Clinical Psych & Mental Health

Definitions in the field of mental health

Deviations from Ideal Mental Health Deviations from Social/Cultural Norms

Failure to Function Adequately

Statistical Infrequency

Deviations from ideal mental health

Absence of criteria created by Jahoda:

Positive attitudes towards self

Self actualisation & personal growth -motivation to reach full potential

Being resistant to stress

Personal autonomy- independant,self reliant

Accurate perception of reality - realistive view of the world

Environmental Mastery - being competent in all aspects

Example of DIMH

A person with anorexia nervosa has lost touch with reality as they perceive own body in a distorted way (thinking they are significantly larger than they are).Thye also do not have a positive attitude towards the self as they often have a negative self-concept and low self-esteem.

Strength of DIMH

A strength of the DIMH definition is that it offers an alternative view on mental disorders by focusing on the positives rather than the negatives and focuses on what is desirable rather than what is undesirable. Even though Jahoda's ideas were never really taken up by mental health professionals, the ideas have had some influence and are in accord with the positive psychology movement from the humanistic approach in Psychology. Additionally, the DIMH definition covers a broad range of criteria for mental health. In fact, it probably covers most of the reasons someone would seek help from mental health services or be referred for help. The sheer range of factors discussed in relation to Jahoda's ideal mental health makes it a good tool for thinking about mental health.

Limitation of DIMH

A limitation of DIMH is that it is very difficult for most people to meet all of the criteria set down by Jahoda. As a result, under this definition, most of us would be classed as abnormal as we would fail at least one criterion at some point. For example, most individuals are usually resistant to stress, but there are times where they may be overwhelmed, such as by experiencing a major life event. This suggests that the conditions for ideal mental health are too stringent. It might be more useful to consider these characteristics as things we should be striving for rather than things that we must have achieved. Therefore it makes it difficult to decide who needed treatment

Limitation of DIMH

A further limitation of the DIMH is that the characteristics listed by Jahoda above are rooted in Western societies and a Western view of personal growth and achievement. For example, self-actualisation (seeking to fulfil one's full potential) may be seen as a key goal in life within some cultures e.g. Western (individualistic) cultures but not Non-Western (collectivist) cultures . In collectivist cultures, elders in the family may plan the young person's future; this might include such things as career paths and arranged marriages. It may therefore be regarded as abnormal to go after your own goals if they are in conflict with those of your own culture. This suggests that cultural relativity severely limits the validity of the DIMH definition as it exhibit imposed etics

Deviations from social/cultural norms

Behaviour that goes against (deviates) the unwritten rules and norms in a given society or community. In any society there are social norms - standards of acceptable behaviour that are set by the social group, for example queuing, not laughing at a funeral.They are generally accepted, so anything that goes against these norms would be considered abnormal.

Example of DSN

Antisocial Personality Disorder (APD) - A person with APD is impulsive & aggressive. An important symptom of APD is that people with APD are abnormal because they do not conform to our moral standards.

Limitation of DSN

One limitation of the DSN definition is that social norms changes over time.The main difficulty with the DSN definition is that norms as defined by society, are not constant but often relate to moral standards that vary over time as social attitudes change. This means that this approach to defining abnormality is very much era-dependent - behaviours that are considered abnormal now may not be considered abnormal in the future. For example, homosexuality was once considered abnormal behaviour because it broke the social norms of the day. Attitudes have changed considerably now, and homosexuality is no longer an abnormal behaviour yet it was only removed from ghe DSM5 as a mental disorder in the 1970s.Therefore caution should be taken when using DSN when defining abnormal behaviour and so challenges the validity of this definition

Strength of DSN

A strength of DSN definitions is that it has cultural relativity. This is because Social/cultural norms by their definition vary tremendously from one community to another. For example, In western societies hearing voices or visual hallucinations is abnormal and would be labelled as symptoms of schizophrenia whereas in across other cultures hearing voices is seen as a great gift to be welcomed and embraced and seeing visions is applauded, not labelled as abnormal behaviour. Therefore, this definition demonstrates cultural relativism as it appreciates that an individual should be diagnosed with an appreciation from the culture they are from.However, this can create problems for people from one culture living within another cultural group. This suggests that caution must be taken when defining an individual from a non-dominant culture using the deviation from social norms definition.

Failure to function adequately

When behaviour suggests that they cannot cope with the demands of everyday life, considered abnormal when it causes distress leading to an inability to function properly, like disrupting the ability to work and/or have satisfying relationships + not being able to experience the usual range of emotions /behaviours. -interferes with day-to-day living.

