Download LECTURE19-PATHOLOGY_THERAPY

Abnormal Psychology,
Psychopathology &
Psychotherapy
What should be labeled deviant?
 What psychiatrists, clinical psychologists or other trained professionals
label deviant? (DSM-IV)
Or,
 Only organically based behavioral disorders (Szaz).
Treating Insanity
• Hippocrates – recognized depression and epilepsy as
medical problem.
• Middle ages – deviant people were locked up
• Bedlam (Bethlehem hospital, London)
• Reform movement
 Pinel (1790)
 Dorothea Dix (1850)
 Medical Model (late 19th century)
Trephination
Exorcizing the Devil to alleviate madness
An old-fashioned straight-jacket
St. Mary’s of Bethlehem Hospital
(“Bedlam”)
Dorothea Dix
Medical Model of Mental Illness
• Psychiatry an offshoot of neurology (Charcot (1860),
Breuer & Freud (1896), Bleuler (1911).
• Freud: Too little was known about the brain; opted for
psychoanalysis. Classified mental illness into two major
categories: neuroses and psychoses.
• “General paresis” discovered by Krafft-Ebbing to have a
physical cause in 1905 (syphilis).
• Pavlov (1904). Concept of conditioning and experimental
neurosis that was mediated by specific brain circuits.
Reactions to the Medical Model
• Harry Stack Sullivan (broke with psychoanalytic tradition).
• Clinical (lay) psychologists allowed to treat patients with
“mental” disorders.
• Carl Rogers, Ph.D. Published first transcript of a therapeutic session.
• Behavior Therapy (Wolpe, Lazarus). Began in 50’s.
• Cognitive Therapy (Seligman). Began in 60’s.
• Thomas Szaz: Mental illness should only refer to behavioral deviations
that have a well defined organic basis. Other deviant behaviors the
product of “problems of living”.
• DSM-III (1983) & IV (1994)
What is a normal personality?
•Least deviant?
•What is deviant?
•Statistical (does 1/10 of population
have mental illness?)
•Adaptive sublimation?
•Self-actualization?
•Quantitative vs. qualitative differences
between normal and abnormal.
Sheldon’s Body Types
Types of Personality Tests
• Objective
MMPI (Minnesota Multi Phasic Inventory)
• Projective
TAT (Thematic Apperception Test)
Rorschach Test
MMPI CATEGORIES
MMPI Categories (cont’d)
Interpretation of Sample MMPI Score
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•
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Overly self-critical
Personality disorder
Poor social adjustment
Unusual thinking and behavior
High level of anxiety
Sample Tat Card
Sample Tat Card
Sample Responses On TAT Test
• (1) My first thought is that it looks like a mother comng to
the door.
• (2) --the doorbell just rang and she’s expecting someone
probably pretty dear.
• (3) maybe it’s her son--that shows I’m homesick.
• (4) stuff in the room--furniture, flowers, bookshelves and
books--looks roughly like the middle-class
home I
came from
• (5) she doesn’t look like my mother, but somebody’s
mother
• (6) even if she has one nude leg.
TAT STORIES IN RESPONSE TO “BOY
LOOKING AT VIOLIN”
• 45-year old business man:
• This is a child prodigy dreaming over his
violin, thinking more of the music that
anything else. But of wonderment that so
much music can be in an instrument and in
the fingers of his own hand. . . .I would say
that possibly he is in reverie about what he
can do with his music in the times that lay
ahead. He is dreaming of concert halls, tours,
and . . . the beauty he will be able to express
and even now can express with his own
talents.
TAT STORY 2
• 45-Year old clerk:
• . . . This is the son of a very well-known, a
very good musician. . . . The father has
probably died. The only thing the son has
left is this violin which is undoubtedly a
very good one. . . . To the son, the violin is
the father and the son sits there
daydreaming of the time that he will
understand the music and interpret is on
the violin that his father had played.
Administering a Rorschach Test
Sample Rorschach Card
Incidence of Mental Illness
Incidence of Depression by Country

DSM
III
(1983)
Disorders first evident in childhood (e.g., mental retardation,
hyperactivity).
 Organic mental disorders: symptoms directly related to
injury to brain or to abnormality (syphilis, Alzheimer’s disease,
extreme alcoholism, brain tumor).
 Substance use disorders.
