time. After the client has established the connection between that image and relaxation, the clinician then moves up the hierarchy to the next level. Eventually, the client can confront the feared situation, while at the same time feeling entirely relaxed. At any point, though, if the client suffers a setback, the clinician moves back down the hierarchy to help the client relearn to associate relaxation with the image one level down. Figure 4.6 shows an example of a fear hierarchy that a clinician might use in systematically desensitizing a person who fears spiders.
      Based on principles of operant conditioning, contingency management is a form of behavioral therapy in which clinicians provide clients with positive reinforcement for performing desired behaviors. The client learns to connect the outcome of the behavior with the behavior itself, in order to establish a contingency or connection. The clinician works with the client to develop a list of positive reinforcements that the client can receive only after performing the desired behavior. For example, if the client is trying to quit smoking, the clinician suggests a schedule in which the client can receive the designated reinforcement aft er going without a cigarette for a specific amount of time (such as permission to play video games). Gradually, the client extends the time period until he or she is able to cease smoking altogether. One contingency management form which hospitals use is the token economy, in which residents who perform desired activities earn tokens that they can later exchange for tangible benefits (LePage et al., 2003).
        Behavioral treatments can also involve the principle of vicarious reinforcement, in which clinicians show models of people receiving rewards for demonstrating the desired behaviors (Bandura, 1971). For example, the clinician may show a video of someone who is enjoying playing with a dog to a client who is afraid of dogs. The vicarious reinforcement in this situation is the enjoyment of playing with the dog. The therapist might also use participant modeling, a form of therapy in which the therapist first shows the client a desired behavior and then guides the client through the behavior change.
       Clinicians working within the behavioral perspective often provide their clients with homework assignments. The clinician may ask the client to keep a detailed record of the behaviors that he or she is trying to change, along with the situations in which the behaviors occur. The homework assignment might also include specific tasks that the clinician asks the client to perform with specific instructions for observing the outcome of completing those tasks.

Figure 4.6

 

COGNITIVE PERSPECTIVE: THEORIES

Psychological disorders, according to the cognitive perspective, are the product of disturbed thoughts. By changing people’s thoughts, cognitive psychologists believe that they can also help clients develop more adaptive emotions.
       Particularly problematic, according to the cognitive perspective, are automatic thoughts—ideas so deeply entrenched that the individual is not even aware that they lead to feelings of unhappiness and discouragement. Automatic thoughts are the product of dysfunctional attitudes, which are negative beliefs about the self that are also deeply engrained and difficult to articulate. Faulty logical processes contribute to the problem. Although everyone makes incorrect logical inferences from time to time, people prone to certain psychological disorders draw conclusions about themselves that are consistently detrimental to their feelings of well-being.
       In the model developed by Albert Ellis, there is an “A-B-C” chain of events leading from faulty cognitions to dysfunctional emotions (Ellis, 2005). A refers to the “activating experience,” B to beliefs, and C to consequences. In people with psychological disorders, these beliefs take an irrational form of views about the self and the world that are unrealistic, extreme, and illogical. These irrational beliefs cause people to create unnecessary emotional disturbance by sticking rigidly to the “musts” and then punishing themselves needlessly. They then engage in unnecessary self-pity and refuse to admit that they need help.

