A Brief History of Psychological Disorders:
We presumably study history to learn from our past mistakes. For as long as there have been people living in groups, there also have been some individuals who behaved in disturbing and atypical ways. As such, people have tried to understand or explain why some individuals are atypical. These explanations are the theories about what causes psychological disorders. Each of these theories starts with a fundamental assumption about how one will look at the problem. And how we look at the problem, determines how we will seek the solution.
A theory about what causes a disorder allows a response to be developed within the context of that theory. For example, if we theorized that low levels of norepinephrine, serotonin and dopamine cause depression, and then a response would be developed to increase the level of these neurotransmitters in the brain. However, if the fundamental assumption that initiates the theory is wrong, then obviously the response will be inadequate as well. However, we must be cautious, since attention itself can cause a placebo effect. As a result some people may find relief from any attention paid to them regardless of the circumstances. Nonetheless, in the example given, there are some questions as to whether the level of certain chemicals in the brain is a cause or an effect of psychological disorder. Since individuals can change the chemical balance in the brain at will as demonstrated with studies of meditation and biofeedback, the psychological disorder may cause the fluctuation in the chemical balance of the brain. After all, does fear cause an adrenaline rush or does the adrenaline rush cause the fear? One could also raise the question as to why, with the understanding that the way we think can cause changes in the brain chemistry, we don’t use that as the response instead of the drugs that are so toxic?
The value of any response (and the theory) is best evaluated by knowing how many and how much it helps people with psychological disorders. A response that helps only a few people with psychological disorders, or helps only a little bit, may be based on an inadequate theory. So the theory should be changed or abandoned for a new theory, and try again. History helps us learn about theories and responses that have been tried, but failed to help people with psychological disorders. Hopefully, by knowing about what didn’t work, we can develop new responses that are more effective and help more people with psychological disorders.
A really short history of causes & treatments of psychological disorders:
1. 500 BC – 500 AD
Especially in ancient Greece (and later in Rome), mental illness was believed to be a medical problem – treatable by physicians. The fundamental assumption was a pathology [germ, genetics or chemistry – in today’s terms] – therefore, it was assumed that a response that ‘cured’ the pathology was the appropriate response. Hippocrates, in particular, was selective within the fundamental assumption and believed that mental disorders were caused by an imbalance of the body’s fluids or humors – blood, bile, phlegm, and water – in line with present day chemical imbalance theories. Too much or too little of any humor [chemical] could cause mental illness 1. For example, too much bile could lead to depression.
The imbalance of humors was treatable. The response was usually to have the sufferer consume powdered plant roots, leaves, or other natural substances. Theoretically, these substances would restore the bodily humors to a balanced state and a balanced body should lead to a balanced mind.
Although Hippocrates’ theory was not correct, some of his ideas are the basis for today’s ‘medical model’ that assumes that psychological disorders may have natural causes and should be treated as a disease. A pharmacopoeia of psychoactive drugs, surgery, and electro-convulsive therapy has replaced treatment with herbs and natural substances.
The notion of bodily humors could also be compared to the contemporary idea of genetically determined psychological traits. In trait theory, too much of some traits may be the source of psychological disorders. For example, an extremely extroverted and emotionally unstable person may have episodes of mania. Regardless of the specific pathology, all of the responses based on a theory of pathology requires an ‘expert’ change agent and the person him or herself cannot take responsibility for him or herself. Unless the person seeks medical help, therefore, the system of supplying help is, of necessity, coercive. This has lead to many excesses in response.
2. 500 AD – 1700 AD
Sometime after the fall of the Roman Empire, the Catholic Church became the major social and political institution throughout Europe. Many psychological disorders were seen as disturbances of the spirit and therefore in the sphere of the church. Abnormal behavior was the product of possession or having one’s mind taken over by demons. The fundamental assumption was that psychological disorders were caused by evil. Evil was regarded negatively and therefore, the issue of whether the person chose to be evil was a critical one. In circumstances where the evil was not by choice – one response was given. Where the evil was by choice – another response was given – and incidentally, is historically the only response that has 100% effectiveness – since it eliminated not only the evil, but also the person.