 Schizophrenic disorders.
 Paranoid disorders.
 Affective disorders (manic and/or depressed moods).
 Somatoform disorders (hysteria, hypochodriasis).
 Dissociative disorders (amnesia, multiple personalities).
 Psychosexual disorders (transsexualism, frigidity,
exhibitionism, sexual sadism, homosexuality-but only if
individual is unhappy).
 Personality disorders (anti-social behavior, narcissistic
personality).
 Anxiety disorders (generalized anxiety or panic, phobias,
posttraumatic stress disorder, obsessive-compulsive disorder).
 Leftovers (marital problems, family therapy).
DSM-IV (1994)
•
•
•
•
•
•
•
•
•
•
•
•
•
Anxiety disorders.
Mood disorders.
Somatoform disorders.
Dissociative disorders.
Schizophrenia and other psychotic disordcrs (delusional).
Substance-related disorders
Eating disorders (aneroxia nervosa, bulimia nervosa).
Sleep disorders.
Impulse control disorders (kleptomania, pyromania,
pathological gambling)
Personality disorders (anti-social behavior, narcissistic
personality).
Disorders first evident in childhood (e.g., mental
retardation, hyperactivity).
Delerium, dementia, amnestic and other cognitive
disorders.
Adjustment disorder (Maladaptive, excessive emotional
reaction to a stressful event within previous 6 months).
DSM III (1983)
DSM IV (1994)
Childhood mental retardation, hyperactivity
Childhood (e.g., mental retardation,
hyperactivity).
Organic mental disorders: symptoms directly Delerium, dementia, amnestic and other
related to injury to brain or to abnormality
cognitive disorders.
Substance use
Substance-related disorders
Schizophrenic
Schizophrenia and other psychotic
disordcrs (delusional
Paranoid
Affective disorders (manic and/or depressed
moods).
Somatoform disorders (hysteria,
hypochodriasis).
Dissociative disorders (amnesia, multiple
personalities).
Psychosexual disorders transsexualism,
frigidity, exhibitionism, sexual sadism,
homosexuality-but only if individual is
unhappy).
Personality disorders (anti-social behavior,
narcissistic personality)
Anxiety disorders (generalized anxiety or
panic, phobias, posttraumatic stress disorder,
Mood disorders.
Leftovers (marital problems, family therapy).
Adjustment disorder (Maladaptive,
excessive emotional reaction to a stressful
event within previous 6 months).
Eating disorders ( aneroxia nervosa , bulimia
nervosa).
Sleep disorders.
Impulse control disorders (kleptomania,
pyromania, pathological gambling)
Somatoform disorders
Dissociative disorders.
Personality disorders (anti-social behavior,
narcissistic personality).
Anxiety disorders
Psychoanalysis
• Based on Freud’s theory of personality
Many varieties, e.g., Jung, Adler, Sullivan
•
M.D. usually required; Ph.D. in clinical psychology now
acceptable (lay analysts)
•
Training performed by certified institutes in three stages:
-formal courses
-personal analysis with an institute analyst
-control analyses supervised by a training analyst.
•
Patients: usually brighter than average; in most cases
neurotic. Typically excluded are homosexuals, alcoholics,
psychotics, patients with character disorders.
Conditions for Psychoanalysis
• MD originally required
• No psychotics, alcoholics, homosexuals, sociopaths
• Time commitment: ~ 5 years
• Financial commitment: $150 x 4; $600/week; $27,000/year.
• Life decisions placed on hold. No marriage, divorce,
moving, changing jobs without consulting analyst.
Freud’s couch
Psychoanalytic Method
• Treatment consists of three to five 50 minute sessions
per week .
• Patient is instructed to free associate. He does this
while lying on a couch that is facing away from the
analyst.
- less fatiguing to the analyst than face-to-face
relationships
-facilitated free association.
• Basic goal is to have awareness of one’s motives and
memories.
• Dream interpretation
• Transference
Goals of Psychoanalysis
• Genetic progression - bring the patient from his point of
fixation in the psychosexual development to the genital stage.
• Structural - the ego should be strengthened in satisfactory
relationships with the super ego.
• Dynamic - direct energy from the defense mechanism to
more productive outlets.
• Topographic - makes the unconscious conscious specifically, the defense mechanisms.