Related to maladaptiveness which prevents them from reaching desired goals and observer discomfort

Example of FFA

Severe depression, can lead to a lack of interest meaning that the depressed person may fail to get up in the morning and hold down a job.

Strength of FFA

A strength of the FFA definition is that it seems to apply to the diagnosis of many disorders, and it is an important criterion with respect to many mental disorders. For example, when you look at depression and anxiety, millions of people experience depression and/or anxiety some of the time. However, a key difference between those diagnosed with depression/anxiety as a mental disorder and the rest of the population is that those who are diagnosed find their depression and/or anxiety is seriously interfering with their everyday lives, e.g. holding down a job, and relationships. Therefore this helps us decide who needs to be prioritised in being treated for depression/anxiety

Limitation of FFA

A limitation of the FFA definition is that in order to determine 'failure to function adequately' someone needs to decide what is ‘adequate'. Some individuals may be quite content with the situation, and they might be unaware that they are not coping. It is others who are uncomfortable and judge the behaviour is abnormal. For example, if you take Rosenhan and Seligman's criteria of observer discomfort, many people with schizophrenia feel they can function adequately and do not feel that they have a problem, however if they demonstrate erratic behaviour this might be uncomfortable and distressing for people around them who may think that the individual is failing to function adequately. This suggests that the FFA definition is subjective, because it is influenced by people's own personal feelings of what is abnormal.

Limitation of FFA

A further limitation of the FFA definition of abnormality is that many individuals with mental health issues can appear to lead perfectly normal lives most of the time. For example, Harold Shipman was a doctor who was responsible for the death of over 200 of his patients over a

23-year period. Despite his appalling crimes, Shipman functioned adequately and was seen to be a respectable doctor. He was clearly abnormal, but he did not display the features of dysfunction and was able to escape detection for many years. This suggests that using FFA as a single way of defining abnormality is inadequate.

Statistical Infrequency

Behaviour which is rare (uncommon). any behaviour that strays FAR from the average would be seen as abnormal. Any individuals who fall outside the 'normal distribution', usually about 5% of the population are perceived as being abnormal.

Example of SI

Schizophrenia is suffered by 1 in 100 people and so is statistically infrequent.

a strength of the SI definition is that once a way of collecting data about a behaviour and a 'cut off point' has been agreed, it becomes an objective way of deciding who is abnormal, and then it can be used in the diagnosis of disorders, for example it can be used to define & diagnose somebody as suffering from intellectual disability disorder (IDD).Individuals who have an IQ below 70 are rare (only 2%) and are therefore labelled as having IDD. All assessment of patients with mental disorders includes some kind of measurement of how severe their symptoms are as compared to statistical norms (as distinct from social norms). Therefore, this suggests that the Statistical infrequency definition is a useful part of clinical assessment.

Limitation of SI

A limitation of the SI definition is that there are many abnormal behaviours that are actually infrequent but quite desirable. For example, a very low IQ is, statistically just as abnormal as a very high IQ, but it is desirable to have a high IQ; very few people have an IQ over 150, yet we would not want to suggest that having such a high IQ is undesirable. Equally, there are some normal behaviours that are frequent but undesirable. For example, 19% of adults have depression and so is relatively common yet it is undesirable. Therefore, using SI to define abnormality means that we are unable to distinguish between desirable and undesirable behaviours. In order to identify behaviours that need treatment, there needs to be a means of identifying infrequent AND undesirable behaviours.

Limitation of SI

Another limitation is that psychological disorders appear to be infrequent in some ethnic groups, but this may simply reflect a reluctance to seek professional help, owing to cultural beliefs. For example, depression, a frequently diagnosed disorder in Western culture, appears to be absent in Asian cultures. A general explanation for this has been that Asian people tend to live within extended families with ready access to social support. However, Rack (1982) claims that depression is equally common among the Asian population, but that they tend to consult the doctor only for physical problems and rarely with 'emotional' distress' they do not see this as the responsibility of the doctor and instead sort it out within the family. Therefore, SI merely reflects the statistical likelihood of seeking professional help, rather than an indication of whether a disorder is present or absent in a particular culture.

Phobias

Anxiety disorder- irrational fears produces an avoidance

Specific phobias - eg.animal/situational (planes/lifts)

Social Phobia- eg.eating in public

Agoraphobia- fear of public places - prons to panic attacks

Behavioural Characteristics of Phobias

Panic - crying/screaming/running away

Avoidance - avoid coming into contact

Endurance - remaining in the presence of the phobic stimulus but continuing to experience high levels of anxiety

Emotional Characteristics of Phobias

Anxiety- prevents sufferer from relaxing - fear is the immediate response

Emotional responses are inappropriate to the situation- extreme & disproportionate to danger posed

Cognitive Characteristics of Phobias

Decrease in concentration- inability to complete tasks

Irrational beliefs - increases pressure to perform well in social situations

Behavioural Approach to Explaining Phobias

Mowed er proposed the two-process model based on the behavioural approach to phobias. This states that phobias are acquired (learned) by classical conditioning and then continue (maintained) because of operant conditioning.