Initially, the church distinguished between voluntary and involuntary possession. In involuntary possession, it was believed that the victim was seized by the devil as a punishment for sin and became mentally ill. Priests provided treatment by attempting to coax out the evil spirits through exorcism rituals such as praying, laying on of hands, scaring out the devil with curses, threats, and so on. Since this was highly ineffective [although remember the placebo effect of attention] it is likely that at some point the priest decided that the person may not really be being punished, but chose the evil.
Such people were believed to have made a deliberate pact with the devil for personal gain or vengeance. These people were branded as witches and believed to have supernatural powers to control normal people, destroy crops and livestock, or cause natural disasters. In these people, the devil needed to be destroyed usually by fire or drowning.
The distinction between voluntary and involuntary possession became blurred, so that by the 1600s, nearly anyone accused of being a witch (or mentally ill) was tortured then murdered. Some history texts on psychopathology point out that a disproportionate number of mentally ill women, rather than men, were killed in Europe during these centuries.
Needless to say, the issue of choice was also blurred, since the only choice the person had in the process was a negative one – which brought the response of punishment. For some period of time, a person might be treated as a victim, which is also demeaning and takes away responsibility. In either case, the presence of psychological problems was catastrophic.
3. 1700 AD – 1900 AD
By the 17th century in Europe, people with psychological disorders or ‘madmen’ [angry men] were seen as dangerous animals that should be caged in order to protect society. Anyone undesirable – criminals, lepers, old people, and the mentally ill – was confined in asylums. Such institutions were usually dungeons where the keepers dumped food and fresh hay in once a week or so. Many institutions charged a small admission fee for the public to view the caged madmen. Needless to say, there was a very high mortality rate among inmates of these asylums. The fundamental assumption was the same as in the prior era – evil. However, the response changed from a moral one to a legal one. Since you were evil, we would lock you up. This was much less effective in getting rid of the evil than burning at the stake, but it did effectively hide such people from society.
Physicians were challenging church doctrine about demonic possession by the 1500 and 1600’s, advocating a newer version of Hippocrates’ medical model of psychological disorders. By 1793, a French physician, Philippe Pinel, introduced a new idea that ‘humane treatment’ in institutions could cure or help people get better so that they could eventually return to the community. Instead of being dangerous animals in a prison, mentally ill people should be seen as sick patients to be treated in a hospital. Some of Pinel’s ideas are the basis of contemporary humanistic theory. Unfortunately, Pinel’s reforms were short lived as the fundamental assumption of pathology has some of the connotations of evil – it is something in the person that we must eliminate – whether they like it or not. The element of coercion and lack of personal choice led many physicians, such as Benjamin Rush, to ‘torture’ people as a method of ‘cure’.
By 1897, medical researchers discovered that untreated syphilis infections were the cause of some psychological disorders. This, of course, was a disaster for people with psychological problems. After 2400 years of assumption of pathology, one was found. This prodded the continued search and in the succeeding 200 years nothing else has been found although claims are abundant.
Other physicians at the time also were experimenting with medical treatments for psychological disorders in the 1700s and 1800s. For example, Benjamin Rush (an American physician) experimented with rapidly spinning patients in special chairs among other atrocities; Franz Mesmer (an Austrian physician) experimented with various concoctions of herbs and natural substances, which he boiled in large vats so patients could breath in the fumes; and Jean Charcot (a French physician) experimented with hypnosis. Sigmund Freud studied with Charcot, and later developed psychoanalytic treatment methods based on little more than speculation.