Client-centered Therapy
• Does not assume medical model (client vs. patient;
counsellor vs. therapist/doctor
• Brief duration (~ 10 vsits)
• Non-directive
• Counselor “reflects” rather than “interprets”
• No dream analysis
• No specific retracing of psychosexual history
PROCESS OF CLIENTCENTERED THERAPY
1. Rigidity - little desire to change. Little recognition
of feelings.
2. Perception of problems, externally dispassionate
display of feeling. Little recognition of
contradictory feelings...
3. Free expression of feelings. Source of feelings
considered. Increased awareness of the “real
me.” Awareness of contradictions.
4. Immediacy of feelings. Real direct experience.
High self-regard. Less intellectualization about
self.
5. Acceptance of self and problem.
EXCERPTS FROM THE FIRST
INTERVIEW IN ROGERIAN THERAPY
• P (patient): I hesitate to meet people - I hesitate
to canvas for my photographic business. I feel a
terrific aversion to any kind of activity, even
dancing. I normally enjoy dancing very much.
But when my inhibition, or whatever you wish to
cal it, is on me powerfully, it is an ordeal for me to
dance. I notice a difference in my musical ability.
On my good days I can harmonize with other
people singing.
• C (counselor): M-hm.
EXCERPTS FROM THE FIRST INTERVIEW IN
ROGERIAN THERAPY (cont’d.)
• P: I have a good ear for harmony then. But when
I’m blocked, I seem to lose that, as well as my
dancing ability. I feel very awkward and stiff.
• C: M-hm. So that both in your work and in your
recreation you feel blocked.
• P: I don’t want to do anything. I just lie around. I
get no gusto for any activity at all.
• C: You just feel rather unable to do things, is that
it?
• ************************
EXCERPTS FROM THE FIRST INTERVIEW IN
ROGERIAN THERAPY (cont’d.)
• P: Well, it’s just reached the point where it
becomes unbearable. I’d rather be dead than
alive as I am now.
• C: You’d rather be dead than alive as you are
now?
Can you tell me a little more about
that?
• P: Well, I hope. Of course, we always live on
hope.
• C: Yes.
EXCERPT FROM THE EIGHTH AND
FINAL INTERVIEW IN ROGERIAN
THERAPY
• P: Well, I’ve been noticing something
decidedly new. Rather than have
fluctuations, I’ve been noticing a very
gradual and steady improvement. It’s just
as if I have become more stabilized and
my growth had been one of the hard way
and the sure way rather than the wavering
and the fluctuating way.
• C: M-hm.
EXCERPT FROM THE EIGHTH AND
FINAL INTERVIEW IN ROGERIAN
THERAPY
• P: I go into situations, and even though it’s an effort, why, I
go ahead and make progress, and I find that when you sort
of seize the bull by the horns, as it were, why it isn’t so bad
as if you deliberate and perhaps - well, think too long about
it, like I used to. I sort of say to myself, “Well, I know
absolutely that avoiding the situation will leave me in the
same rut I’ve been talking,” and I realize that I don’t want to
be in the same old rut, so I go ahead and go into the
situation, and even when I have disappointments in the
situation, I find that they don’t bring me down as much as
they used to.
EXCERPT FROM THE EIGHTH
AND FINAL INTERVIEW IN
ROGERIAN THERAPY (cont’d.)
• C: That sounds like very real progress.
• P: And what pleases me is that my feelings are on an even keel,
steadily improving, which gives me much more of a feeling of security
than if I had fluctuations. You see, fluctuations lead you from the
peaks to the valleys, and you can’t get as much self-confidence as
when you’re having gradual improvement.
• C: M-hm.
• P: So that the harder way is really the more satisfactory way.
• C: Then you’re really finding a step-by-step type of improvement that
you hadn’t found before.
Phobia
Descripion
Phobia
Description
Acrophobia
Heights
Monophobia
Aerophobia
Flying
Mysophobia
Agoraphobia
Public places
Nyctophobia
Aichmophobia
Sharp pointed Ophidiophobia
objects
Spiders
Parthenophobia
Snakes
Claustrophobia
ThunderPorphyrophobia
storms
Closed spaces Triskaidekaphobia
The color
purple
#13
Entomophobia
Insects
Xenophobia
Strangers
Hematophobia
Blood
Zoophobia
Animals
Arachnophobia
Brontophobia
Being
alone
Dirt &
Germs
Darkness
Virgins
Relative Frequency of Phobias
How Phobias Vary With Age
BEHAVIOR THERAPIST’S
INSTRUCTIONS
“Let all your muscles go loose and
heavy. Just settle back quietly and
comfortably. Wrinkle up your
forehead now; wrinkle it tighter....And
now stop wrinkling your forehead,
relax and smooth it out. Picture the
entire forehead and scalp becoming
smoother as the relaxation
increases....