COGNITIVE PERSPECTIVE: TREATMENT

If dysfunctional thoughts cause dysfunctional emotions, as the cognitive perspective proposes, then changing a person’s thoughts should alleviate the distress that they cause. In cognitive restructuring, the clinician attempts to change the client’s thoughts by questioning and challenging the client’s dysfunctional attitudes and irrational beliefs. The clinician also makes suggestions that the client can test in behavior outside the therapy session. For example, the clinician might give the client who is afraid of dogs the assignment to visit for five minutes with the neighbor’s dog while, at the same time, practicing relaxation.
      In cognitive behavioral therapy (CBT), as the term implies, clinicians focus on changing both maladaptive thoughts and maladaptive behaviors. Clinicians incorporate behavioral techniques such as homework and reinforcement with cognitive methods that increase awareness by clients of their dysfunctional thoughts. Clients learn to recognize when their appraisals of situations are unrealistically contributing to their dysfunctional emotions. They can then try to identify situations, behavior, or people that help them counteract these emotions. The goal of CBT is to give clients greater control over their dysfunctional behaviors, thoughts, and emotions.
      Cognitive theorists and therapists have continued to refine methods that target the problematic ways in which people view and deal with their psychological problems. Acceptance and Commitment Therapy (ACT) helps clients accept the full range of their subjective experiences, including distressing thoughts and feelings, as they commit themselves to tasks aimed at achieving behavior change that will lead to an improved quality of life (Forman, Herbert, Moitra, Yeomans, & Geller, 2007). Central to ACT’s approach is the notion that, rather than fighting off disturbing symptoms, clients should acknowledge that they will feel certain unpleasant emotions in certain situations. By accepting, rather than avoiding such situations, individuals can gain perspective and, in the process, feel that they are more in control of their symptoms.

HUMANISTIC PERSPECTIVE: THEORIES

Humanistic theorists and clinicians saw their ideas as a radical departure from the traditional focus of psychology, which minimized the role of free will in human experience. These theorists also saw human behavior in much more positive terms and viewed psychological disorders as the result of restricted growth potential. Existential psychology heavily influenced the work of humanistic theorists, a theoretical position that emphasizes the importance of fully appreciating each moment as it occurs (May, 1983). According to existential psychology, people who are tuned in to the world around them and experience life as fully as possible in each moment are the psychologically healthiest. Psychological disorders arise when people are unable to experience living in the moment. People develop disorders not due to fundamental flaws in their biology or thoughts, but modern society imposes restrictions on our ability to express our inner selves (Frankl, 1963; Laing, 1959).
       By the mid-twentieth century, psychologists who were disenchanted with the major theoretical approaches to understanding human behavior and psychological disorder had come to believe that psychology had lost its contact with the human side of human behavior. These humanists joined together to form the “third force” in psychology, with the intention of challenging psychoanalysis and behaviorism. Two of the most prominent theorists within this tradition were Carl Rogers and Abraham Maslow.
      Carl Rogers’ (1902–1987) person-centered theory focuses on each individual’s uniqueness, the importance of allowing each individual to achieve maximum fulfillment of potential, and the individual’s need to confront honestly the reality of his or her experiences in the world. In applying the person-centered theory to the therapy context, Rogers (1951) used the term client-centered to reflect his belief that people are innately good and that the potential for self-improvement lies within the individual rather than in the therapist or therapeutic techniques.
       Rogers believed that a well-adjusted person’s self-image should be congruent with the person’s experiences. In this state of congruence, a person is fully functioning—meaning that the individual is able to put his or her psychological resources to their maximal use. Conversely, a psychological disorder is the result of a blocking of the individual’s potential for living to full capacity, resulting in a state of incongruence or mismatch between self-image and reality. However, congruence is not a static state. To be fully functioning means that the individual is constantly evolving and growing. 
        According to Rogers, psychological disorders that develop have their origins in early life, when a person’s parents are harshly critical and demanding. In this situation, people develop chronic anxiety about making mistakes that will subject them to further disapproval. Rogers used the term “conditions of worth” to refer to demands that parents place upon children. In order to be loved they feel they have to meet these criteria. As adults, they are constantly trying to meet the expectations of others instead of feeling that others will value them for their true selves.
       Abraham Maslow’s (1962) humanistic model centers on the notion of self-actualization, the maximum realization of the individual’s potential for psychological growth. According to Maslow, self-actualized people have accurate self-perceptions and are able to find rich sources of enjoyment and stimulation in their everyday activities. They are capable of peak experiences in which they feel a tremendous surge of inner happiness, as if they were totally in harmony with themselves and their world. But these individuals are not simply searching for sensual or spiritual pleasure. They also have a philosophy of life that is based on humanitarian and egalitarian values.
       Maslow defined the hierarchy of needs, which proposes that people are best able to experience self-actualization when they meet their basic physical and psychological needs. We call needs that are lower on the hierarchy deficit needs, because they describe a state in which the individual seeks to obtain something that is lacking. An individual who is preoccupied with meeting deficit needs cannot achieve self-actualization. For example, people who are motivated solely to make money (a lower-order need) will not be able to move up the hierarchy to self-actualization until they set their materialistic motives aside. Self-actualization is not a final end-state in and of itself, but is a process in which the individual seeks true self-expression.

