Reading for Trainers
I. Theory of Cause – Fundamental Assumption
Why do people have problems in living?
This requires a review of the literature on human service methods – remember as you are reviewing these models that you are going to be asked to identify the fundamental assumption that underlies each model.
The Biomedical Model
Those who advocate the biomedical model typically approach abnormality as a medical researcher approached illness, with the following sequences of definition: identify a syndrome [diverse symptoms that tend to occur together], search for the etiology [cause] of the syndrome, and decide on the treatment for the illness. Having observed the symptoms of a syndrome, biomedical researchers will consider three possible causes for the illness: germs, genes and biochemistry.
The idea that psychological disorders have physical etiologies is both ancient and venerable. But it was not until the latter half of the nineteenth century that anyone convincingly demonstrated that any form of psychological disorder was caused by organic illness. At that time, it was found that syphilis caused general paresis, the symptoms of which seemed to be mainly delusions of grandeur [false notion that one is rather more important than the objective facts indicate]. Beyond that, no other evidence of pathology has been found.
Despite continued efforts, schizophrenia continues to puzzle the medical researchers. Although some genetic correlation has been found, it is sufficient only to demonstrate that the propensity might be inherited, and not necessarily the “disease” itself. Additionally, the “dopamine hypothesis”, as it is called, states that schizophrenic behavior is caused by too much dopamine in the brain. Dopamine is a chemical in the brain that allows “messages” to be relayed from one neuron to another. There is a considerable amount of evidence in favor of this hypothesis. But all of it is rather indirect. The most important evidence comes from the fact that drugs usually relieve the symptoms of schizophrenia also lower the amount of usable dopamine in the brain. This is called dopamine “blocking”.
This is similar logic to the suggestion that it is a lack of aspirin that causes headaches – since by adding aspirin, the headache goes away. Another major anomaly is the question of whether the presence of the dopamine is an ‘effect’ or a ‘cause’. Since we know through rigorous study that such practices as meditation or biofeedback can change the chemistry of the brain, one might just as easily assume that the presence of ‘schizophrenia’ causes an increase in dopamine. After all, does the fear cause the adrenaline surge or the adrenaline surge cause the fear?
The major weakness in this biomedical approach is that it has sometimes been observed that psychological events sometimes cause pathology, and changing these events – without directly changing anything about the body – can indeed cure. Secondly, biomedical treatments often produce unpleasant and harmful side effects. Finally, some disorders may indeed be illnesses of the body, but others are problems in adjustment to living. General paresis is a disease, the consequence of syphilitic spirochetes. But, despite all the rhetoric to the contrary, it still remains to be seen if and what other ‘illnesses’ will be able to be placed in that distinct category.
The Psychodynamic Model
There is a specific influential set of theories that, taken together, are called psychodynamic. They are so named because they are concerned with the unconscious psychological forces that influence the mind and subsequent behavior. These inner forces – desires and motive – often conflict. When they do, people may experience anxiety and unhappiness, against which they may try to defend themselves.
Psychodynamic approaches to personality and abnormality begin with the work of the Viennese physician, Sigmund Freud. His own methods of studying and changing personalities are called psychoanalysis. Throughout his life, his consuming intellectual and clinical passion was with psychic energy. He assumed that people are endowed with a fixed amount of psychic energy and how they used it would lead to either a vigorous or listless life.
Freud was able to attract a number of original thinkers who elaborated on his views. In the case of three well-known individuals [Jung, Adler and Rank] these disciples disagreed and broke with him. Others have built upon, modified and altered his original notions. The most consistent conflict has been between Freud’s emphasis on biological urges [defined as the id impulse] as the determinants of behavior and the feeling of others who felt that the determinants were more social. Rank and Adler, in particular, saw the self, or “will”, as a creative force enabling people to become more than their genetic heritage. Others, notably Erickson and Horney, viewed people as fundamentally social. Therefore, psychosocial, rather than psychosexual, development became their focus.
Psychodynamic treatment focuses on conflict, anxiety, and defense. It seeks to alter thought and behavior by examining early conflicts and especially by making conscious that which is repressed, through free association and discussing dreams and resistances. In doing so, psychic energy is freed for more constructive purposes, and the individual is able to find more constructive resolutions for conflict. Anxiety is reduced because impulses now find “safe” methods of expression. Coping strategies, where they are required, thereby become more mature. Psychodynamic theory is nothing less than a comprehensive description of human personality. Perhaps the greatest of Freud’s contributions is his view that the psychological processes that underlie normal and abnormal behavior are fundamentally the same. Neither conflict, nor anxiety, nor defense, nor unconscious processes are the sole possession of abnormal people. Rather, the outcome of conflict and the nature of defense will determine whether behavior will be normal or abnormal.