Classical conditioning learning due to associating a neutral stimulus with something that already triggers a fear respons. For example, a dog (neutral stimulus) becomes associated with the fear of being bitten (unconditioned stimulus) producing the unconditioned response of fear and so the sight of the dog (conditioned stimulus) creates the condition response of fear and so creating a phobia of dogs.

Operant conditioning explains maintenance of the phobia through negative reinforcement. Responses acquired by CC usually tend to decline over time. However, phobias are often long lasting.

Negative reinforcement increases the frequency of behaviour so when an individual avoids a situation that is unpleasant, it is rewarding, because it reduces anxiety, which means that the behaviour will be repeated. Therefore, the individual will avoid their phobic object or situation.

Strength of the two process model

One strength of the two-process model is that there is research support for the ideas. Bagby reported the case of a woman who had a phobia of running water that she acquired from her feet getting stuck in some rocks near a waterfall.Although she was eventually de-conditioned, the neutral stimulus of the sound of the running water became associated with the fear she had felt and thus her phobia of running water was acquired. Mowrer himself provided support for how phobias can be maintained through Operant conditioning. He conditioned rats to fear a buzzer through the use of electric shocks and then through operant conditioning he trained the rats to escape the electric shocks by making the avoidance response of jumping over a barrier when the buzzer sounded. As this was negatively reinforcing the rats, they repeated the behaviour every time the buzzer was sounded, maintaining their fear of the sound of the buzzer. These pieces of research provide strong support for the idea that phobias can be acquired through classical conditioning and maintained through operant conditioning.

Strength of the two process model

Another strength of the two-process model (2PM) was that it has practical applications, the 2PM was a definite step forward as it went beyond the original idea of just classical conditioning to explain phobias. It explained how phobias could also be MAINTAINED over time and this had important implications for therapies because it explains why patients need to be exposed to the feared stimulus. Once a patient is prevented from practicing their avoidance behaviour the behaviour ceases to be reinforced and so it declines.This can be seen in the success of systematic desensitization, which pairs the feared stimulus with relaxation, which are two incompatible emotions, as a treatment for phobias. The effectiveness of systematic desensitisation in addressing phobic symptoms lends support to the behaviourist explanation of phobias.

Limitation of the 2PM

A limitation of the behaviourist model is that it focuses solely on the role of the environment in the development of phobias, whereas other researchers have identified that phobias have an innate component suggesting that nature plays a part. Seligman suggested the preparedness theory to explain why some phobias are more readily acquired than others. This theory proposes that humans have been 'prepared' by evolution to be fearful of things which in our distant past were a danger to survival. Our ancestors who were predisposed to avoid stimuli like snakes, heights & spiders improved their chance of survival, resulting in them passing on these adaptive characteristics through genetic transmission to their offspring. This suggests that the behaviourist model of phobias, with its focus on nurture, is not a complete explanation of phobias.

Limitation of 2PM

A limitation of the behavioural approach to explaining phobias is that it ignores the role of cognitive factors. It should be possible to trace a phobia back to its original learning experience, but this is often not possible. Ost & Hugdahl claim that nearly half of all people with phobias have never had an anxious experience with the object of their fear,. If it is the same learning principles that underpin all phobias, then it is not clear why only some people develop phobias following a similar trauma. DiNardo et al found that 50% of people with a fear of dogs had had some kind of negative experience with a dog in their childhood. However, 50% participants who had no phobias at all reported that they had experienced a traumatic event involving a dog. Di Nardo et al. noted that those who had developed a phobia tended to have focused more the likelihood of that kind of event happening again, suggesting a role for cognition in the development of phobias.This suggests that cognitive factors may play a role in the development of phobias.

Behavioural approach to treating phobia

Systematic desensitization (SD) is a behavioural therapy designed to gradually reduce phobic anxiety through the principle of classical conditioning. When the sufferer learns to relax in the presence of the phobic stimulus it is called counter-conditioning. So SD aims to replace a faulty association between the conditioned stimulus and conditioned response that has resulted in a phobic response.For many patients SD can be completed within 4 to 6 sessions, while more severe phobias can take around 12 sessions.