HUMANISTIC PERSPECTIVE: TREATMENT

A theory rich with implications for treatment, person-centered theory now forms the foundation of much of contemporary therapy and counseling. The client-centered model of therapy proposed specific guidelines for therapists to follow in order to ensure that clients are able to achieve full self-realization. According to Rogers, clinicians should focus on the client’s needs, not on the preconceived clinician notions about what is best for the client. In fact, reflecting this emphasis on the inherent strengths of people seeking treatment, Rogers originated the use of the more collegial term “clients” rather than the illness-oriented term “patients.”
      Rogers believed that a clinician’s job is to help clients discover their inherent goodness and in the process, to help each client achieve greater self-understanding. To counteract the problems caused by conditions of worth in childhood, Rogers recommended that therapists treat clients with unconditional positive regard. This method involves total acceptance of what the client says, does, and feels. As clients feel better about themselves, they become better able to tolerate the anxiety that occurs with acknowledging their own weaknesses because they no longer feel driven to see themselves as perfect. The clinician tries to be as empathic as possible and attempts to see the client’s situation as it appears to the client.
       Contemporary humanistic and experiential therapists emphasize that, as much as possible, therapists can be most effective if they can see the world from the eyes of their clients. Therapists working within the client-centered model are trained in the techniques of reflection and clarification. In reflection, the therapist mirrors back what the client has just said, perhaps rephrasing it slightly. These techniques allow clients to feel that the clinician is empathetically listening and not judging them. Gradually, they feel increasingly confident to reveal their true, inner selves because they know that the clinician will not reject or label them as inadequate.
     Rogers also suggested that clinicians should provide a model of genuineness and willingness to disclose their personal weaknesses and limitations. By doing so, clients realize that they don’t have to put up a false front of trying to appear to be something that they’re not. Ideally, the client will see that it is acceptable and healthy to be honest in confronting one’s experiences, even if those experiences have less than favorable implications. For example, the Rogerian clinician might admit to having experiences similar to those the client describes, such as feeling anxious about speaking before a group.
        Motivational interviewing (MI) is another client-centered technique that uses empathic understanding as a means of promoting behavioral change in clients (Miller & Rose, 2009). In motivational interviewing, the clinician collaborates with the client to strengthen the client’s motivation to make changes by asking questions that elicit the individual’s own arguments for change. MI, like the client-centered approach in general, emphasizes the client’s autonomy.

SOCIOCULTURAL PERSPECTIVE: THEORIES

Proponents of the family perspective see abnormality as caused by disturbances in the patterns of interactions and relationships that exist within the family. These disturbed patterns of relationships may create the “identified patient”; namely the individual in treatment whose difficulties reflect strains within the family.
       Researchers within the sociocultural perspective also focus on social discrimination as a cause of psychological problems. Discrimination on the basis of gender, race, sexual orientation, religion, social class, and age, for example, can contribute to disorders in the realms of physical and mental health. Starting in the 1950s, researchers established the finding that psychological disorders are more commonly diagnosed among people in lower socioeconomic strata (Hollingshead & Redlich, 1958). This relationship may reflect the fact that people of lower social class experience economic hardships and have limited access to quality education, health care, and employment. Socioeconomic discrimination is further compounded by membership in ethnic or racial minorities. When people have few opportunities or when they encounter oppression because of unalterable human characteristics, they are likely to experience inner turmoil, frustration, and stress, leading to the development of psychological symptoms.
      Psychological disorders can also emerge as a result of destructive historical events, such as the violence of a political revolution, the turmoil of a natural disaster, or the poverty of a nationwide depression. Since World War I, American psychologists have conducted large-scale studies of the ways in which war negatively affects psychological functioning. People who are traumatized as the result of terrorist attacks, exposure to battle, persecution, or imprisonment are at risk for developing serious anxiety disorders. Similarly, fires and natural disasters, such as earthquakes, tornadoes, and hurricanes, leave more than physical destruction in their wake.