These theories, unfortunately, rely too heavily on observations of individual cases and are difficult to prove or disprove. Studies have too often failed to provide support for them . Moreover, in emphasizing and focusing on the role of the person, they often neglect to take into account the situation or context of the aberrant behavior. In addition, the process is couched in a biomedical metaphor that tends to make the person with problems in living dependent upon the expertise of the therapist through attribution, if not fact. Finally, psychodynamic therapies have not proven notably effective in dealing with the more intransigent and challenging cases.
The Existential/Humanistic Model
The humanistic and existential psychologies constitute a third major approach in psychology, focused on the distinctly human elements, in which there are powerful roles for will, responsibility and reciprocal determinism. Humanistic psychologies are concerned with the positive aspects of living, and most specifically with self-actualization.
These approaches are centrally concerned with conscious human experiences and are united in revolting against the narrow deterministic view that often characterizes other theories. They hold that people can exercise much greater freedom in taking action than was acknowledged previously, and see people as what they choose to make of themselves. Some aspects of human experience are taken to be determined by genetics or constitution, by age and gender, and by the very times in which people live. But this is not the whole of it, for those determinants lie outside of individual control. Human beings can imagine, dream, engage in reflective thoughts, use symbols, and create and manipulate meanings. These abilities allow people to plan and choose among alternative courses of action, rather than simply performing rigidly proscribed actions. Human experience is, thus, characterized by reciprocal determinism; that is, we interpret our environment and therefore control our responses to it. We affect the environment as much as it affects us.
When people believe that they have no freedom, personal crises may ensue. This may first lead to psychological reactance; the tendency to react against these constraints rather than to make free choice. When people believe that they cannot control their own future, they may become severely depressed. When they feel that all of their thoughts and behaviors are predetermined, they may become paranoid. One’s feeling free to choose and control and one’s own use of that freedom are significant elements in the humanistic and existential approaches to abnormality.
Humanistic psychologists are generally opposed to formal personality diagnosis [such as labeling of depression, schizophrenia]; instead they hold that each person lives in a “continually changing world of experience in which s/he is the center”. Diagnostic categories do not summarize private experience, they are created from without, on the basis of observed behavior and verbalization, as well as diagnostic assumptions regarding how a mature person should function. Those perceptions and assumptions do not conform with the humanist notions.
The notion of the self is central to understanding the private world of experience. The self is that aspect of personality that embodies a person’s perceptions and values. There are two kinds of values: those acquired from experience and those that are introjected or acquired from others. Values that arise from experience are easily labeled and therefore easily accessible to the individual. Values that are introjected, however, may be a source of confusion, for they often require a person to deny his or her own feelings in order to conform to the desires of another. This causes tension and conflict.
Humanistic psychologists place great emphasis on three features of self: feelings, experience and perceptions. When the self is integrated and not threatened, experience and feelings are deep and alive, and perceptions are accurate. When the self is threatened or divided, experiences become blunted and perceptions distorted.
Humanistic psychologists stress that people are naturally good. They propose that, given the kinds of psychological conditions that are necessary for psychological development, people will grow and fulfill themselves, they will self actualize. In fact, they see that the natural destiny of people is to actualize their potentials. They will do precisely that, providing they are given adequate nourishment and are not thwarted by others. Conditions for such proper psychological growth includes the need for self regard and for positive regard for others. These needs are gratified to the extent that the person experiences unconditional love. The principal causes of psychological disorder arise from the application of conditional love; love that is withdrawn when the individual does not behave as the other wishes. Under such conditions, children become what their parents want them to be, not what they want themselves to become. Their own self-actualizing drives have been thwarted. In this way, over time, many people lose track of who they are and live out their lives in unwilling accommodation to the desires of others.
Humanistic theories are concerned with defining the needs that are central to human functioning [see, for example, Maslow’s hierarchy of needs]. As each of the lower needs becomes gratified, more and higher needs emerge and require fulfillment. If at any level, the needs are not gratified, conflict ensues. Until the conflict is resolved, the individual does not proceed to the next level. Moreover, if lower needs cease to be satisfied, regression to lower levels is likely. Those who have all levels of needs fulfilled, self-actualizing people, tend to accept themselves and others. They tend to be relatively autonomous of their environment. They are not, however, without problems and conflict. But these experiences do not arise from deficiency motivated sources. Rather, life itself is, in fact, often difficult and sad, and is the source of problems in their lives.
Existential psychologists assert that the central human fear from which most psychopathology develops is the fear of dying, Death means being forgotten, being left out. Death means helplessness, aloneness, finiteness. They posit two strategies to overcome the fear of nonbeing; by coming to believe oneself special, and by fusion.