4. 1900 AD – 2000 AD
II. Psychological Responses
Freud’s fundamental assumption concerned ‘drives’ – the urge to eat, drink, have sex, etc. and their conflict as the basis for psychological concerns. From this perspective, he was not scientific, only opinionated. However, he was a genius, and while his assumptions were wrong, he led the world to the idea that the problem was in the mind and foreshadowed many of the cognitive responses that we have today. Unfortunately, he did not test his responses to see if they worked. Further, he continued the thought that the person required an ‘expert’ to ‘cure’ him or her of the affliction. He continued the ‘medical model’, but changed the nature of the pathology.
• repressed anxieties about unresolved childhood conflicts
• “schizophregenic mother” or schizophrenic family system
• help client to get in touch with repressed feelings & conflicts in order to gain insight; once the client understands the s/he can resolve the conflict.
• techniques include:
1) free association to overcome resistance
2) interpretation of dreams
3) analyzing transference
These are of a very different order than psychoanalysis in that the fundamental assumption was that it was the person’s interaction with the environment that caused the psychological disorders and because of that, the person had a role in finding the solution. This may be the first shift from external to internal control of the process of change. Unfortunately, the movement kept all of the trapping of the medical model – being doctors or therapists, treating, etc. The very language of the profession undermined this fundamental shift.
• environmental stressors
• lack of social support or friends
• person-centered therapy
1) unconditional positive regard
2) active listening
• Gestalt therapy
For the first time, science entered into the psychological arena. Behaviorists were concerned with what is and what outcome occurs. They therefore discovered some very pertinent concepts: the Law of Effect – that which gets rewarded gets done. The fundamental assumption is a utilitarian one that people will seek pleasure and avoid pain. Therefore, they will learn behaviors that receive the most positive reinforcement and avoid those that receive the most pain. They therefore could design, based on scientific evidence, response that had successful outcomes. Unfortunately, they avoided the obvious. What works with pigeons will not necessarily work for human beings. Behaviorists who were enamored by the stimulus – response mechanisms were unable to accept a mediating factor.
• peculiar reinforcement history
• classical conditioning
systematic desensitization & aversive conditioning
• operant conditioning
The mediating factor that stands between stimuli – response in human beings is thought and its corollary, emotion. The fundamental assumption of the cognitive approach is that the person is the sum total of his or her thoughts and the behavior will not change until the thoughts change. Distorted thoughts lead to distorted behavior. Cognitive approaches, however, are still behavioral. Cognition is a mental behavior and is open to the same utilitarian principles. The difficulty occurs around the beliefs that a person has about him or herself and his or her place in the world and about other people and their place in the world and what they think about you. These personal schemata [networks of thought that converge to provide the basis upon which the individual make decisions] lead to a third part of the Cognitive Triad – expectation [predictions about what the future holds]. These predictions are both short-term – how will I do on this test – and long term. Clearly this is the functional aspect of the personality, if I believe that will be successful or not successful this is the core of who I am.
• irrational belief systems
• learned helplessness & attributions of self-blame
• rational-emotive therapy
• cognitive-behavioral therapy for depression
Generally, biomedical responses (also called somatic therapies) essentially accept Hippocrates theory – that psychological disorders are physical disorders. Something must be ‘wrong’ with normal biological or physiological processes and this causes the psychological problems. Responses for psychological problem must, therefore, include some kind of medical intervention or treatment for the body.
1. Drug Therapy (psychopharmacology) – In the 1950s, biochemists developed Thorazine, a psychoactive drug that helps control symptoms of schizophrenia. This allowed many individuals to leave psychiatric hospitals and live with family, friends, in supportive care facilities, or on their own. The drug was also highly toxic and caused substantial physical ailments. Since the 1950s, dozens of new drugs have be developed to treat a range of psychological symptoms all of which continue to have dramatic and negative side effects.