Process of Systematic Desensitisation

1)The therapist teaches the patient to relax as deeply as possible. The idea behind this is that fear & relaxation cannot exist at the same time (reciprocal inhibition) & so relaxation replaces the fear. Relaxation might involve breathing exercises, for example they might be taught the 7/11 technique, which is a breathing exercise where you breathe in for a count of 7and out for a count 11 or the patient might learn mental imagery techniques. Patients can be taught to imagine themselves in relaxing situations (such as imagining lying on a beach) or they might learn meditation.

2. Anxiety hierarchy - This is put together by the client & therapist. It is a list of situations related to the phobia that provoke anxiety arranged in order from least to most frightening eg. picture of a small spider as low on their anxiety hierarchy and holding a tarantula at the top of the hierarchy.

3. Finally the patient is gradually exposed to the phobic stimulus while in a relaxed state, which eventually will lead to extinction. This takes place across several sessions, starting at the bottom of the anxiety hierarchy. When the patient can stay relaxed in the presence of the lower levels of the phobic stimulus, they move up the hierarchy. Treatment is successful when the patient can stay relaxed in situations high on the anxiety hierarchy.

Strength of SD

A strength of SD for the treatment of phobias is that research shows that it is effective in the treatment of specific phobias. Gilroy et al followed up 42 patients who had been treated for spider phobia in three 45-minute sessions of SD. A control group was treated by relaxation without exposure to spiders. At both 3 & 33 months after the treatment the SD group were less fearful than the relaxation group. Additionally, McGrath et al reported that 75% of clients with phobias responded to SD. According to Chay et al believed that in vivo exposure is more successful than ones using pictures or imagining the feared stimulus (in vitro). These pieces of research provide reliable evidence which demonstrate that SD is a useful technique in the treatment of specific phobias.

A weakness of SD as a treatment for phobias is that it may be that the success is more to do with exposure to the feared situation than relaxation.It might also be that the expectation of being able to cope with the feared stimulus is most important. For example, Klein et al compared SD with supportive psychotherapy for patients with specific/social phobias. They found no difference in the effectiveness, suggesting that the 'active ingredient' in systematic desensitisation may simply be the generation of hopeful expectancies that the phobia can be overcome. This suggests the exact reason why systematic desensitization is effective remains unclear.

Strength of SD

A strength of SD is that patients seem to prefer it to flooding. This is because SD in comparison to flooding involves a gradual, step-by-step approach allowing individuals to build confidence and manage anxiety at each stage. As patients are exposed to the feared stimulus in a controlled: and manageable way, working slowly through the hierarchy they are less likely to experience the same degree of anxiety as flooding. This means that it is less likely lower attrition rates than flooding. This suggests that SD is an appropriate treatment for a wide range of clients with phobias.

Limitation of SD

Another limitation of SD as a treatment for phobias is that the psychodynamic model claims that SD focuses only on symptoms & ignores the causes of abnormal behaviour. Psychoanalysts claim that the symptoms are merely the tip of the iceberg - the outward expression of deeper underlying emotional problems. Psychoanalysts believe that whenever symptoms are treated without any attempt to work out the deeper underlying problems, the problem will only show itself in another way, through different symptoms. This is known as symptom substitution. Behaviourists however reject this criticism & claim that we need not look beyond the behavioural symptoms as the symptoms are the disorder.

Flooding

Flooding is a behavioural therapy that is based on the idea of extinction. A person is exposed to the most frightening situation immediately. For example, a person with a phobia of dogs would be placed in a room with a dog and asked to stroke the dog straight away for an extended period of time, in a safe & controlled environment.

1)Immediate exposure to the phobic stimulus. Flooding involves in-vivo exposure until the person is calm & does not fear the stimulus, without a gradual build up. So, an arachnophobe receiving flooding treatment may have a large spider crawl over their hand until they can relax fully. Flooding sessions are typically one session, often lasting two to three hours.

2)Exhaustion of the phobic response. The patient quickly learns that the phobic object is harmless through the exhaustion of their fear response. This is known as extinction. The result is that the conditioned stimulus (spider) no longer produces the conditioned response (fear). In some cases, the patient may achieve relaxation in the presence of the phobic stimulus simply because they become exhausted by their own fear response.

3)Avoidance behaviours maintain the phobia as the phobic cannot learn that the thing they fear is not harmful. So, stopping the phobic patient from making their usual avoidance responses is necessary to prevent reinforcement of the phobia.