The notion of specialness holds that the laws of nature apply to all mortals except oneself. It underlines many valued character traits, such as physical courage, ambition and striving. But, at the extreme, the unconscious belief in one’s specialness may also lead to a spectrum of behavior disorders.
Protection against fear of death or nonbeing can also be achieved by fusion with others. Fusion is a strategy especially used by those whose death fears take the form of loneliness, by allowing them to attach themselves to, and make themselves indistinguishable from others. This fear of “standing apart” has valuable social features, leading to marriage and children, clubs, communities and organizations. At the extreme, however, fusion is responsible for much unhappiness. Among such individuals, abuse is accepted, not because there is nowhere else to go, but because of a connection with the abuser which they are afraid to destroy.
A desire for either specialness or fusion can lead to unauthentic or false modes of behavior in that they are designed to achieve unattainable goals. Bending to others in order to belong can cause the gradual loss of focus on what the goal was.
The assumption of responsibility is central to existential thinking for responsibility means authorship. We are, thus, responsible for the way we perceive the world and for the way we react to those perceptions. To be responsible is “to be aware that one has created one’s own self, destiny, life, predicament, feelings and if such be the case, one’s own suffering.”
Existential psychologists generally pay careful attention to language; they are particularly sensitive to the use of such words as can’t and it, which imply behavior removed from individual control. Responsibility avoidance is, therefore, occasionally achieved by losing control. More accurately, it is achieved by the appearance of losing control, by seeming to go out of one’s mind, by making it appear that forbidden actions were taken, because one was drunk or “crazy”. But behavior that is “out of control” is never really so. Otherwise, it could hardly be purposive.
Existentialist use will in at least two senses. First, there is will, as in will power. This is exhortative will. A second and more significant will is associated with future goals, called goal-directed will. Much as memory is the organ of the past, the goal-directed will has been called “the organ of the future”. It develops out of hope, expectation and competence. It is not urged upon us, but is a rather freely chosen arousal. It cannot be created; only unleashed or uninhibited. Goal-directed will arises from the capacity to wish. Willing is nourished by wishing, and in turn, will provides the power that may ultimately gratify the wish. Disorders are, thus, found among people who have no notion of what they want to do. They may simply fear wanting; they may fear rejection; or they may want others, magically, to discover their silent wishes and fulfill them.
Existential/humanistic therapist seek to explore inner experiences, with emphasis on the here and now. They emphasize personal responsibility, freedom and will; and finally, they participate actively in the therapy.
The best-known humanistic therapy is client-centered therapy, which rests on two fundamental assumptions. The first of these is that therapy proceeds best when the client experiences the therapist’s unconditional positive regard. This arises from the belief that people are fundamentally good even when they are doing “bad” things. Second, the therapist attempts to achieve empathy with the client, to see the world as the individual does.
Gestalt, another type of existential therapy, has little interest in the past, except as it impacts on the immediate present. When it does, it is seized and made extraordinarily vivid. The therapist will ask the client to act out the conflict and re-experience the emotions, teaching people to know, control, and be responsible for their feelings. In this view, confronting feelings is the first step in taking responsibility for them.
Logotherapy, yet another existential therapy, uses a variety of techniques to communicate that individuals are free to control their lives and to endow them with meaning. The first is dereflection, which involves turning away the client’s attention from symptoms and pointing out how much the individual could be doing, becoming and enjoying if not so preoccupied with self. The second is paradoxical intention, which encourages clients to indulge and even exaggerate their symptoms.
These existential/humanistic approaches to personality are very difficult to evaluate, in large measure, because the approaches are really a group of philosophical positions rather than a scientific theory. Much about them cannot be evaluated, such as matters of belief and values. Other aspects of these approaches require careful evaluation. With the exception of client-centered therapy, these treatments have not undergone careful evaluation. Client-centered therapy has been able to establish that the therapist’s empathy and warmth have positive impact on client outcomes.
The Behavioral Model
Behaviorism is not only a model for the study of abnormal behavior it is a worldview. Its first assumption is environmentalism, that is, that all organisms, including humans, are shaped by their environment. Individuals learn about the future through association with the past. That is why, for example, our behavior is reactive to rewards and punishment. The second assumption of this model is experimentalism, which states that, through an experiment [a simulated trial], one can discover and identify what aspects of the environment has caused particular behavior and how this behavior can be changed. The third assumption is optimism concerning change. The thinking here is that if an individual is a product of the environment and if those parts of the environment that have molded him can be identified by experimentation, the individual can be changed when the environment is changed.