Psychoactive drugs may be designed to mimic the normal effects of neurotransmitters, or increase the amount of the neurotransmitter being released (agonist), or block receptors sites (antagonist), etc. However, no psychoactive drug is a perfect replacement for normal brain functioning. For example, we suspect that multiple neurotransmitters interact and influence the effects of one another. Many of the neuro-chemical processes are not well understood, so we cannot replicate these processes with drugs. Also, there are side effects – these are the extra effects of the drug that are not needed or wanted. For example, many drugs like Thorazine caused Tardive Dykenesia, a condition that causes Parkinson like tremors and sluggishness and which is incurable.
2. Electro-convulsive Shock Therapy (ECT) – This is used only with depressed clients who are dangerously suicidal and who have not responded to other forms of treatment.
Needless to say people have died, received broken bones and other dramatic responses to such intervention. Loss of memory is a regular part of this extreme approach.
3. Psychosurgery – Brain tissue is removed or destroyed. More common in the past, today this is a rarely used treatment for psychological disorders
Psychoanalysis assumes that the past experiences cause current psychological problems. Because these post experiences were emotionally upsetting, negative and hurtful, the person represses memory of these experiences into the unconscious. Therefore, the therapist talks with the client to reconstruct or uncover these past experiences. However, since the memories are unconscious, the therapist must use indirect methods to discover these repressed memories. Furthermore, since these unconscious memories are painful, the client is likely to use defense mechanisms to resist discovering these painful past experiences.
The indirect methods that a psychoanalyst uses includes:
• free association – the therapist says several words and the client says the first thing that comes to mind in response to each stimulus word.
• dream interpretation – unconscious conflicts are believed to be symbolically represented in dream content. Recurring dreams or emotionally charged dreams are especially important for uncovering unconscious memories.
• transference – the therapist tries to be a stand-in or substitute for other persons in the client’s life who caused the past emotional stress. For example, if a person has an unresolved anger toward his/her father, the therapist encourages the client to see the therapist as a father-like substitute – and transfer the angry feelings into the client-therapist relationship. Now, the therapist can help the client with expressing, managing and resolving conflicts associated with these feelings.
Behavioral therapies assume that the behavior is the problem and that there are no unconscious conflicts or underlying problems of self-esteem. Instead, psychological disorders are behaviors that have been learned – sometimes under extreme or unusual circumstances. If disordered behavior is learned, then it can be unlearned or extinguished. Classical conditioning and Operant conditioning theories each offer variations of behavioral therapies.
Classical Conditioning Therapies:
(1) Systematic Desensitization – This therapy has been especially effective for treating phobias. It is based on the idea that an individual cannot be relaxed and anxious at the same time. First, the situations that trigger anxiety are identified and rank ordered based on how much anxiety each situation triggers. Second, the client is taught relaxation techniques. Next, the client imagines the least anxiety-provoking situation and practices the relaxation techniques. Several trials of relaxing while imagining the anxiety situation may be needed until the situation triggers a relaxation response instead of an anxiety response. This process is repeated with the next situation on the hierarchy, then the next, then the next. Eventually, the client will practice relaxation techniques in the real situations until there are no more anxiety responses in those situations.
(2) Aversive Conditioning – This therapy has been used most with undesirable compulsive behaviors, such as alcoholism or child molesting. It is also based on the idea that a fear response cannot occur at the same time as a pleasurable or arousal response. This stimulus that has provoked a positive response is paired with an aversive stimulus. For example, alcoholic drinks are laced with another drug that induces vomiting. Several trials of drinking and vomiting should extinguish the undesirable behavior. Unfortunately, aversive conditioning has the same problems associated with using punishment as a learning tool. A client may learn not to drink in the presence of the therapist, but drinking in the neighborhood bar is still O.K.
Operant Conditioning Therapies
(1) Token Economies – A system of rewards or points is created to reward positive or desirable behaviors. Rewards or points are lost when the client performs undesirable behaviors. Token economies work best when they are used in institutional settings or group-homes where there can be frequent monitoring of behavior and frequent rewards. As the client gets used to the token economy, time intervals between rewards can be increased. Eventually, points or rewards also need to be replaced with naturally occurring positive or negative consequences.