BEHAVIOR THERAPIST’S
INSTRUCTIONS (cont’d.)
Now frown and crease your brows and study
the tension....Let go of the tension again.
Smooth out the forehead once
more....Now, close your eyes tighter and
tighter...feel the tension...and relax your
eyes. Keep your eyes closed, gently,
comfortably, and notice the relaxation ....
Now clench your jaws, bite your teeth
together; study the tension throughout the
jaws....Relax your jaws now. Let your lips
part slightly....Appreciate the relaxation....
BEHAVIOR THERAPIST’S
INSTRUCTIONS (cont’d.)
Now press your tongue hard against the
roof of your mouth. Look for the
tension....All right, let your tongue return
to a comfortable and relaxed position ....
Now purse your lips, press your lips
together tighter and tighter....Relax your
lips. Note the contrast between tension
and relaxation. Feel the relaxation all over
your face, all over your forehead and
scalp, eyes, jaws, lips, tongue and throat.
The relaxation progresses further and
further...”. [from Wolpe and Lazarus
Behavioral
Therapy
Treatment of
A Phobia
(Sensitization)
BEHAVIOR THERAPY
TRANSCRIPT
“The patient, a 14-year-old boy, suffered
from an intense fear of dogs which lasted
for two and one-half to three years. He
would take two buses on a roundabout
route to school rather than risk exposure
to dogs on a direct 300-yard walk. He was
rather a dull (IQ = 93), sluggish person,
very large for his age, trying to be
cooperative, but sadly unresponsive--especially to attempts at training in
relaxation.
BEHAVIOR THERAPY
TRANSCRIPT (cont’d.)
In his desire to please, he would state that
he had been perfectly relaxed even though
he had betrayed himself by his intense
fidgetiness. Training in relaxation was
eventually abandoned, and an attempt was
made to establish the nature of his
aspirations and goals. By dint of much
questioning and after following many false
trails because of his inarticulateness, a
topic was eventually tracked down that
was absorbing enough to form the subject
of his fantasies, namely, racing motor-
BEHAVIOR THERAPY
TRANSCRIPT (cont’d.)
He had a burning ambition to own a certain Alfa
Romeo sports car and race it at the Indianapolis
500. Emotive imagery was induced as follows:
“Close your eyes. I want you to imagine, clearly
and vividly, that your wish has come true. The
Alfa Romeo is now in your possession. It is your
car. It is standing in the street outside your house.
You are looking at it now. Notice the beautiful,
sleek lines. You decide to go for a drive with some
friends of yours. You sit down at the wheel, and
you feel a thrill of pride as you realize that you
own this magnificent machine.
BEHAVIOR THERAPY TRANSCRIPT (cont’d.)
You start up and listen to the wonderful roar of the
exhaust. You let the clutch in and the car streaks
off. You are out in a clear open road now; the car
is performing like a pedigree; the speedometer is
climbing into the nineties; you have a wonderful
feeling of being in perfect control; you look at
trees whizzing by and you see a little dog standing
next to one of them-- if you feel any anxiety, just
raise your finger....” An item fairly high up on the
hierarchy was: “You stop at a cafe in a little town,
and dozens of people crowd around to look
enviously at this magnificent car and its lucky
owner; you swell with pride; and at this moment a
large boxer comes up and sniffs at your heels. If
you feel any anxiety....” [from Lazarus and
Comparisons of Different
Approaches to Psychotherapy
Behavior Modification
What is to be modified?
Role of therapist:
Psychoanalysis
Learned behavior
Symptoms
Deliberate
None - minimal
Active
Indirect
Direct
Passive
Scientific
Intuitive
of behavior:
Real
Symbolic
Aim:
Goal directed
General
Philosophy of treatment:
Interpretation
restructuring
Basis of change:
What is dealt with:
Training
Present behavior
Insight
Past behavior