For the behaviorist, two basic learning processes exist. It is from these two that all behavior, both normal and abnormal, derives. In this view, individuals learn what goes with what through Pavlovian or classical conditioning. In addition, they learn what to do to obtain what they want and rid themselves of what they do not want through instrumental or operant conditioning.
Pavlovian or Classical Conditioning
Just after the turn of the century, the Russian physiologist, Ivan Pavlov, accidentally made a discovery that would form the basis of the behavioral school of psychology. Pavlov was studying the digestive systems of dogs, specifically the salivary reflex. In the course of his work, he notices that the dogs began to salivate merely when he walked into the room. This could not be reflex, since he had not observed it to happen at the beginning of the experiments. It only occurred once the dogs had learned that his appearance signaled food. Pavlov’s appearance had become associated with a future event; food. This came to be called a conditioned response.
Thus, an unconditioned stimulus [i.e., an agent which arouses activity] food, became tied to a conditioned stimulus, Pavlov’s appearance, to produce the conditioned response. There are two processes in Pavlovian conditioning that occur time and time again, regardless of the species, the kind of conditioned stimuli or unconditioned stimuli, or the kind of response being tested: acquisition and extinction. Acquisition is the learning of a response based on the pairings of a conditioned stimulus and unconditioned stimulus. Extinction is the loss of the conditioned response’s power to produce the formerly acquired response.
There are situations in the world that arouse strong emotions in us. Some of these arouse emotions unconditionally, that is, from our very first encounter with them; for example, a loud clap of thunder startles us the first time we hear it. Other objects acquire emotional significance: the face of a person we love produces a sense of wellbeing; seeing a stranger in a dark alleyway arouses dread. Pavlovian conditioning provides a powerful account of how objects take on emotional significance; it is this account that makes conditioning of interest to the student of abnormality. According to the behavioral account, the basic mechanism for all acquired emotional states is the pairing of a neutral object [conditioned stimulus] with an unconditioned emotional state [unconditioned stimulus]. With enough pairings, the neutral object will lose its neutrality, become a conditioned stimulus and, all by itself, produce the emotional state.
The therapeutic optimism of this behavioral view follows directly from this view of the disorder. If the disorders are, in fact, the symptoms and do not necessarily reflect pathology, elimination of the symptoms will cure the disorder. This sharply contrasts with the biomedical and psychodynamic stance on therapy: for these modes, getting rid of the symptom is only cosmetic; the cure consists of removing the underlying disorder .
Instrumental or Operant Conditioning
B.F. Skinner built on Pavlov’s findings and the work of Edward L. Thorndike, specifically, his “law of effect”. This proposed that, in a given stimulus situation, when a response is made and followed by positive consequences, the response will tend to be repeated; but when a response is followed by negative consequences, it will tend not to be repeated.
Skinner defined the elements of the law of effect rigorously. His three basic concepts consist of the reinforcer [both positive and negative], the operant, and the discriminative stimulus. The positive reinforcer is an event that increases the probability that a response will occur again. A negative reinforcer decreases the probability of recurrence of a response that precedes it. An operant is a response whose probability can be either increased by positive reinforcement or decreased by negative reinforcement. The discriminative stimulus is a signal that means that reinforcement is available if the operant is made.
The operant clinician used these principles in asking three essential questions:
- What undesirable or maladaptive operants does the individual engage in?
- What reinforcers maintain these maladaptive responses?
- What environmental changes, usually reinforcement or discriminative stimulus changes can be made to change the maladaptive behavior into adaptive behavior?
The model and the interventions that follow from it are specifically scientific in nature and can be tested for effectiveness.
A major drawback to this approach is the belief held by some that the original theories did not take into account the intelligent and complex decision-making processes of the human species, hardly likely to be documentable. The major issue is in selection of the target behavior, or that behavior that is to be increased or decreased in activity; and the selection of the reinforcement. These issues raise ethical questions about control and intuitive questions about the human will.
The Cognitive Model
The cognitive school is a modern outgrowth from and reaction to the behavioral school. The basic premise of behavioral therapy is that behavior is determined by events in the environment. Moreover, abnormal behavior is a learned response to the environment. When the clinician changes the environment, the client’s behavior will change.
Implicit in the behavioral view is the assumption that the connection between the environment and behavior is direct. However, cognitive psychologists, hold that more than just this direct relation between environment and response influences behavior. They contend that what a person thinks, believes, expects, attends to – in short, his or her mental life – influences how s/he behaves. Behaviorists, when pressed, frequently admit that mental life exists. But they deny that such cognitions play a causal role in behavior.