Strength of flooding

A strength of flooding as a treatment for phobias is that it appears to be an effective treatment. Wolpe took a girl who was scared of cars & drove her around for hours. Initially the girl was hysterical, but she eventually calmed down when she realized that her situation was safe, from then on, she associated a sense of ease with cars. Further support was also found by Marks et al who compared flooding to SD as a fear-reducer in 16 phobic patients who were treated in a repeated measures design with both procedures. Flooding therapy led to significantly superior results compared to SD, according to doctors' ratings, & reduced anxiety reported by the participants. The improvements were maintained over 12 months. Therefore, suggesting that flooding is a successful treatment for phobias.

Limitation of flooding

A limitation of flooding as a treatment for phobias is that although flooding is highly effective for treating simple phobias it appears to be less effective for more complex phobias like social phobias. This may be because social phobias have cognitive aspects, for example, a sufferer of a social phobia does not simply experience an anxiety response but thinks unpleasant thoughts about the social situation. This type of phobia may benefit more from cognitive therapies because such therapies tackle the irrational thinking. This suggests that the effectiveness of flooding as a method of treating phobias is more dependent on the type of phobia.

Limitation of flooding

Flooding may not be appropriate as a treatment for phobias due to the increased anxiety & distress that is caused because of the intense and immediate exposure to the feared object. Whilst flooding is not unethical, as patients give full informed consent with the therapist ensuring the patient is fully prepared for the procedure, Schumacher et al found that patients & therapists rated flooding as significantly more stressful than SD. As a result, flooding can lead to high refusal rates & attrition rates. On the other hand, research evidence from Shipley et al found there are few negative side effects after flooding, with ONLY 0.2% of patients experiencing side effects. This suggests that flooding can be an appropriate and safe treatment

Emotional characteristics of Depression

Depressed Mood - overwhelming feelings of sadness/hopelessness. This lowered mood is more intense & pronounced that in the daily kind of experience people in general can have

Loss of Interest and Pleasure - lack of enthusiasm associated with a lack of concern/pleasure in daily activities.

• Worthlessness - constant feelings of low self-worth and or inappropriate feelings of guilt.

Cognitive characteristics of Depression

Reduced Concentration- difficulty in paying & maintaining concentration + poor decision making skills are likely to interfere with the individuals work.

• Negative Beliefs about Self - experience persistent negative beliefs about themselves and their abilities.

• Suicidal Thoughts - constant thoughts of death and/or suicide.

Behavioural characteristics of Depression

Change in Activity - reduced amounts of energy resulting in fatigue, lethargy & high levels of inactivity. In some cases, depression can lead to the opposite effect - (psychomotor agitation). Agitated individuals struggle to relax and may end up pacing up and down.

• Change in Eating and Sleeping Patterns - people may experience a change in appetites which may mean they eat more or less than usual and have significant weight changes + Insomnia or excessive sleeping

• Social Impairment - there can be reduced levels of social interaction with friends and relations.

The cognitive approach to explaining depression

Becks Negative Triad

Beck believed that depression is caused by negative thinking (about self) which comes before the development of depression.

He proposed the negative triad, which consists of three types of negative automatic thoughts that occur regardless of what is happening in reality. These negative automatic thoughts are about: the

• self (e.g. 'nobody loves me'),

• the world (e.g. 'the world is an unfair place') and self-fulfilling

• the future (e.g. '| will always be a failure.').

Beck added that cognitive biases & negative self-schemas maintain this negative triad.Depressed people may develop negative self-schemas, often through harmful experiences in childhood such as parental rejection and criticism from teachers. Such negative events mould the person's concept of themselves as unwanted or unloved. This then filters into adulthood providing a negative framework to view life in a pessimistic fashion.

Negative self-schemas may lead the depressed person to cognitive biases which makes them prone to making errors in their thinking such a over-generalisation which is when you make a negative conclusion based on a small piece of negative feedback leading to self low worth

This negative thinking is difficult to control and may lead to the person developing a dysfunctional view of themselves causing them to be vulnerable to depression.

Ellis’ ABC model

Albert Ellis believed that depressives mistakenly blame external events for their unhappiness however it is their interpretation of these events that is to blame for their distress. He proposed that the key to depression lay in irrational beliefs. According to this model, depression is produced by the irrational thoughts triggered by unpleasant events. In his ABC model:

Activating event: something happens in the environment around you.

Belief which is held about the event which may be rational or irrational

Consequence - rational beliefs lead to healthy emotions whereas irrational beliefs lead to unhealthy emotions.

The consequence is caused by the beliefs about the activating event. Individuals who become depressed interpret unpleasant events in excessively negative or threatening ways. Having such irrational beliefs leads to unhealthy negative reactions and emotions.