SOCIOCULTURAL PERSPECTIVE: TREATMENT

How do clinicians intervene with people suffering from conditions which sociocultural factors cause or exacerbate? Clearly, it is not possible to “change the world.” However, clinicians can play a crucial role in helping people come to grips with problems that have developed within a family system, the immediate environment, or extended society.
        In family therapy, the clinician encourages all family group members (however defined) to try new ways of relating to each other or thinking about their problems. The family therapist, sometimes working with a co-therapist, meets with as many family members as possible at one time. Rather than focusing on an individual’s problems or concerns, family and couples therapists focus on the ways in which dysfunctional relational patterns maintain a particular problem or symptom. They also use a life-cycle perspective in which they consider the developmental issues, not only of each individual, but of the entire family or couple. Furthermore, family and couples therapists see the continuing relationships among the family members as potentially more healing than the relationship between clinicians and clients.
       The particular techniques that clinicians use in family therapy depend greatly on the therapist’s training and theoretical approach. An intergenerational family therapist might suggest drawing a genogram, a diagram of all relatives in the recent past, in an effort to understand the history of family relationships and to use this understanding to bring about change. A structural family therapist might suggest that a subset of the family members enact a disagreement as if they were characters in a play about the family. Strategic family therapists might work with family members to develop solutions to the issues that are causing difficulty. An experiential family therapist might work with the family members to develop insight into their relationships with each other.
          In group therapy, people who share similar experiences share their stories with each other, aided by the facilitation of the therapist. According to Irvin Yalom (1995), a founder of group therapy, group therapy has a positive impact by allowing clients to find relief and hope in the realization that their problems are not unique. In the group, they can acquire valuable information and advice from people who share their concerns. Furthermore, in the process of giving to others, people generally find that they themselves derive benefit.
         Clinicians use milieu therapy in treatment settings such as in-patient hospitals to promote positive functioning in clients by creating a therapeutic community. Community members participate in group activities, ranging from occupational therapy to training classes. Staff members encourage clients to work with and spend time with other residents, even when leaving on passes. Every staff person, whether a therapist, nurse, or paraprofessional, takes part in the overall mission of providing an environment that supports positive change and reinforces appropriate social behaviors. The underlying idea behind milieu therapy is that the pressure to conform to conventional social norms of behavior fosters more adaptive behavior on the part of individual clients. In addition, the normalizing effects of a supportive environment are intended to help the individual make a smoother and more effective transition to life outside the therapeutic community.
       Although clinicians cannot reverse social discrimination, they can adopt a multicultural approach to therapy that relies on awareness, knowledge, and skills of the client’s sociocultural context. For example, therapists need to be sensitive to the ways in which the client’s cultural background interacts with his or her specific life experiences and family influences. A commitment to learning about the client’s cultural, ethnic, and racial group and how these factors play a role in assessment, diagnosis, and treatment, characterize knowledge. Multicultural skills include mastery of culture-specific therapy techniques that are responsive to a client’s unique characteristics.

BIOPSYCHOSOCIAL PERSPECTIVES ON THEORIES AND TREATMENTS: AN INTEGRATIVE APPROACH

Now that you have read about the major perspectives on abnormal behavior, you probably can see value in each of them. Certain facets of various theories may seem particularly useful and interesting. In fact, you may have a hard time deciding which approach is the “best.” However, as we have said repeatedly, most clinicians select aspects of the various models, rather than adhering narrowly to a single one. In fact, in recent decades, there has been a dramatic shift away from narrow clinical approaches that are rooted in a single theoretical model. Most clinicians use approaches that are integrative or eclectic. The therapist views the needs of the client from multiple perspectives and develops a treatment plan that responds to these particular concerns.