The cognitive psychologist contends that disordered cognitive processes cause some psychological disorders and that, by changing these cognitions, the disorder can be alleviated and perhaps even corrected. Underlying the cognitive model is the view that mental events -that is, expectations, beliefs, memories, etc. – can cause behavior. Believing this, the cognitive counselor looks for the cause, or etiology, of psychological disorders in disordered mental events. The counselor’s job is to draw out all of the distorted negative thoughts, to have the client confront the contrary evidence, and then to have the client change these thoughts.
For the purposes of therapy, cognitive processes can be divided into short-term and long-term processes. The short-term processes are conscious. People are aware of them or can become aware of them with practice. These include expectations, appraisals and attributions.
Expectations are cognitions that explicitly anticipate future events. In his early work, Albert Bandura showed that people learned not only by direct reinforcement, but also by observing others being reinforced. He concluded that the behavioral principles of reinforcement were insufficient and that such “vicarious learning” must involve the learning of expectations. He proposed two kinds of expectancies: an outcome expectation, that is a person’s estimate that a given behavior will lead to a desired outcome; and an efficacy expectation, the belief that the individual can successfully carry out the behavior that produces desired outcomes.
Appraisals are evaluations of both what happens to us and what we do. Sometimes they are very obvious, but at other times we are unaware of them. Such automatic thoughts often precede and cause emotion. The individual is not only expecting future consequences, he is also appraising his actions. He judges them to be failures, and this appraisal causes negative emotions. This appraisal process is automatic. After a lifetime of practice, it occurs habitually and rapidly. The individual must, thus, be trained to slow down the thought process to become aware [mindful] of such thoughts. Automatic thoughts are not vague and ill formed; rather, they are specific and discrete. While they may seem implausible to the objective observer, they seem highly reasonable to the person who has them. The goal of the clinician is to enable the client to catch hold of his self-defeating thoughts as they come about, criticize them, control them, and thereby avoid the occurrence of anxiety.
Attributions are an individual’s conceptions of why an event has happened. Depending on the causal analysis made, different consequences ensue. An individual might make an external [an impersonal force, like bad luck or a difficult situation] or an internal [a personal force such as one’s own ability or effort] attribution. In addition, s/he may make a stable [one that persists in time] or an unstable [transient] attribution. Finally, an attribution for failure can be global or specific. An attribution to global factors means that failure must occur generally, that is, on many different tasks, while an attribution to specific factors means that failure occurs only on this one task.
Long-term cognitive processes are seen as different. They are hypothetical constructs, inferred dispositions that govern mental events now in consciousness. One of these long-term cognitive processes is belief. Albert Ellis, the founder of rational-emotive therapy, argues that psychological disorder stems largely from irrational beliefs. These irrational and illogical beliefs shape the short-term distorted expectations, appraisals, and attributions that produce psychological disorder. Counseling here is an aggressive one. It makes a concerted attack on the client’s beliefs in two ways: 1) the clinician is a frank counter-propagandist who contradicts superstitions and self-defeating propaganda embodied in the irrational beliefs of the client, and 2) the clinician encourages, persuades, cajoles, and occasionally insists that the client engage in behavior that will itself be forceful counter-propaganda against the irrational beliefs.
Cognitive counselors, then, believe that distorted thinking causes disordered behavior and that correcting distorted thinking will alleviate and even change the disordered behavior. Behavior counselors, in contrast, view disordered behavior as learned from past experience and they attempt to alleviate the disorder by training new, more adaptive behaviors. These two positions are not incompatible and many counselors try both to correct distorted cognitions and to train new habits.
The cognitive and behavioral models have been seriously criticized on the stance that human beings are more than their behaviors and cognitions, and that it is superficial to treat only the symptoms rather than the whole person. Such a position is, of course, self-serving, as we have already seen. Cognitive behavior management – the combination of the cognitive and behavioral models in the management of atypical behavior is the only evidence-based model.
Pathology [disease, genes or chemistry]
Psychological Forces [distortion of drives such as sex, sleep, food]
Environmental stimuli – reciprocal determinism
Maladaptive thoughts about self, others and future prospects
The trainer will need to present the basic premises of each and discuss what must be the fundamental assumption of each. From there the trainer will need to identify the fundamental assumption of cognitive approaches: We are the sum total of our thoughts and discuss its implications.
An underlying problem generates symptoms that demand attention. But the underlying problem is difficult for people to address, either because it is obscure or costly to confront. So people ‘shift the burden’ of their problem to other solutions – well intentioned, easy fixes which seem extremely efficient. Unfortunately, the easier ‘solutions’ only ameliorate the symptoms; they leave the underlying problems unaltered. [Senge – 1990]