Cognitive therapies recognize the importance of disordered behavior patterns, but also that one’s thoughts and feelings about oneself, relationships, and so forth, affect psychological disorders. In particular, a symptom of many disorders is negative thoughts about the self such as self-blame. Another negative thought process common in many psychological disorders is overgeneralization. Often self-blame and overgeneralization are accompanied by an external locus of control – or the belief that the self cannot influence his or her own experiences.
Self-blame is the belief that everything that goes wrong is one’s own fault. For example, many women who are physically beaten by relationship partners blame themselves for the partners’ violent behavior. The woman thinks that she does not love enough or that she is a bad cook or that she nags too much and provokes the beating. Similarly, she may believe that she does not deserve a better relationship partner or that she could not live independently, so she stays in the abusive relationship.
Overgeneralization is extending beliefs about one situation to many other unrelated situations. For example, a student who fails a calculus class will also believe that she is bad at all math – statistics, algebra, geometry, etc. Furthermore, the student may believe that she is just a bad student regardless of the subject and that she will probably flunk out of college, will have problems finding or keeping a job, and that no one would want to have a relationship with a failure like her.
External locus of control is the belief or perception that fate, destiny, or other environmental factors determine what happens to an individual and the individual’s “free-will” or “self-determination” have little or no impact on what happens to the individual. If this belief is exaggerated, a person may fall into a pattern of learned helplessness, where a person feels helpless, hopeless and no expectation of being able to do anything to improve his situation. Learned helplessness (or lack of personal control) is common among people with mood disorders, anxiety disorders, and substance abuse problems. (See chapter 14 in the textbook for more information.)
(1) Rational-Emotive Therapy (RET) – This therapy directly challenges the logic of an individual’s self-blaming, overgeneralizing, learned helplessness, and other irrational beliefs. It assumes that there is a thought or belief system for every behavior; for maladaptive behaviors these beliefs are irrational or illogical (Albert Ellis, 1974). An example of an irrational belief system would suggest that:
“Because I want something it is not only desirable or preferable that it exist, but it absolutely should exist and it is awful when it really doesn’t. It is so awful, that I just can’t stand it!”
The therapist often restates the clients illogical believes in extreme, absurd terms…. so absurd that the client is likely to disagree with the therapist. The therapist contradicts irrational beliefs or statements by the client. Clients are often given “homework” to take risks or do things that they are afraid of and take notes about all the bad things that did not happen. The therapist often uses strong, confrontational language with the client.
(2) Cognitive Therapy (cognitive-behavioral therapy) – This therapy is commonly used with depressive disorders and generally is effective. The focus of therapy is to identify, then dismantled negative self-thinking and replace these negative thoughts with more positive thinking. Some cognitive therapies use humanistic techniques (e.g. unconditional positive regard) to accomplish goals similar to those of RET
Client-centered therapy – the therapist focuses on the client’s conscious self, listens to the client without judging or interpreting comments, and expresses unconditional positive regard for the client.
• active listening
• invite clarification
• reflect feelings
Does Therapy Help?
Research Findings. The short answer is “yes, therapy helps people with psychological disorders.” But, not everyone is helped to the same extent.
• Therapy is most effective when the problem is clear-cut and the client is motivated to get better.
• Improvement may not be permanent; people do have relapses and these are most likely to occur when they face new traumatic, stressful life circumstances.
• No one type of therapy (e.g., psychoanalysis, behavioral, cognitive, or humanistic) is substantially better than the others; all psychological therapies seem to have positive effects.
Common Features that seem to help.
• A therapist offers a new perspective to the client – by looking at problems in a new way, people can have new ideas for solutions.
• The therapist offers an empathic, caring, trusting relationship to the client.
• The new perspective and caring relationship helps the client develop hope and optimism about his or her situation.